Diabetes Hits Hardest in Poor Countries That Aren't Overweight. Why?

[Music] Pat and Visalakshi have something surprising in common there are two phases of a disease that in the last few decades has become a global epidemic I've diagnosed when I was 31 years that I have diabetics both my parents have both sides my grandparents had so I thought I should better check myself the doctor calls me and says yeah I have to be the one to tell you you have type 2 diabetes and my first reaction was who said it wasn't it just a fluke she goes no you have diabetes type 2 diabetes is usually portrayed as a Western disease so it was a complete shock to us when we found out that 80% of the cases are now in developing countries a simple explanation for this is that globalization is spreading a western lifestyle around the world more and more people like Visalakshi have access to the same processed foods and modern conveniences as people like pat but it's actually the differences between these two women have brought us to India because those differences are causing scientists to profoundly rethink their understanding of this disease if you didn't know India had a diabetes problem some of the numbers will be shocking they certainly were to us 66 million people here have type 2 diabetes and that number is growing rapidly to get a sense we visited dr. Mohan has diabetes specialty center in Chennai his network of diabetes clinics has over 300,000 active patients the projections are it will cross a hundred million people in 2030 that is the official IDF projection we want to take my view on it yes we'll get to that number but we'll be much faster in fact what they had said was that we will reach when it was 30 million they said by 2025 will reach 50 million here we are 68 million now and the number of a pre-diabetes stage before diabetes is 77 million people so things happen much faster 65 percent of the population today in Chennai has either diabetes or pre-diabetes so the normal people are actually in minority now [Music] there's no doubt that changes to diet and physical activity are part of the story according to some measures India has the fastest growing economy in the world right now and that rapid development is changing the way people with people work traditionally very thin they were poor they have nothing to eat for many years had to walk in the past to get to school year to walk two miles if you work in the field then you're plowing the field if you have to get water you have to go and draw it from some end and carry the water it's completely changed from the way it used to be just 30 years ago a bad news part of the news exactly what happens electrification comes and then water supply comes to the village the bus stops get closer and closer so 100 yards from you the bus stops it's convenient this is progress from here it's easy to jump to the conclusion that progress leads to a fatter and lazier population which leads to diabetes but there's a kink in that story while the u.s. is one of the fattest countries in the world India remains one of the thinnest medically speaking you're considered overweight if your body mass index is above 25 if it's above 30 your obese in the United States obesity and type 2 diabetes largely go hand-in-hand but in India the face of diabetes is a skinnier one to scientists who study these things this is a major mystery [Music] if you read the standard textbook of Medicine the biggest risk factor for diabetes is age and obesity so increasing age and being overweight and obese but as soon as I went to England and started sitting in the clinic in Oxford where I trained I could see the patients there were very different than what I was seeing in India so then I realised the Indians get it at a younger age and at a lower body mass index and then the next question is why exactly why doctor CH Nick has spent the past two decades trying to answer that question and in the process he's transformed this diabetes clinic at kem Hospital in Pune into a leading center for research he started by taking a closer look at his patients and he found that BMI wasn't telling the whole story body mass index first came on the scene in the early 1940s when a statistician at the Met Life Insurance Company noticed a correlation between BMI and life expectancy in the decades since it's been widely adopted as a measure of health but all it really is is a ratio of weight to height yogic set out to find something more concrete these two instruments made a big difference this is a skin caliper you catch hold of your skin fold so that you can measure how many millimeters and it's a major of fat under the skin and this instrument which is even simpler it's a measuring tape using these two instruments yosh Nick realized that though many of his diabetic patients looked thin and had low BM eyes they actually had a lot of fat it was just hard to see and I coined that term which confused everyone saying Indians were thin but fat and people really didn't believe it in fact some of our original papers were resounding ly rejected by major journals across the Atlantic so they didn't shake your idea was wrong for anything they said this is of no interest to our readers you start thinking a bad dress was not Kem hospital unit but someplace in Northeast of us for example then they would have said what a great discovery [Laughter] hello hi John so then Yosh Nick and his colleague John you'd kitten of University College London found a more dramatic way to prove the point that looks perfect what about this picture that was published where did the picture come from this picture which they called the Wai Wai paradox originated when the two researchers decided to run some tests on themselves the first shock came when Yas Nick and you team discovered that they had the same BMI and when they measured their body composition using a new machine called a DEXA that yogic had just purchased for his clinic they got another shot I had never expected my body fat to be more than twice as much as yours it was eventually published in 2004 along with a short caption pointing out the limitations of BMI when comparing different ethnic groups we adored that in 20 minutes time that's right we decided to repeat the experiment on me so I had a BMI of 22.7 and a body fat percentage of 23.9 so can we see yours yeah dr. Yash Nix BMI was lower than mine but his body fat percentage was much higher - no the shortcomings of BMI are now widely accepted at least in the scientific community when it comes to health what matters is how much fat you have not how fat you look it also matters what kind of fat you have and yannick found that Indians tended to have more fat in their abdomen so called visceral fat which many researchers have found is strongly associated with diabetes risk but understanding how Indians are different doesn't explain why they're different an obvious answer would be that its genetic but Yannick stumbled on another possible explanation when he heard about the work of a British epidemiologist named David Barker Barker was studying something that wouldn't seem related to diabetes at all fetal malnutrition if there is poor environment very early in life that means when you're growing in the womb then what do you get you get low back to it and he then found records in Hertfordshire where a nurse had gone around majoring babies at birth and serially in first few years of life so he traced about 500 of these people studied their metabolism studied their heart disease risk and other things and produce this remarkable data that people with low birth weight we're at high risk of heart disease and diabetes this was a radical idea these diseases after all were often blamed on too much food but Barker was saying that part of the problem might be not enough nutrition when you're growing in the womb many in the medical establishment were skeptical they attack David Barker saying that we know the answer controlled blood pressure control cholesterol and heart disease will go away so Parker set out to test his malnutrition theory on a larger scale India's capital of low birth weight babies far lower than any other population and I have to say David Baca was very lucky they came and met me Barker and Yannick embarked on a decades-long collaboration that would lead to some remarkable findings in a study published in the International Journal of obesity in 2003 they compared Indian babies to Caucasian babies in the UK and found that even at birth Indians had more fat despite being significantly smaller and often malnourished and when they followed a cohort of Indian babies over the first eight years of their lives they literally added a new dimension to our understanding of diabetes take this graph for example showing the correlation between insulin resistance and a given child's weight at eight years old not surprisingly the heavier children had the worst results but adding birth weight to the equation suggested that another previously hidden factor was also at play it was actually the children who were born the smallest and then gained the most weight as kids who seemed to have the highest risk of diabetes and in a country undergoing an extremely rapid economic transition this was an increasingly likely scenario your mother might have been undernourished when she was pregnant but you could grow up eating at McDonald's and yet if there's something about malnutrition in the womb that puts you at risk for diabetes what is it to try to answer that question yaws NIC and Barker launched an even more ambitious study they started by tracking the health and nutrition of a couple thousand rural women those who became pregnant were followed up with and their children became the focus of the puna maternal nutrition study which has now been running for 18 years so see we have over 800 in our court children and then twice that number of parents to 2400 people that's right the major major undertaking and we follow the children from but every six months for their growth measurement and then every six years we call children and their parents for very detailed studies of growth body composition metabolism hormonal status neurocognitive windings and XYZ we have done it on hundreds of people for last 20 years how long does it take to go through this whole cohort about one and a half to two years yes it also takes a massive team of social workers number crunchers and administrators lab technicians and researchers and clinicians where were we heading we are heading to the religious near morning dr. gajanan took us to meet two of the subjects of this study so in this twenty years you've been coming out here a lot has changed the way things have changed in last twenty thirty years is just mind boggling they used to fetch water from the well there are now piped water supply electricity has become more common about 70 percent of the houses that time very electrified now it's 95 percent zero percent of our families had a four-way vehicle now eight percent of our families now 14 and of course these kinds of changes which are happening all over India right now can have a big impact on diet physical activity and ultimately the health for hundreds of millions of people like puja and her mother Savita she is the representative of f0 generation she's f1 so this is a term in genetics the first generation the index generation we call f0 okay f1 is the offspring and her offspring will be f2 and then there will be F 3 4 which will be beyond our tank so she weighed 2 K loads and 550 grams but still quite small still quite small huijin's mothers before pregnancy was 40 kg which compared to an American Institute of Medicine standard she will be classified as undernourished before pregnancy and undernourished people are supposed to put on more weight so she will be expected to put on something like 12 kg or more she put on only 7 kg so this is the shift of the spectrum we have of nutrition body weight gain of weight in pregnancy and that is how it reflects in the low birth weight of the children during savita's pregnancy 20 years ago they monitored her diet including the level of vital micronutrients in her blood they also tracked her physical activity so they do the whole work of the house bring water and everything and then 6 hours they are on the field in this hot Sun and then again would come back in the evening and do cooking because it's so hot here that the even morning food would go stale in the evening and this physical activity is there till the ninth month til she will deliver after she was born poojas growth was accorded every six months in every six years she was subjected to a battery of tests very good so I think she is remembering more than 6 years then 12 years and recently when they were 18 yes what they were looking for was some kind of correlation between poojas health and her mother's diet from years earlier what they found was a complex web of interactions between lots of variables but one factor in particular stood out vitamin b12 our most dramatic finding was that mothers who had low b12 concentration in the blood in pregnancy their children had some difficulty and Link glucose and we call this insulin resistance so far this is just a correlation but it's another data point in support of what has come to be called the Barker hypothesis that adult diseases can be traced back to factors early in life we say non communicable diseases as opposed to communicable diseases and now we are saying they can be communicated from the mother to the children by actually environmental influences it's a major new way to think about diseases like diabetes and it happens to dovetail with recent developments in the burgeoning new field of epigenetics it's the idea that your environment including chemicals like vitamin b12 can actually change your DNA about the genetic structure something happens which changes the transfer of that information what we call epigenetic changes epi means about and genetic is genetics so code remains the same but it changes the way that gene expresses this is a big deal I mean this is like a major sea change yes in sort of classical genetic thought yes and the classic example where I learnt it very very well was on the Alberta mice so these are the famous agouti mice these are the good mice the environmental epigenetics and nutrition lab at the University of Michigan headed by dr. Dana dalla noi is one of the numerous places where scientists are now studying how DNA is affected by environmental factors what you can immediately see is that they range in Coke color from brown to a mouse that's purely yellow over here and what's also really interesting about these mice they're genetically identical they have 100% the same DNA yes but what's different is their epigenome it's a series of molecular switches and markers that tells genes when to turn on where to turn on and how much to turn on and as a result of genes being switched on and off these mice will have very different futures even though they have the same genetic code at birth they are all the same size they all look identical except for the coat color difference but over time the mice that have the yellow coat very early in life will grow more they eat more and they will become obese whereas the brown and black mice remain lean the yellow mice also go on to get diabetes because of the dysregulated expression of this agouti gene while they're genetically identical brown counterparts are protected from these outcomes scientists have identified a number of environmental factors that seem to play a role in determining whether a pregnant Mouse's offspring are more likely to be brown and thin or yellow in fat dr. Dolin oiz lab has been studying the effects of BPA which is found in many plastics and seems to push the mice towards yellow and an earlier study out of Duke University found that b12 was on the list of compounds that seemed to make the mice brown and healthy an individual's epigenome is constantly changing across time but you're most vulnerable in development if you could intervene early in life and turn a yellow mouse brown that's a really great starting point to be able to think about translating this to humans in medicine or in clinical practice we have what we call levels of prevention so we have primary prevention secondary prevention Tashia prevention all doctors are trained for secondary and mostly for tertiary prevention all you are doing is key you lost three thoughts so I'm preventing now the fourth toe from going and I can't be very sure and it's very frustrating you are seeing end stage conditions all the while the research in the intergenerational and early life has brought in one more type of prevention which is called primordial prevention and primordial prevention comes even before primary prevention where you are reducing the susceptibility so that you are producing a better bloop on which different factors acting will produce less damage dr. Yash Nick is already starting to focus on primordial prevention as the young women who have been participating in his study their whole lives begin to have babies of their own it's quite small of tiny dough kz gosh nick and his team are running a trial to see if providing better nutrition to these mother's during pregnancy including supplements of vitamin b12 will reduce diabetes risk for their babies as they grow she is the f2 generation in Daponte maternal nutrition study her grandmother was our f0 generation her mother is the f1 is this considered non-controversial that the risk factors for diabetes are being passed from mother to child and to me it's non-controversial and as a scientist you have to believe in something then you work to disprove yourself what have you done that patrol this place what we have just now started the trial it's to be understood that evidence in such matters come slowly because we are looking at evolution along the life course so in five years time when our first round of data collection is over in this I'll be able to tell you more confidently what we have achieved you you you [Music] you

Channel: Slate

Views: 78,146

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Keywords: Slate, Slate.com, Slate Magazine, Diabetes, science, medicine, Type 2 diabetes

Id: aGuED1JczbI

Length: 25min 27sec (1527 seconds)

Published: Mon Jan 29 2018

Reddit Comments

[u/PapaTua]

Epigenomics is a fascinating concept and an interesting take on gene expression.

[u/beardybuddha]

*Type 2 diabetes.

[u/[deleted]]

Deep fry the health benefits out of veg, replace with spices and clarified butter with a side of starchy rice and bread followed by a sugar loaded sweet (if lucky) and little exercise , can confirm 3 years in India

[u/gregory_domnin]

They point to low b12 in the mother’s as a possible culprit. Here in the states the difference between grass fed beef and grain fed is interesting in that grass fed has considerably more b12 yet we have been eating primarily grain fed. More evidence that our corn subsidies are not in fact helping us.

[u/SassyAsFuq]

India eats a metric fuck ton of carbs.

[u/[deleted]]

Amount of sugar, salt and fried foods that they eat. And genetics has part of the reason why they're skinny and the other part is is still a poor country for the most part and people have to bust their ass for a living to make a dollar which means they're burning the calories but that doesn't necessarily mean they're healthy.