A Bitter Truth

BODY BUILDER AND FITNESS coach Raman Singh (name changed) has always held a vendetta against carbs. For the last five years, he has had his medical checkups done every six months, but when the Mumbai-based 40-year-old was diagnosed with high blood sugar levels some months ago, which could only be treated with insulin shots, he was not only shocked but also outraged. “I was like, how can this happen to me?” First, he had a retest done from another diagnostics centre. Doctors obliged him out of compassion, he recalls, only to prove the earlier diagnosis right.

Singh had contracted Covid-19 in the first wave in India, just before he was declared a diabetic. “My Covid experience was not easy, but it was also not as bad as those of some friends and family,” he tells Open, emphasising that he is under strict medication and is, “for a strange reason”, not averse to carbs anymore. Like Singh, “you have to now live with it (both diabetes and insulin shots)” is the attitude of CPM politburo member MA Baby, too, after he was newly diagnosed with diabetes after being through a near-death experience with the virus last August. He finally lived to tell the tale, narrating last September in a national newspaper about his weeks-long coronavirus ordeal in which he said he imagined Pingala Keshini, the goddess of death portrayed in Arogya Niketan, a Bengali novel by Tarasankar Bandyopadhyay, roaming around in the ICU of Thiruvananthapuram Medical College where he spent the most crucial 12 days of his multiple weeks in hospital, fighting to come back from the brink.

Several studies have shown that Indians have a greater degree of insulin resistance and a stronger genetic predisposition to diabetes than people in most other countries of the world. Covid-induced diabetes is increasingly becoming a matter of grave concern, therefore, in the country, especially during the second wave of the pandemic. From teens to senior citizens, those who have recovered from Covid are grappling with having to go on diabetes medication in addition to concomitant fatigue in long Covid, or long post-Covid complications. In some cases, the steroids-induced high sugar levels go away soon while for many others, they are there to stay.

According to a study published by Frontiers, which carried peer-reviewed articles in its journals, India has more than 40 million diabetes cases with “a good majority across the nation not aware of the disease and comorbid factors”. It notes that the diabetes population in young adults has a tendency to become readily or more vulnerable to comorbid diabetes illnesses. One of the articles it carried on December 11th, 2020, titled ‘Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention’, says, “The young Indian population, which constitutes 65% of the country, is fast adapting to a new lifestyle, which was not known earlier. They are at a high risk of the increasing burden of diabetes and associated complications. The new evolving lifestyle is not only affecting people’s health but also mounting the monetary burden on a developing country such as India.”

From teens to senior citizens, those who have recovered from Covid-19 are grappling with having to go on diabetes medication in addition to concomitant fatigue in long Covid, or long post-Covid complications. In some cases, the steroids-induced high sugar levels go away soon while for many others, they are there to stay

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True, diabetes numbers about India do paint a gory picture: 62 million Indians suffer from the disease, a figure which grew 442 per cent from 1980 to 2014, according to The Lancet. One million Indians die every year from this disease, with the country contributing 7 per cent of all global cases, of which Type 2 diabetes is the largest chunk. Type 2, which is 20 times more common than other forms like childhood diabetes (Type 1), is caused by a variety of reasons: excess weight, a sedentary lifestyle, an unhealthy diet and even a family history.

And now, like a curse, you have the Covid-19 assault on the country’s diabetes scourge.

Pune-based diabetologist and endocrinologist Dr Anjali Bhatt weighs in on this latest challenge in the post-Covid era. “The relationship between diabetes and Covid-19 is bidirectional (acting in two directions),” she points out, explaining that it was predominantly realised that patients with diabetes have more severe symptoms as well as mortality due to Covid-19. As time progresses, we are now finding that there is a concerning surge of newly detected diabetes in patients infected with Covid-19, Bhatt observes.

She adds: “Plausible mechanisms for this surge could be many, such as unmasking of patients during the evaluation of Covid infection who have diabetes for long but are previously undiagnosed. As such it is estimated that close to 50 per cent of patients with diabetes in India are unaware that they have diabetes. Most patients get detected as the blood glucose levels are checked due to some other illness.”

According to her, an observation made by several others of her tribe, another way by which Covid-19 can cause diabetes “is (by way of) stress response to the infection and logistic/social problems faced during the illness”. She says that some antiviral and steroid medications used for management of Covid infections, too, are known to increase blood glucose level. She hastens to add that the effects of stress and medications on blood glucose levels are more pronounced and longer lasting in patients who have pre-existing impairment in glucose metabolism like pre-diabetes, obesity and strong family history of diabetes. Prediabetes is a condition when blood sugar levels are higher than normal, but not yet high enough to be called Type 2 diabetes.

While Covid-19 tends to attack beta cells, it is those who have diabetes or prediabetes that tend to suffer the most. Their conditions worsen if Covid is severe. This is certainly a major challenge for not only Covid management but also diabetes control, says Dr Joseph Babu, diabetologist

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The noted diabetologist-cum-endocrinologist adds: “Studies evaluating the possibility of direct effect of Covid-19 virus on pancreases leading to a new type of diabetes are underway but could not come to any conclusion as yet.” Bhatt herself has a lot of patients in whom Covid-19 infection has worsened previously well-controlled diabetes, as in the case of MA Baby. “After the recovery from the infection, they now find it difficult to keep their blood glucose levels within the range or need an increase in their anti-diabetes medications,” she says from her own diagnoses and quoting several papers published in peer-reviewed journals.

In their paper published by Nature titled ‘Diabetes and Covid-19: a bidirectional relationship’, Ranjit Unnikrishnan and Anoop Misra argue that the bidirectional relationship between Covid-19 and hyperglycemia (high levels of blood sugar levels) or diabetes presents a major challenge to healthcare systems as the pandemic spreads across the globe. “It is essential that individuals with pre-existing diabetes get their blood glucose levels under control at the earliest so as to minimise adverse outcomes of Covid-19, should they contract the infection. At the same time, physicians involved in the care of patients with Covid-19 should be aware of the diabetogenic potential of this virus and look for new-onset hyperglycemia and diabetes in their patients, especially those treated with corticosteroids,” they write. Diabetogenic is a qualifier for anything that produces diabetes, and steroids are often considered diabetogenic drugs.

Their report argues that the coronavirus infection has been associated with the development of new-onset hyperglycemia and diabetes, “and worsening of glycemic control in pre-existing diabetes, due to direct pancreatic damage by the virus, body’s stress response to infection (including cytokine storm) and use of diabetogenic drugs…In addition, public health measures taken to flatten the pandemic curve (such as lockdowns) can also adversely impact persons with diabetes by limiting their access to clinical care, healthy diet, and opportunities to exercise.”

To elaborate, hyperglycemia means there is too much sugar in the blood because the body lacks enough insulin, and could be a
temporary condition.

According to the National Cancer Institute, US, cytokine storm is a severe immune reaction in which the body releases too many cytokines into the blood too quickly. Cytokines are a large group of proteins secreted by specific cells of the immune system and play an important role in normal immune responses. Large amounts of them released all at once can be harmful.

THE NATURE PAPER QUOTES earlier studies from China during the initial days of the pandemic about Covid and the new-onset diabetes that require exceedingly large doses of insulin to rein in hyperglycemia. Some others state that new diabetes in Covid-19 patients could be due to a combination of cytokine storm, corticosteroid use, and direct damage of beta cells, which make insulin, essentially a hormone that stabilises the level of glucose in the blood. Beta cells are found in the pancreas within clusters of cells known as islets of Langerhans. Alpha cells of islets of Langerhans release glucagon, which does the opposite function of insulin. While insulin converts high blood sugar into glucose or energy, when the blood sugar levels are low, glucagon converts stored glucose into sugar, both working towards stabilising blood sugar levels.

The relationship between diabetes and Covid-19 is bidirectional. Plausible mechanisms for this surge could be many, such as unmasking of patients during the evaluation of Covid infection who have diabetes for long but are previously undiagnosed, says Dr Anjali Bhatt, diabetologist & endocrinologist

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The paper by Misra and Unnikrishnan points out that preliminary studies indicate diabetes might also be associated with increased risk of long-term consequences of Covid-19, such as tiredness, muscle and joint pain, breathlessness, and inability to focus, a condition that is now often called long Covid.

Kerala-based senior diabetologist Dr Joseph Babu is of the view that “exacerbation” of blood sugar levels is the most common phenomenon among Covid patients he treats these days. “While it is true that Covid-19 tends to attack beta cells, it is those who have diabetes or prediabetes that tend to suffer the most from the viral infection. Their conditions worsen if Covid is severe. This is certainly a major challenge for not only Covid management but also diabetes control,” says the 72-year-old veteran.

Babu says that it is often the case that any patient with a history of diabetes has to be administered insulin whether or not he or she was under insulin previously after they suffer from a serious ailment—including a heart attack, or even urinary and gum infections. Likewise, in the case of Covid, too, such patients need to be given insulin. But the challenge with Covid, he says, is its unpredictability. “The condition of someone whose vitals and other markers are normal would suddenly deteriorate. It is a highly unpredictable disease because we don’t have much experience of treating it, and any comorbidity, especially diabetes, worsens things,” Babu says. From his experience, cases of people getting acute diabetes due to Covid with no prior history of high blood sugar levels is less common. “Anyhow, it all depends on the severity of the viral infection,” he says.

Meanwhile, a 2021 paper says that 94 per cent of those who had the black fungus disease also suffered from diabetes, strongly indicating a link. It appeared in the Journal of Fungi, titled ‘When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis’. The researchers found that the black fungus disease, also known as mucormycosis, was most common in patients with diabetes and prediabetes. It says: “Mucormycosis (MCR) appears to be the intersection of two crises: the one of Covid-19 and the other of poorly controlled DM (diabetes mellitus) in the setting of the pandemic…most CAMCR (COVID-19-associated mucormycosis) cases are well documented…Hyperglycemia control seems important for prevention and management in MCR.”

Dr Able Lawrence, professor of clinical immunology and rheumatology at Lucknow’s Sanjay Gandhi Post Graduate Institute of Medical Sciences, offers some practical solutions to the crisis at hand. He notes, “While Covid-19 itself increases risk-worsening of diabetes or development of new diabetes, overuse and misuse of corticosteroids even in individuals without any indication for steroids is contributing to the epidemic of diabetes and mucormycosis”. He feels that sufficient attention has not been given to cheap and generic drugs such as Colchicine and Telmisartan, which, when given in the early phase of the disease, can reduce complications and mortality. “These are not championed by pharma majors who want to sell their shiny, expensive drugs with even less evidence of benefit,” he claims. He also regrets the tendency among some doctors to stop Metformin (a first-line diabetes drug) in patients with Covid-19 when there is evidence that patients taking Metformin are less likely to die. “Stopping it increases risk of poor blood sugar control in the face of steroids and consequent risk of mucormycosis,” he states, quoting studies.

MOST DOCTORS OPEN SPOKE to agree that in the long run, besides medication, diet helps, too. Open had earlier reported on how a low-calorie diet helps reverse diabetes, a proposition that had earlier largely been ruled out by scientists. That holds true whether or not the condition is Covid-induced. Dr Roy Taylor, a professor at Newcastle University, UK, and a physician with a vast expertise and experience in metabolic research on diabetes, has been involved in practical studies of diabetes cases. He had said in an interview some years ago: “It showed for the first time that the underlying defects of poor insulin production and insulin resistance in the liver could be entirely reversed to normal by a calorie-restricted diet.”

With Covid lockdowns restricting people’s movement as well as scope for exercise, the only hope for the time being is a strict diet and home workouts. Even so, with Covid showing no signs of going away anytime soon, the weight of the burden of diabetes on Indians only seems to be getting heavier.

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