A 35-year-old lady, SB, weighing all 25 kgs and a Body mass index of around 12 walked into our outpatient clinic in a remote forest fringe village in Surguja in central India. Tuberculosis, Diabetes and HIV illness were our top differentials for this level of wasting as we saw her walk into our clinic with the support of her daughter. She had diabetes for the last two years which was not responding to oral medicines. She was most distressed by her recurrent need to pass urine especially when she grew weak and dependent on other family members for such daily chores. The patient was admitted to a private hospital 2 years ago for a foot infection when she was diagnosed with diabetes which did not improve with oral medicines. She spent an inordinate sum of money on ineffective medical care in the last 2 years due to which they lost the only asset, their agricultural land. Her difficulty in walking was due to largely absent muscle mass and excessive tingling, pain and numbness in her legs present for months now. Her vision was also reduced to 6/60 in both eyes and funduscopic examination showed changes of diabetic retinopathy. The waist-to-hip ratio was 0.9 with a waist circumference of 61 cm and hip circumference of 68 cm.
SB belonged to one of the many rural families living with her four children and in-laws. Her husband had already died at home due to tuberculosis, largely uncared for by the impoverished health system of the countryside with the family losing out on him, scarce resources and their collective hope.
SB had been having predominantly milled white rice procured from the public distribution system (PDS) which formed over 90% of the calories in her frugal diet. The remaining part would usually comprise seasonal vegetables, potatoes and/or some other local tubers. Pulses were available once or twice a week and some fish once in 15 days. As our patient’s father-in-law told us about food availability,” In my father’s time, harvest of one season used to last two years or more. Now, when we grow anything on the same land, we incur losses and cannot even secure food grains for our family and are dependent on the rations from the PDS.” All three daughters dropped out of school. The family had been progressively devoured by the rising medical costs, the declining number of earning members and nose-diving financial and social resources.
Her blood sugar was 570 mg/dl and needed to be started on Insulin besides oral. The patient never had ketoacidosis. Her old photographs from before her illness showed her to be someone with a small built without abdominal obesity. It wasn’t of much use to do expensive scarcely available diagnostic tests to find out her C-peptide levels and Insulin levels but given the course of illness, body size and blood sugar levels, Insulin supplementation was critical.
Social theory
The phenotype of lean diabetes, with severe adult malnutrition has been reported patchily from central India and Ethiopia but finds little research, and academic interest. The existence of such a form of diabetes has been invisibilized as it doesn’t find mention in the World Health Organization’s classification of diabetes. The care of such a patient often requires Insulin, specialised knowledge, refrigerator, management of complications and changes in the diet.
The predisposition of South Asian population to early diabetes and complications is well documented. Its roots may be traced to its colonial past of the population suffering from famines, and food deprivation for prolonged periods possibly leading to epigenetic changes thereby affecting carbohydrate metabolism adversely.
Furthermore, an effort to achieve food sovereignty in post-independent India led to Green Revolution which promoted policies and practices to grow resource intensive food grains focusing only on carbohydrate rich rice and wheat to the detriment of millets, pulses and oilseeds. These millets, and pulses were grown as per local ecology and agricultural practices accumulated over centuries of lived experience.
The neoliberal economic policies since the 1990s have potentially worsened the situation whereby markets have worked against the interests of small and marginal farmers in the agriculture sector. It has led to a progressive decline in their socio-economic conditions whereby their purchasing power has reduced and market-driven rise in food prices make dietary diversity unaffordable. Rising healthcare costs due to increasingly profit-driven healthcare aggravates their precarious situation. Her lean diabetes points to many structural problems like poverty, profit-driven healthcare costs, commercialization of food systems, the disappearance of local sustainable food diversity.
– Chetanya Malik, Shilpa Khanna, Dhiraj Deshmukh, Dhanwantri Porte, Harendra Sijwali, Yogesh Jain