South Asians’ Impaired Ability to Burn Fat Makes Them More Prone to Diabetes

With more than 50 million diabetics ‒ mainly type 2 ‒ India is facing a full-blown diabetes epidemic. Another100 million are at the stage of pre-diabetes. Only China suffers from far more cases of diabetes.

While anecdotal evidence suggests diabetes has assuming epidemic proportions in the subcontinent as a result of improved incomes but poorer lifestyle and dietary choices, especially among the middle class, a new study reveals that people from South Asia are at greater risk of developing type 2 diabetes because of the way their muscles burn and store body fat.

Researchers from the University of Glasgow, Scotland, analyzed the rates of fat metabolism in 20 men of South Asian origin and 20 white European men.

Their findings suggested that South Asian men have a lower rate of fat metabolism during exercise than their European counterparts, as well as reduced sensitivity to insulin – indicating a possible tendency towards glucose intolerance and type 2 diabetes.

The scientists said the association between fat metabolism rate and insulin sensitivity was due to key differences between the muscles of south Asians and Europeans.

They discovered that the expression of genes key to fat metabolism was lower in the muscles of south Asians, affecting their ability to process fat and thus increasing the risk of insulin resistance – a major factor in the development of type 2 diabetes.

Dr Jason Gill, who led the study, said: “Our results suggest that the ability of south Asians’ muscles to use fat as a fuel is lower than in Europeans.”

“In other words, if a south Asian man and a European man were walking alongside each other at the same speed, the south Asian man’s muscles would be burning less fat and this may contribute to a greater risk of developing diabetes.”

Dr Victoria King, from British charity Diabetes UK, said: “This new insight could provide the basis for future studies looking at lifestyle, or drug interventions to enhance the uptake and burning of fat in muscles, reducing the risk of type 2 diabetes in this high risk group.”

The study was published in the peer-reviewed medical journal PLoS One.

Diabetes: Shortage Of Vascular Surgeons In India Costs 80,000 Limbs Every Year

India has less than 100 vascular surgeons since the establishment of the first department of vascular surgery in 1978. The states of Orissa, Madhya Pradesh, Bihar and Manipur don’t have any vascular surgeon.

No government-run hospital in the country’s capital New Delhi, including the premiere All India Institute of Medical Sciences, has a department of vascular surgery. Chennai and Bangalore in the southern states of Tamil Nadu and Karnataka respectively, with 20 surgeons each, are slightly better off.

Only last year, the number of seats for post-graduate degree in vascular surgery in the country was raised from four to eight in medical colleges. Including diploma holders, the country produces only 16 vascular surgeons yearly. This, experts feel, should be trebled in two years.

“A large number of people wheeled in for amputations are either trauma victims or long-term diabetics. At least 40% of people with decade-long diabetes develop vascular problems. In a country where more than 40 million people are estimated to have diabetes, the number of people estimated to have vascular problems is large. Add to this road accident victims day and you know why there is a need to produce a greater number of vascular surgeons,” says Dr Sekar, who is also the president of the Vascular Society of India. Though there are no clear statistics on amputations, it is estimated that at least one lakh people lose a limb every year. Of these, nearly, 80,000 amputations are avoidable.

Sakthiraj Ekambaram, 29, a chronic smoker, complained of pain every time he walked for more than 20 minutes. “I had to stop for a couple of minutes and walk again. The doctor sent me to the gym,” he said. Luckily, Sakthiraj, decided to consult a vascular surgeon for the wound that did not heal for long. “That is when I discovered that the blood supply to my legs was very low. My feet were cold unlike other parts where blood flowed and I did not have good sensation on my feet. I underwent a procedure that saved my legs,” he said. But not all patients are as lucky has Sakthiraj, says Dr Sekar.

Pulling out the case sheets of a 40-year-old patient, he continues, “A chronic diabetic, this patient had one of his limbs amputated last year. This year, he had his other leg amputated too. Almost 50% of diabetics who go in for amputation of one limb, lose their second limb in another year. A vascular disease is an indicator of a heart disease because if there are blocks in the leg, there can be blocks in the heart too,” says Dr Sekar.

“When people are disabled, the burden is high on the family and the government,” says Dr Ravul Jindal, the only qualified vascular surgeon in Chandigarh. “Some patients who can afford the treatment are referred to doctors in other states. The others undergo amputation surgeries. These are done by general surgeons or orthopedic surgeons to prevent infection from spreading to other parts of the body,” says Dr Jindal.

The society is now waging an aggressive war with the Union health ministry and at least ten state governments urging them to start new departments in vascular surgery. Vascular surgeons say they consider several options before deciding to remove a limb.

“The blood vessels in the legs and hands are just like arteries and veins in the heart. If there is a block in arteries of the heart, it can reduce supply of blood and cause heart attack, which is death of the heart muscle. When similar things happen on the leg, it leads to death of muscles in the leg. They begin to rot (gangrene). Just like the heart, we have options of using balloons to remove blocks by a procedure called angioplasty, place drug coated thin wires in the vessels to prevent clots or even do a by-pass graft,” says Dr Paresh Pai, consultant vascular surgeon at Mumbai’s Lilavati Hospital. “But on most occasions, patients are refered to us very late. We want to create awareness among doctors and patients on foot care. For instance, if a wound remains unhealed for long, doctors should first check if there is adequate blood supply and restore it. For this, the patient should come in early,” he says.

Representatives from the association would meet Union health minister Ghulam Nabi Azad and health secretary Sujatha Rao to discuss a road map. First, they want the ministry to increase the number of seats for post-graduate degree in vascular surgery. “At present, there are only seven training centers for vascular surgery, training 12 students every year. We want them to double the number of seats in a year and increase it by at least three times by 2012,” Dr Sekar said.

Thank you Pushpa Narayan/Times of India

Surgical Procedure Can Control Type 2 Diabetes, Claims Brazilian Surgeon

A new procedure which requires surgical intervention through Ileal Transposition (or small intestinal switch) can effectively control Type 2 diabetes, a Brazilian surgeon claimed in Hyderabad, India on August 21.

Dr Aureo Ludovico de Paula, was in the city to address the first international conference and live workshop on this procedure along with his Indian counterpart Dr Surendra Ugale.

Ugale who is also the organizing secretary of the workshop said, “the new research has shown that there are some intestinal hormones which have a great effect on the pancreas and insulin secretion especially in response to food intake. Dr Paula has devised a laparoscopic operation which he claims is proving to be a cure for Type 2 diabetes.”

Paula said, “The surgery can control diabetes without insulin, arrest the metabolic syndrome of the body organ deterioration, thus avoiding future diabetic complications.”

The doctor who has performed 700 surgeries with 95% remissions said the operation involves a long segment of ilium (ending portion of small intestine) which is shifted to the upper small intestinal area, where food particles will reach it very soon on eating a meal.

This causes an immediate secretion of good hormone GLP-1 which acts on the B cells of pancreas to secrete insulin and control blood sugar.

The fall out is a biochemical process that facilitates insulin secretion in the presence of undigested food and controls Type 2 diabetes, a metabolic disorder that is marked by the failure to absorb sugar and starch due to lack of the hormone insulin, Paula said.

Type 2 diabetes is the most common form of diabetes. In this disease, either the body does not produce enough insulin or the cells ignore it.

Ugale explained that Type 2 Diabetes affects several organs. The solution therefore is to stimulate these hormones in lower intestine that in turn secrete GLP which in turn stimulates the pancreas to stimulate the insulin and get fresh beta cells.

He said patients who already have diabetes for ten years and using medication, and are suffering from five associated diseases are ideal candidates for this kind of surgical intervention which costs less than US $10,000 (in India).

The surgery not only controls high blood pressure but also improves kidney cholesterol nerves reduces excess weight and also one need not take any medicines. He also can eat normally post surgery, including sweets.

However, doctors insist that first of all in any patient they would advise lifestyle changes, exercise followed by medication, if there is diabetes and if the patient is not doing well only then surgery is advised.

Presently a centre in Mumbai and Hyderabad are performing this surgery. A centre has also come up in Coimbatore.

Over hundred doctors from all over the country and endocrinologists are participating in the two-day seminar

Diabetes: Safety Concerns Force FDA To Halt Enrollment For Avandia Trials

The FDA On July 21 ordered drug maker GlaxoSmithKline to stop enrolling new patients in a controversial clinical trial of its widely marketed diabetes drug, Avandia (rosiglitazone).

The clinical trial, called TIDE, was mandated by the FDA to assess safety risks of the drug, which is prescribed to treat type-2 diabetes.

But it has been highly controversial because Avandia has been linked in a variety of studies to an increased risk of heart attack and other adverse cardiovascular effects.

Critics, including one of the Food and Drug Administration’s own safety researchers, have said publicly that the trial should be stopped immediately, asserting that it is unethical to expose patients to risks that have been shown statistically to be quite real.

GlaxoSmithKline recently announced that India has already suspended all participation in the TIDE trial in the country.

In India, at least 20 cities including Mumbai, Bangalore, Chennai and Hyderabad had enrolled over 150-200 subjects earlier this year for conducting these clinical trials, which are part of the global post-marketing studies to asses its safety risks.

This development is significant in the wake of the fact that a total of around 2,000 diabetics were to be enrolled from India.

A debate has been raging on the blockbuster drug, Avandia since studies reported serious side-effects like heart attacks and strokes associated with its use, in 2007. It is widely-prescribed by doctors here in India, with 9-10 companies marketing it.

The country’s drug controller general recently halted the trials, for which subjects were being enrolled since February, across various hospitals and clinics all over.

Dr Anoop Misra, director and head diabetes, Fortis Hospitals in New Delhi said: “This step taken by FDA of stopping this unethical trial is welcome, though belated. I hope further step of banning this drug is taken soon. I am also happy to note that DCGI (India) stopped this trial in India before FDA decision, and such efficient steps and regulations are required in India.”

The FDA on its part said its action does not mean the drug will be removed from the market. But the agency is demanding that GlaxoSmithKline update physicians and ethics oversight boards involved in the trial regarding all new safety information about the drug.

It said the information “can be used’’ to update consent forms for new patients and current participants. Critics, including members of Congress, have said the current consent forms in use in the trial are inadequate given the extent of the scientific warning signs.

The potential dangers of Avandia have already discouraged enrollment in the trial.

The trial’s design called for global enrollment of 16,000 patients, with about a third in the United States. But the trial’s lead investigator, Hertzel Gerstein, of McMaster University in Ontario, Canada, said last week only about 1,120 patients had been recruited worldwide, because of the widespread safety concerns.

By a vote of 20 to 12, an FDA advisory panel last week recommended that the drug be permitted to remain on the market. But half of the members who voted to keep it on the market also supported strong restrictions on prescribing, including education programs about the risks for doctors and patients, which specialists predict will dramatically cut into GSK sales figures.

GlaxoSmithKline said in a statement that new enrollment in the trial would be stopped “pending FDA review of recommendations from its Advisory Committee meeting July 13-14. Patients already enrolled may continue in the trial.”

“This pause in enrollment will give clinical trial investigators and patients time to learn about the data presented to the FDA Advisory Committee and the Committee’s recommendations,” said Dr Ellen Strahlman, GSK’s Chief Medical Officer. “We are committed to working with the FDA in the best interest of diabetic patients.”

Avandia, which was approved for the market in 1999, was prescribed 2 million times by US doctors in 2009. It was once the largest-selling drug in its class, with more than $3 billion in global sales. It sold around $1 billion in 2009, with half of that revenue in the US.

Indians Get Diabetes Before Europeans

Underscoring the importance of an individual’s genetic make-up in disease development, a new study has confirmed the association of eight gene variants with type 2 diabetes in Indians.

With Genome Wide Association studies worldwide revealing the likely link of about 20 loci with type 2 diabetes, scientists from Centre for Cellular and Molecular Biology (CCMB) and three other institutions in the country investigated the association of eight common and well-established genetic variants with type 2 diabetes in 5,148 Indians.

The study was recently published in ‘Diabetes’, a journal brought out by the American Diabetes Association.

According to Giriraj R. Chandak, senior scientist from Centre for Cellular and Molecular Biology, the onset of diabetes among Indians was a decade earlier than in Europeans and at a lower body mass index (BMI), probably because of excess fat around the abdomen.

As a result, the other health problems associated with diabetes too get manifested earlier than in Europeans or others. With each of the variants having its own impact in developing the risk for diabetes, it was found that the effect was much higher in Indians.He said there could be more than the eight variants which were so far found to be associated with diabetes in Indians.

The identified variants increased the risk of diabetes by 21 to 25 per cent. The risk of developing diabetes was found to be higher when an individual carried more than a single variant.

Stating that the study gave a clear idea of how genetics played an important role in development of diabetes, the senior scientist said, it however, remained to be seen how the gene variants interact with other lifestyle risk factors like diet and lack of exercise.

Early identification of such genetic variants could help in prediction of diabetes risk in individuals as also in developing targeted drug therapy.

The other institutes involved in the study are Institute of Genomics and Integrative Biology, Delhi, King Edward Memorial Hospital and Research Centre, Pune and Indian Statistical Institute, Kolkata.

Y Mallikarjun/The Hindu