Dr Usha Sriram, leading endocrinologist in Chennai, has a long and illustrious career in Diabetes, with over a decade of it practising in Chicago. Here she speaks to Deepti Sharma about healthcare in the US, the thrifty gene hypothesis, Diabetes in women and her unique initiative – Women in Endocrinology & Diabetes (WENDI), among other things…
The health care system in the US is very different from that in India. For starters, most people carry health insurance and medical expenses out of their own pocket may be 10-20%; while in India, medical expenses come mostly out of your own pocket. This may deter people from seeking help in a timely manner, particularly for preventive health. This is an area I would like to see some help from the government and employers. I do like the fact that the US system is highly regulated and there is accountability and most people follow a system or guidelines. The professional associations are powerful and strong and do a lot for awareness and advocacy. Medical record keeping, credentialing, continuing medical education and recertification are key to raising the level of excellence.
One of the most important aspects of being a good and ethical physician is being able to communicate well and be a good listener. I have been taught by some extraordinary people both in India and the US, who have been good communicators and it is this quality that I have tried to adapt as much as possible.
Diabetes in the young
Type 2 diabetes in the young is on the rise and the incidence in children under 15 is unacceptably high. The reasons are pretty much the same as those in the adults, but the fact they will have to live with the problem for another 70-80 years, sets them up for complications and may actually compromise their longevity.
Children tend to be more sedentary now, with less outdoor activities and more TV watching, internet and video games. Children are also under enormous stress, having to excel academically to be able to get into good colleges. Above average is no longer enough. Need for outstanding performance in exams allows them very little time for relaxing and concentrating on physical fitness.
Parents should set an example by eating healthy, being physically active and providing an environment that enables to follow a healthy lifestyle. Parents should also encourage, appreciate and reward healthy behaviour. Extended family members should also aid the efforts. Taking children to parks, playgrounds, field trips and doing activities like cycling, swimming, etc will make physical fitness fun and enjoyable.
Health issues in a changing world
The reason South Asian populations are more susceptible to Diabetes is possibly a combination of genetics and environment. Considering the rapid rise in diabetes prevalence over a short period of time, it is most likely lifestyle related factors that are playing a bigger role. South Asians as a race are meant to be small. While younger generations have become taller, it is the weight increase in childhood, adolescence, early and late adulthood that has set us up for bigger problems like diabetes and heart disease.
We use more gadgets, vehicles and watch more TV than ever before. Our lives are more stressful and a greater dependence on fast food, quick meals, less sleep and a more "hurried life". While this has contributed to obesity and the metabolic syndrome, there is a large segment of the population that is grappling with malnutrition of a different kind: undernutrition. Many rural communities and some urban areas have lean people with diabetes. Women from these areas may give birth to small sized babies. Babies born small may have a higher risk of diabetes and heart disease as adults.
Thrifty genes hypothesis
I do believe in the thrifty gene hypothesis. It was in 1962 that James Neel coined the term "thrifty genotype" where an individual is able to modify insulin release and glucose storage to adapt to an environment of feast and famine. Modern day continuous "feasting" is deleterious to the individual with the thrifty gene.
Evolutionary theories may not entirely support and validate the theory but epidemiologic data have confirmed the escalation of obesity and diabetes in populations with rapidly changing socio economic conditions. In a 1998 review he described an expanded form of the original hypothesis, where he felt that a complex theory of metabolic disorders may be due to intermittent starvation. He hypothesised that physiological systems adapted for an older environment are being pushed beyond their limits by environmental changes and that has likely led to these problems.
Prevention in GDM babies
Research has shown that children whose mothers had GDM while bearing them are at increased risk for Diabetes as adults. This is a great opportunity for prevention of diabetes. Women of child bearing age are increasingly been diagnosed with pre-diabetes, metabolic syndrome and even frank type 2 diabetes. They also tend to be older and heavier at the start of their pregnancy. Polycystic ovary syndrome is an additional risk factor for gestational diabetes. Women are at very high risk for diabetes during diabetes for all the above reasons and very importantly family history of diabetes. Children born to mothers with gestational diabetes are at increased risk for type 2 diabetes, visceral adiposity and obesity. It is therefore critical to educate women in colleges and work places regarding gestational diabetes and steps they can take to prevent it. Also, obstetricians need to be sensitised regarding early screening, aggressive management and most importantly post partum follow-up.
WENDI is a coalition of Women in ENdocrinology and DIabetes. Women have unique needs and special strengths. Women, by nature are gentle, nurturing and can multitask. Women are gifted in being able to share information. It is unfortunate that even in 2012, many women are undereducated, under nourished, and undervalued as human beings. We as a group would like to take up the cause of these women and women with Diabetes and hormone related health issues and empower through knowledge. The WENDI team has extraordinarily strong advocates for women's health and we felt that the collective strength of this group is a force to reckon with and the group can do wonders for women from all walks of life, of all ages, socioeconomic status, education and regions of India.
Breaking the inertia
Physicians have an inherent trait, what is presently labelled as clinical inertia that delays escalation of therapy to optimise HbA1c. What causes this inertia is still an unsolved mystery. Maybe we want to give patients more time to pursue healthier lifestyle or maybe we worry about multiple medications or high doses. It usually results in persistently high HbA1c over long periods of time. We need counselling of patients about eating, activity, and adherence to therapy, self monitoring and surveillance for complications.