Chronic diseases like diabetes have emerged as a major clinical and public health challenge globally. According to the International Diabetes Federation (IDF), Diabetes Atlas, 7th Edition published in 2015, 415 million people are suffering from diabetes globally with the number increasing to 642 million by 2040. Moreover, one in two adults with diabetes is undiagnosed. With 5 million deaths in 2013 alone and a death every 6 seconds, diabetes has become a major cause of mortality globally.1 Diabetes is no longer a disease of the affluent, with 75 percent of patients coming from low and middle income countries.1 According to the recent Indian Council of Medical Research India Diabetes (ICMR–INDIAB) study, which is perhaps the largest epidemiological study on the prevalence of diabetes, it was estimated to be 62.4 million individuals with diabetes and 77.2 million with prediabetes.2
Obesity and insulin resistance are important accompanying factors in patients with type 2 diabetes mellitus (T2DM). However, in developing countries like India, there is a double burden of malnutrition wherein there is a simultaneous existence of under nutrition and over nutrition.3 In children, malnutrition can lead to diabetes which is called malnutrition related diabetes mellitus (MRDM).3 On the contrary, diabetes itself can lead to malnutrition due to many physical (dysphagia), medical (gastro paresis) or social conditions (poor socioeconomic condition and lack of knowledge of proper diabetic diet). Many of these factors are highly prevalent among diabetic individuals including comorbid depression, gastro paresis and eating disorders.4-6
Rapidly growing economies often experience the coexistence of underweight and overweight problems, referred to as the double burden of nutrition. There is, however, less empirical certainty on the socioeconomic patterning of the double nutritional burden within a country.7 Indian have a peculiar phenotype which is referred to as “thin fat.” Although the BMI of Indians is lower, they are much more adipose than their western counterparts. This is due to consistent malnutrition among mothers in their young age and during pregnancy. This leads to children being born with higher adiposity and more catch up growth. To add to this, there is higher exposure to refined carbohydrate- rich foods as they are cheaper. This leads to chronic protein malnutrition along with lower intakes of essential vitamins like B 12, vitamin D. Obesity, an increasingly significant health problem worldwide, is associated with insulin resistance, diabetes, and metabolic syndrome. Abdominal obesity has been shown to be more strongly linked to insulin resistance, type 2 diabetes, and cardiovascular disease than total adiposity. However, the association between total and abdominal obesity with diabetes may vary by race and ethnicity.8-9 Low muscle mass may impair glucose disposal since skeletal muscle is the major site of insulinstimulated glucose uptake.
India data, especially the STARCH study shows that nutrition among both persons with diabetes and no diabetics is highly skewed. The STARCH study throws light on macronutrient composition of diet among Indians. It clearly indicates that protein intake among Indians (both with and without diabetes) is very low. Indian diets typically contain 65-70 percent of calories from carbohydrates and only 10-12% calories from protein.11 Also that choice of carbohydrate is from refined sources like polished white rice, or refined wheat and its products. This leads to consistent post prandial hyperglycemia, which is a huge concern among persons with diabetes in India. Chronic hyperglycemia is a cause of malnutrition as many calories are lost in the form of glucose in urine. Also, many taboos both cultural and hearsay, prevent people from choosing food which many be beneficial for them. Hence, in India, nutritional education will play a important role in maintaining health of people with Diabetes. Typically, pure nutritional education programs are difficult to conduct as they are perceived as unimportant. These programs gain importance only when they are part of disease educational programs. In India, having abdominal fat is considered as a sign of prosperity. Most of the persons with type 2 Diabetes have a greater waist to Hip ratio and hence they perceive that they are well nourished. Therefore, nutritional education in the form of therapeutic nutrition is gaining more importance. While doing so, others in the family get advantage of basic nutritional education and understanding role of nutrition in prevention of diseases. They are also made aware of the fact that in India protein intake is lower than expected and there is lack of enough vegetables and fruits in the diet.
However, the exact mechanism for hyperglycemia associated muscle mass reduction is still unclear. Moreover, as per the current recommendations along with drugs, lifestyle modification which includes dietary changes comprise an important aspect of diabetes management.12 Of these, appropriate balanced nutrition can play an important role in tiding over this problem of sarcopenia in diabetes. Nutritional recommendations should be individualized and should be acceptable to the individual patient.13 However, appropriate nutritional treatment, implementation, and ultimate compliance with the plan is not always possible as there are differences in dietary structure as per the type of diabetes, a surplus of information available from various sources which can be confusing to the patient and healthcare professionals. Moreover, nutritional science is constantly evolving which can make some dietary concepts redundant which were true a few days back.13 Nevertheless, the importance of appropriate nutrition needs to be conveyed to the diabetic patients in a very comprehensive and easy to understand manner which can be done with the help of trained Diabetes Educators.
To create professional diabetes educators and also nutritional educators, National Diabetes Education Program (NDEP) was developed in India.14 In a developing country like India with a skewed doctor: patient ratio, training of nonmedical personnel as certified diabetes educators is bound to help the clinician. These certified diabetes educators would ensure a standardized level of both diabetes and nutrition knowledge, skills, and experience related to the disease of diabetes and diabetes education and healthcare delivery. Over the past few years, the NDEP has been successful in educating and empowering 3729 qualified diabetes educators. The diabetes educators include paramedics, support staff of the clinician, doctors and dieticians. NDEP is a 1 year course where diabetes educators are trained in 10 modules with diet management being one of the important modules. Comprehending and meeting the needs of a vast array of different dietary habits was another key issue to be considered while designing a uniform structure for the program.
Within India, culture and geography have a deep impact on nutritional preferences and also availability of foods. Different cultures have differing attitudes toward illness and what food should be eaten during those illnesses in general and diabetes in particular. This also had to be addressed to make the program culturally sensitive and appropriate. The diet module imparts education on various aspects of nutrition like medical nutrition therapy, pre assessment of nutritional requirements, dietary recommendations, importance of macro and micronutrients, reading food labels, recognizing healthy and unhealthy food choices, caloric requirements and sick day diet management. The role of the diabetes educators is likely to become a part of effective strategies for health prevention and promotion particularly to the hard to reach populations in India such as the rural areas. The beneficiaries are multiple- patient as well as their family. Thus, the responsibility for nutrition is not limited only to the dietician – dietetic colleges are few and typically located in metros or tier 1, tier 2 cities. Via this education, we are empowering people even in rural areas- without access to formal nutritional training to understand nutrition and take provide basic nutritional guidelines to people of their community. This is the most effective way with which to combat malnutrition for a country as heterogeneous as India.
References
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