Malnourished but diabetic: An atypical form of ‘the rich man’s disease’ is spreading among Chhattisgarh’s tribals

This story has been updated

Nirasiya Bai’s three sons are used to their mother fainting every other week. Over a decade ago, when the problem was still new, panic would grip the household every time she would get dizzy or start slurring. But practice over the years has trained her children to better gauge the warning signs. Small pieces of shakkar (brown sugar) are now kept handy and placed swiftly under her tongue every time she is on the verge of collapsing. In March alone, three such incidents have occurred.

The 52-year-old resident of Shivtarai village in Chattisgarh’s Bilaspur district is a diabetes patient, diagnosed with the disorder in 2010. At the time, her fasting blood sugar (FBS) level (on an empty stomach) and postprandial blood sugar (PP2BS) level (two hours after eating) were 297 miligram per decilitre (mg / Dl) and 361 mg / Dl respectively, well beyond the acceptable range. Nearly every other family in the village houses a diabetes patient like Nirasiya. ‘Sugar ki bimari’, what diabetes is colloquially referred to as, no longer has a unique ring to it.

The rise of non-communicable diseases (NCD), including diabetes, has been recognised as a problem area by the Indian government. In a Lok Sabha answer from December 2021, the Union health ministry illustrated how the proportion of deaths due to NCDs rose from 37 per cent in 1990 to 61 per cent in 2016, indicating an “epidemiological transition with a shift in disease burden to NCDs”.

What often remains amiss from this discourse is the penetration of such NCDs, typically argued to be lifestyle disorders of the affluent, in India’s tribal population. Case in point being Nirasiya Bai, belonging to the Gond community, a scheduled tribe recognised by the Union Ministry of Tribal Affairs.

In urban areas, diabetes mellitus is often associated with being overweight or obese. With a body mass index (BMI) of 17.1 kilogram / square metre — below what is considered to be the healthy range of 18.5-24.9 kg / m2 — Nirasiya does not fall in either of these categories. She is frail, weak and lacks the energy she had prior to her diabetes diagnosis, which impedes her from carrying out the physical labour agriculture demands.

Dr Gajanan Phulke, associated with Jan Swasthya Sahyog (JSS), a public health initiative based in rural Chhattisgarh and working at their community health centre in Bilaspur’s Ganiyari village, typically sees four-five different phenotypes of diabetes. Some patients have very high blood sugar levels which can be controlled easily with oral medication, some have low blood sugar levels and require insulin, there are also patients of fibrocalcific pancreatic diabetes and a small proportion of obese patients, he said.

But a common phenotype he encounters is lean diabetes — a term first coined in 1965 by researchers from Odisha who described it as the “dual stress of intermittent starvation and overload on carbohydrate metabolism may be related to the atypical patterns of clinical diabetes”. This is the subset patients like Nirasiya belong to.

In a 2017 editorial for the BMJ Journal, Dr Yogesh Jain, paediatrician and founding member of JSS, illustrated how Type 1 diabetes patients make up only a minority of the people he treats.

The others are typically diagnosed with diabetes around 50 years of age and with identified long-term consequences such as retinopathy, nephropathy, neuropathy, foot infections and cardiovascular diseases.

Only some of them belong to the Type 2 category, with an average BMI greater than 21-22, while several are living with the lean diabetes phenotype and typically have a BMI less than 20.

Research from Cuttack and Ethiopia on lean diabetes has revealed a median adult BMI of 20.6 kg / m2 with associated financial impoverishment, childhood malnutrition, younger age of onset, severe hyperglycemia needing insulin and absence of ketosis upon withdrawal of insulin. 

Here, Dr Nihal Thomas — head of the department of endocrinology, diabetes and metabolism at Christian Medical College Vellore — adds a caveat:

The Ethiopian study probably has a mixture of type 2 and lean diabetes group since the median BMI is 20.6 kg /m2, a range which would cover both these groups.

He further outlines the distinct differences between the two beyond the BMI. “In Type 2 diabetes, the pancreas doesn't have a profound deficiency of insulin, the body is resistant to insulin and the liver has an abnormal output of glucose, particularly at night. The lean condition doesn't present with any of these characteristics,” he explained.

Nirasiya’s gait has altered since her diabetes diagnosis. With an arm constantly on her waist, her left foot takes most of her body weight, while she experiences a tingling sensation and pain in the right. She can no longer walk long distances without slippers.

These are early signs of what is known as diabetic neuropathy, a type of nerve damage which, if left unattended, can lead to ulcers, sores and even amputation.

While her blood sugar levels were under control when this reporter met with her, Nirasiya has been irregular with her treatment. Since her diagnosis, she has been admitted to the JSS community health centre (CHC) in Ganiyari village at least 10 times where she spent, on an average, four-five days per visit. “She only seeks treatment when she is extremely unwell, is about to collapse and has lost a dangerous amount of weight,” Janaki, a senior health worker with JSS told Down To Earth (DTE).

Barring adherence to treatment, an absent set of guidelines to manage lean diabetes only further compounds the problem. Lean diabetes was officially recognised by the World Health Organization (WHO) in 1985 as “malnutrition-related-diabetes mellitus” for those with a BMI lower than 19 kg / m2; the classification was later withdrawn in 1999 on grounds of insufficient substantial evidence.

As per the current national guidelines, calorie restriction and increased physical activity is recommended for patients of diabetes mellitus. But for people like Nirasiya, that’s nearly a death sentence.

Reliance on rice

She consumes eight tablets every day — one multivitamin in the morning, two medicines for diabetes twice a day and one for hyperthyroidism thrice a day. This is accompanied by two insulin injections per day, 20 units in the morning and 14 units in the evening.

The diversity in the drugs she currently takes to manage her NCDs used to belong with her diet about two decades ago. An overreliance on rice — which many have been described as an unintended consequence of the Green Revolution and the introduction of the Public Distribution System (PDS) — which triggered a shift away from the traditional millets like jowar (sorghum), bajra (pearl millet) and makka (maize) and naturally occurring fruits and vegetables in the forest. This is a key reason behind the rise of NCDs in the tribal population.

Between the second (1988-1990) and third (2008-2009) rounds of the National Nutrition Monitoring Bureau survey among India's tribal population, the intake of cereals and millets decreased by 50 g / CU / day.

The average daily intake o f proteins and Vitamin A saw a similar trend; down by about 3 g / CU / day and 117 µg / CU / day respectively. Energy intake also came down, decreasing by about 150 kcal / CU / day.

This monotonous diet, coupled with a lifestyle shift characterised by little physical activity — augmented in part by the introduction of machinery thereby reducing agricultural labour — has made the tribal population more vulnerable to NCDs like diabetes.

Between April 2022 and February 2023, Kota CHC — the block under which Shivtarai village falls — diagnosed 922 new patients of diabetes, data shared by the district’s health office showed. “Disaggregated data is not available but the Kota block is home to a majority of the district’s tribal population,” Dr Anil Shrivastava, chief medical health officer of Bilaspur district, said. Here, diabetes is the second most common NCD, succeeded by hypertension which saw 1,063 new cases in the same time period.

In 2013, the Chhattisgarh government established NCD clinics in all five CHCs in the district which has a four-member strong staff — a medical officer, counsellor, lab technician and nurse. The 41 primary health centres also have a dedicated NCD personnel who reports to the respective CHC.

“Around the same time, the government also mandated NCD screening for all pregnant women above 30 years of age,” Shrivastava said. However, he admits that while they are able to screen for diabetes patients, the follow-up ratio remains poor.

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