The bitterness of sugar

In 2022, India emerged as the world’s largest consumer of sugar, a rather dubious distinction¹. A whopping 29.5 million metric tons of sugar was consumed by Indians collectively in one year²!!! It’s no surprise then, that more than a 100 million Indians live with diabetes-as per ICMR-INDIAB data³.

‘As sweet as sugar’ might sound melodious, but it is best limited to an English idiom or as a song. In reality, abnormally high levels of sugar in the blood (diabetes) are associated with some hard-hitting and bitter facts. High blood sugar (diabetes) damages several critical organs of the body, which increases the risk of developing multiple serious health complications. People with diabetes are at a very high risk of developing heart disease, kidney disease, eye disease, nerve damage, and several other complications⁴,⁵. Among these, the most alarming risk is that of heart disease. Did you know that the most common cause of death in people with diabetes is a heart attack? However, almost all these complications can be prevented by keeping blood glucose, blood pressure and cholesterol levels in control.⁴.

One of the most important risk factors for heart disease in patients with diabetes is obesity. Abdominal obesity is a particularly high-risk factor for heart disease in patients with diabetes⁶. Abdominal obesity is defined as a waist circumference of 90 cm or more in men and 80 cm or more in women⁷. More than 80% of patients with type 2 diabetes are overweight or obese⁸. Unfortunately, Indians are prone to having both diabetes as well as abdominal obesity⁹. What adds to the problem is that many drugs used for controlling diabetes led to weight gain⁶. Many patients with diabetes require insulin injections, which are also known to cause an increase in weight¹⁰. Hence, the overall risk of heart disease in Indian patients with diabetes becomes very high. Moreover, the likelihood of death after a heart attack is higher in patients with diabetes who are obese¹¹.

The good news is that weight loss can lower the risk of heart disease in patients with diabetes and reduce the number of medicines or doses required to keep diabetes under control⁶. Hence, along with the focus on maintaining normal blood sugar, it is equally important to focus on weight. A weight loss of even 5-10% leads to considerable improvement in the blood sugar levels. In fact, in some patients, a weight loss of 10-15% has been found to control blood sugar to the level that diabetes medications were no longer required up to 3 months or more¹². It is important to discuss weight loss measures with your doctor. The most common measures likely to be suggested for weight loss are diet modifications and exercise. Some of the effective dietary modifications are eating healthy foods that are low in refined carbohydrates, including more fibre and protein in your meals and reducing the total calorie intake. Nevertheless, diet planning needs to be individualised-no standard plan that can be recommended for everyone¹². Exercises should include a mix of aerobics and strength training. Like diet, the exercise plan also needs to be individualized for each person in consultation with the diabetes specialist. Even as little as an increase of 500 steps per day reduces the risk of heart disease by 2–9%¹². It has been recommended by the American Diabetes Association that patients with pre-diabetes should lose at least 7% of their weight and plan moderate-intensity physical activity for at least 150 minutes per week¹³.

As simple as it might sound, weight is a sensitive issue for many people, and achieving an ideal, healthy weight is easier said than done. Almost one-third of patients with diabetes are unable to achieve even a weight loss of 5% after one year of following the dietary and exercise recommendations⁶. Even those who do succeed in losing weight in the first few months hit a plateau after 4-6 months and start regaining the lost weight⁶. Some people might even require medications for weight loss along with diet planning and exercise¹². In short, every diabetes patient’s journey is different and there is no single approach that is right for everyone. By discussing and following up regularly with your diabetes specialist, you can manage your diabetes and modify the risk factors that can help you prevent the complications associated with it. These are essential to keep the bitterness of sugar in check!

References
1. India emerges as the world’s largest producer and consumer of sugar and world’s 2nd largest exporter of sugar. Ministry of Consumer Affairs, Food & Public Distribution. Oct 2022. Available at Link
2. CNBC TV 18. Available at Link
3. Anjana RM, Unnikrishnan R, Deepa M, Pradeepa R, Tandon N, Das AK, et al. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023 Jul 1;11(7):474–89.
4. Raghavan S, Vassy JL, Ho YL, Song RJ, Gagnon DR, Cho K, et al. Diabetes mellitus–related all-cause and cardiovascular mortality in a national cohort of adults. J Am Heart Assoc. 2019;8(4).
5. What causes complications associated with diabetes? Available at Link
6. Van Gaal L, Scheen A. Weight management in type 2 diabetes: Current and emerging approaches to treatment. Diabetes Care. 2015 Jun 1;38(6):1161–72.
7. Dhawan D, Sharma S. Abdominal Obesity, Adipokines and Non-communicable Diseases. Vol. 203, Journal of Steroid Biochemistry and Molecular Biology. Elsevier Ltd; 2020.
8. Bramante CT, Lee CJ, Gudzune KA. Treatment of Obesity in Patients with Diabetes. Diabetes Spectrum. 2017 Nov 1;30(4):237–43.
9. Borgharkar SS, Das SS. Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: The TIGHT study. BMJ Open Diabetes Res Care. 2019 Jul 1;7(1).
10. Edens MA, van Dijk PR, Hak E, Bilo HJG. Determinants of excessive weight gain after the initiation of insulin therapy in type 2 diabetes mellitus: Retrospective inception cohort study (ZODIAC 60). Diabetes Res Clin Pract. 2023 Jun 1;200.
11. Henning RJ. Obesity and obesity-induced inflammatory disease contribute to atherosclerosis: a review of the pathophysiology and treatment of obesity [Internet]. Vol. 11, Am J Cardiovasc Dis. 2021. Available at Link
12. Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, et al. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022 Nov 1;45(11):2753–86.
13. Franz MJ. Weight management: Obesity to diabetes. Diabetes Spectrum. 2017 Aug 1;30(3):149–53.

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