‘We Could Reverse Type 2 Diabetes In India In The Next 5 Years’

Mumbai: Aseem Malhotra PhD, is a man with a mission--to drastically reduce the amount of carbohydrates we eat. He claims by cutting back on sugary and starchy foods, we will not only benefit from feeling healthier and losing weight but lessen our chances of developing type 2 diabetes. Even those currently enduring insulin injections and the constant monitoring of blood sugar levels that are part and parcel of living with diabetes, have the ability to ‘reverse’ their condition and eradicate the disease in its entirety.

“As a frontline doctor who qualified over 17 years ago, I have witnessed the increasing stress placed on health systems and am well aware of the factors behind it. More and more people are living with chronic disease and it’s diet and lifestyle which is causing this,” Malhotra, 40, told IndiaSpend, “I decided to research what went wrong and how we got to this point and I realised that public enemy number one is sugar.”

Malhotra is a consultant cardiologist and recently the best-selling co-author of The Pioppi Diet, a low-carbohydrate, Mediterranean-inspired meal plan. He is one of the most influential and well-known health campaigners in the UK and writes regularly in academic medical journals and international media about his campaign against sugar and highlighting the harms of too much medicine.

Named alongside anti-obesity activists such as Michael Bloomberg and Michelle Obama, Malhotra has been featured in The New York Times for his documentary film "The Big Fat Fix", which premiered in the British parliament. In 2015, he became the youngest member of the board of trustees of the London-based health think tank, The King's Fund.

India currently represents 49% of the world’s diabetes burden, with an estimated 72 million cases in 2017--a figure expected to almost double to 134 million by 2025.

Known as a ‘lifestyle disease’, and simply referred to as ‘sugar’ in common parlance in India (e.g. “she has to manage her sugar carefully”), diabetes--a condition caused by the body’s inability to regulate insulin-levels, which can lead to tissue damage and organ failure--is linked to inactivity and the excessive consumption of high-calorie foods: Both changes that accompany economic development.

Malhotra believes there is a severe lack of understanding on how food affects health. For this reason he became a public health advocate, in order to bring about policies that help people make healthier choices. The answer, it seems, lies in a small town in Southern Italy where life expectancy is 10 years higher than the average Tour de France cyclist’s.

“People usually associate Italy with high starch food, but in fact pasta is only eaten as a small starter, pizza once a fortnight and very little sugar--once a week on Sundays. Compare this to India where it’s more like three times a day.”

The good news though according to Malhotra, is that lifestyle changes can have a very quick impact on health.

“Just getting the basics right can be so beneficial. For example, it’s the modern starches and sugars causing excess consumption that is the problem. Therefore we removed that from the plan and focused on the components of the Pioppi diet which are likely to have provided benefit such as extra virgin olive oil and a handful of nuts”.

In an e-mail interview, Malhotra spoke about the health risks associated with modern lifestyles, why globally we need to raise awareness about the impact of food on health and what can be done to curb the menace of lifestyle diseases. Edited excerpts:

Heart disease and diabetes are seen as ‘lifestyle diseases’, associated with high consumption of sugar and carbohydrates and their rising prevalence linked to an increase in gross domestic product (GDP). It seems as Indian’s get richer, so do their diets--what do you think can be done to stop a looming crisis in its tracks?

This is ultimately a false economy. A report by investment bank Morgan Stanley in 2015 revealed that countries that fail to curb their high population sugar consumption will face close to 0% economic growth by 2035. An unhealthy population plagued by diet-related disease is an economically unproductive one.

A public awareness education campaign, similar to what has been done with tobacco in India, would help. We need to warn people about the dangers of excess sugar and starch consumption on their metabolic health, especially for those that have, or are at risk of developing, type 2 diabetes and heart disease.

On a government level, regulatory action that specifically addresses the availability, affordability and acceptability of junk food will have a much greater impact at the population level. This requires raising the price of junk food and implementing bans on junk food advertising for example. A health warning being placed on sugary drinks and fruit juice would be a good start.

However, we also know that cases of type 2 diabetes are rising amongst the urban poor in India. What do you think are the main drivers behind this phenomenon and the solutions to tackling it?

It’s the fact that the traditional diet is being replaced by ultra-processed foods, namely sugary drinks and processed carbohydrate snacks that are cheap but also nutritionally poor, which are driving it. The solutions are the same as I mentioned above.

The annual cost to treat diabetes in India is estimated to be $420 (Rs 27,400) per capita, which if constant would reach an annual $30 billion (Rs 1.95 lakh crore)--over six times the 2018 health budget--by 2025. What steps can policymakers take to manage this expenditure? Can you envisage a move away from prescription medicines to alternative forms of treatment?

This is a truly staggering cost burden. The current management of type 2 diabetes, which makes up 90% of diabetics and is lifestyle-related (as opposed to type 1 diabetes that is not), is completely upside down.

Type 2 diabetes is a condition that is predominantly related to an intolerance of the body to metabolise carbohydrates and is treated with drugs to control blood glucose. This neither addresses the root cause nor has any impact on heart attack death rates (the most feared complication of the condition).

Billions of rupees go into drug treatment alone that is by and large ineffective for patient outcomes, but also comes with side effects. In the United States for example, it is estimated that there are 100,000 visits to the Emergency Room as a direct result of diabetes medication side effects, and I suspect in India those cases will be far higher.

There is good news though, and I’ve seen this with many of my own patients. Changing their diet, specifically cutting starchy carbohydrates and sugar, has not only allowed them to reduce the need for medication within a few weeks, but many actually “reverse” or send their type 2 diabetes into remission.

In April 2018, the Ministry of Health and Family Welfare (MOHFW) tweeted a controversial infographic that seemed to indicate a healthy diet consists solely of vegetarian foods, no eggs, meat products and certain sources of healthy fats. What does this tell us about the interaction between policymakers and healthcare professionals in India? How can citizens be expected to make informed decisions given the confusing mix of information available?

Firstly, to understand how such a gross error of dietary advice has been committed by the MOHFW we must understand that nutritional science, like medicine is not perfect and is constantly evolving. In fact, the father of the evidence-based medicine movement, the late Professor David Sackett, said “half of what you learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation. The trouble is no one can tell you which half so you have to learn to learn on your own”.

Some of this advice from the MOHFW will be based upon an outdated fear of saturated fat causing heart disease by raising cholesterol. This has now been completely debunked in the British Journal of Sports Medicine in highest impact BMJ paper published last year that I co-authored with two eminent international cardiologists.

Also as regards to eggs, this will be because of a misunderstanding that cholesterol in the egg yolk raises blood cholesterol. This is also completely false. In fact in 2015 the US dietary guidelines removed cholesterol as a nutrient of concern.

Finally, we need to ask questions about the conflicts of interest found within the panel that made up this advice. It may be that most were vegetarian because of religious reasons. While this must be respected (my own mother is vegetarian), this should not be conflated with unscientific claims about meat. In fact, eggs and lamb are two of the most nutritious foods one can eat and there is absolutely no harm from their consumption. On the other hand, vegetarian foods such as bread and rice when consumed in excess and especially when combined with sugar, is not only nutritionally devoid but a big contributor to metabolic disease.

Our greatest weapon in the fight against such health misinformation is transparency. We must make sure groups who form such advice are fully accountable--this includes ensuring they are systematic with the evidence, but also that they are free from any conflicts of interest.

The government has pledged to provide free universal healthcare, dubbed ‘Modicare’, to half a billion people by 2020. What lessons can India learn from the way the UK’s National Health System (NHS) has been managing the UK’s heart disease, diabetes and obesity crises?

This is a great initiative but there are important lessons to be learnt from the UK. India must make sure that their model of care is not an illness model--where the system focuses on diagnosing and treating, and not investing in prevention and lifestyle diseases.

The NHS needs to change from managing a chronic disease model (with largely ineffective drugs for the overwhelming majority taking them) to one of prevention through lifestyle. We also mustn’t forget that lifestyle changes improve quality of life very quickly, which modern medicine for treating conditions like heart disease, high blood pressure and type 2 diabetes cannot do.

You have said before that commercial interests in medicine have led to the demonisation of fat and spread misinformation that has contributed to a rapid increase in type 2 diabetes and related illnesses in recent decades. How can governments and related stakeholders improve transparency in medical research and the healthcare industry as a whole?

When selected and commercially biased information is used to determine health advice it will lead to poor outcomes for the population. This is at the root of the type 2 diabetes crisis. We have to collectively acknowledge that the food industry have a fiduciary obligation to make a profit for their shareholders, not look after your health.

The same applies to the pharmaceutical industry. The real scandal is that those with a responsibility to patients and scientific integrity, namely academic institutions, doctors and medical journals, collude with industry for financial gain.

They have to be more transparent when they review scientific literature, ensuring recommendations are based using the totality of data, not cherry picked selected data that suits industry interests. Additionally, the very panels making the recommendations cannot have conflicts of interests, either personal, financial or institutional.

You have recently developed the ‘Pioppi’ diet--based on the eating habits and lifestyle of the residents of Pioppi (a small town in southern Italy where life expectancy is around 90 years)--and shown its ability to improve heart health and reverse type 2 diabetes. Can you tell us more about its main principles and if they can be applied to diets across India?

To put this in to context, globally poor diet is now responsible for more disease and death than physical inactivity, smoking and alcohol combined. The principles of the diet and lifestyle plan of the Pioppi Diet are based on the root cause of heart disease and type 2 diabetes as pointed out in our BJSM editorial--insulin resistance and chronic inflammation.

The most impactful way to tackle these risk factors are through simple lifestyle changes that we highlight in the book. A diet that is free from ultra-processed food and low in starchy carbohydrates, engaging in moderate activity every day, something simple such as a 30-minute brisk walk, reducing stress through meditation and even understanding the importance of social interaction.

Social isolation and loneliness is a big risk factor for premature death. There’s no market for these messages and that’s why most people don’t realise how powerful they are. But these are the measures that will be most effective to manage type 2 diabetes, high blood pressure, heart disease and also significantly to reduce the risk of developing cancer and dementia.

Unlike medications, which have a marginal effect at best for a small minority of people that take them, they come without side effects and improve one’s quality of life. If we strived to achieve this across the population, we could reverse type 2 diabetes in India in the next 5 years.

In May 2018, the Mayor of London laid out proposals to ban junk food advertising on the transport network and there have been moves to reduce the number of adverts shown to children on Indian television. To what extent do you think this will have a real impact in preventing or reducing cases of obesity? Are there any other immediate actions that governments can take which would be more effective?

I personally know the Mayor of London, Sadiq Khan, and he’s been very supportive of my work. His proposals are absolutely correct. When the Academy of Medical Royal Colleges, which represents every doctor in the UK, gave a 10-point plan in 2012 for measure to curb obesity, banning junk food advertising was one of the proposals. I was part of the steering committee and six out of 10 recommendations specifically targeted the food environment. We were the first international medical body to call for a tax on sugary drinks which was implemented a few months ago. Such a move would certainly have an impact in India where consumption of sugary drinks is a major driver of chronic disease and tooth decay.

We also recommended compulsory education and training for healthcare professionals in the impact of nutrition on health. The public would expect doctors to understand, and be trained to understand, how different food patterns affect chronic disease. Yet I don’t remember receiving a single lecture on this in medical school. This must change.

Overturning dietary guidelines that incorrectly demonises fat, and in particular saturated fat, from foods like butter, ghee and cheese would also help. The Mayor of Manchester, Andy Burnham, who was the former secretary of state for health, endorsed the Pioppi Diet saying it had the potential to make millions of lives healthier and happier.

Only last week and with Andy’s support, Tameside (a Manchester borough) is being encouraged to follow the Pioppi Diet for 70 days to mark the 70-year anniversary of the NHS after the local hospital became the first in the country to ban the sale of sugary foods and drink from the hospital canteen. For me, this move is particularly special as I grew up in Tameside and it was my motion in 2013 calling for a ban of the sale of junk food in hospitals that made it part of policy of the British Medical Association.

(Sanghera, a graduate of King’s College London, is an intern with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

__________________________________________________________________

“Liked this story? Indiaspend.org is a non-profit, and we depend on readers like you to drive our public-interest journalism efforts. Donate Rs 500; Rs 1,000, Rs 2,000.”

Mumbai: Aseem Malhotra PhD, is a man with a mission--to drastically reduce the amount of carbohydrates we eat. He claims by cutting back on sugary and starchy foods, we will not only benefit from feeling healthier and losing weight but lessen our chances of developing type 2 diabetes. Even those currently enduring insulin injections and the constant monitoring of blood sugar levels that are part and parcel of living with diabetes, have the ability to ‘reverse’ their condition and eradicate the disease in its entirety.

“As a frontline doctor who qualified over 17 years ago, I have witnessed the increasing stress placed on health systems and am well aware of the factors behind it. More and more people are living with chronic disease and it’s diet and lifestyle which is causing this,” Malhotra, 40, told IndiaSpend, “I decided to research what went wrong and how we got to this point and I realised that public enemy number one is sugar.”

Malhotra is a consultant cardiologist and recently the best-selling co-author of The Pioppi Diet, a low-carbohydrate, Mediterranean-inspired meal plan. He is one of the most influential and well-known health campaigners in the UK and writes regularly in academic medical journals and international media about his campaign against sugar and highlighting the harms of too much medicine.

Named alongside anti-obesity activists such as Michael Bloomberg and Michelle Obama, Malhotra has been featured in The New York Times for his documentary film "The Big Fat Fix", which premiered in the British parliament. In 2015, he became the youngest member of the board of trustees of the London-based health think tank, The King's Fund.

India currently represents 49% of the world’s diabetes burden, with an estimated 72 million cases in 2017--a figure expected to almost double to 134 million by 2025.

Known as a ‘lifestyle disease’, and simply referred to as ‘sugar’ in common parlance in India (e.g. “she has to manage her sugar carefully”), diabetes--a condition caused by the body’s inability to regulate insulin-levels, which can lead to tissue damage and organ failure--is linked to inactivity and the excessive consumption of high-calorie foods: Both changes that accompany economic development.

Malhotra believes there is a severe lack of understanding on how food affects health. For this reason he became a public health advocate, in order to bring about policies that help people make healthier choices. The answer, it seems, lies in a small town in Southern Italy where life expectancy is 10 years higher than the average Tour de France cyclist’s.

“People usually associate Italy with high starch food, but in fact pasta is only eaten as a small starter, pizza once a fortnight and very little sugar--once a week on Sundays. Compare this to India where it’s more like three times a day.”

The good news though according to Malhotra, is that lifestyle changes can have a very quick impact on health.

“Just getting the basics right can be so beneficial. For example, it’s the modern starches and sugars causing excess consumption that is the problem. Therefore we removed that from the plan and focused on the components of the Pioppi diet which are likely to have provided benefit such as extra virgin olive oil and a handful of nuts”.

In an e-mail interview, Malhotra spoke about the health risks associated with modern lifestyles, why globally we need to raise awareness about the impact of food on health and what can be done to curb the menace of lifestyle diseases. Edited excerpts:

Heart disease and diabetes are seen as ‘lifestyle diseases’, associated with high consumption of sugar and carbohydrates and their rising prevalence linked to an increase in gross domestic product (GDP). It seems as Indian’s get richer, so do their diets--what do you think can be done to stop a looming crisis in its tracks?

This is ultimately a false economy. A report by investment bank Morgan Stanley in 2015 revealed that countries that fail to curb their high population sugar consumption will face close to 0% economic growth by 2035. An unhealthy population plagued by diet-related disease is an economically unproductive one.

A public awareness education campaign, similar to what has been done with tobacco in India, would help. We need to warn people about the dangers of excess sugar and starch consumption on their metabolic health, especially for those that have, or are at risk of developing, type 2 diabetes and heart disease.

On a government level, regulatory action that specifically addresses the availability, affordability and acceptability of junk food will have a much greater impact at the population level. This requires raising the price of junk food and implementing bans on junk food advertising for example. A health warning being placed on sugary drinks and fruit juice would be a good start.

However, we also know that cases of type 2 diabetes are rising amongst the urban poor in India. What do you think are the main drivers behind this phenomenon and the solutions to tackling it?

It’s the fact that the traditional diet is being replaced by ultra-processed foods, namely sugary drinks and processed carbohydrate snacks that are cheap but also nutritionally poor, which are driving it. The solutions are the same as I mentioned above.

The annual cost to treat diabetes in India is estimated to be $420 (Rs 27,400) per capita, which if constant would reach an annual $30 billion (Rs 1.95 lakh crore)--over six times the 2018 health budget--by 2025. What steps can policymakers take to manage this expenditure? Can you envisage a move away from prescription medicines to alternative forms of treatment?

This is a truly staggering cost burden. The current management of type 2 diabetes, which makes up 90% of diabetics and is lifestyle-related (as opposed to type 1 diabetes that is not), is completely upside down.

Type 2 diabetes is a condition that is predominantly related to an intolerance of the body to metabolise carbohydrates and is treated with drugs to control blood glucose. This neither addresses the root cause nor has any impact on heart attack death rates (the most feared complication of the condition).

Billions of rupees go into drug treatment alone that is by and large ineffective for patient outcomes, but also comes with side effects. In the United States for example, it is estimated that there are 100,000 visits to the Emergency Room as a direct result of diabetes medication side effects, and I suspect in India those cases will be far higher.

There is good news though, and I’ve seen this with many of my own patients. Changing their diet, specifically cutting starchy carbohydrates and sugar, has not only allowed them to reduce the need for medication within a few weeks, but many actually “reverse” or send their type 2 diabetes into remission.

In April 2018, the Ministry of Health and Family Welfare (MOHFW) tweeted a controversial infographic that seemed to indicate a healthy diet consists solely of vegetarian foods, no eggs, meat products and certain sources of healthy fats. What does this tell us about the interaction between policymakers and healthcare professionals in India? How can citizens be expected to make informed decisions given the confusing mix of information available?

Firstly, to understand how such a gross error of dietary advice has been committed by the MOHFW we must understand that nutritional science, like medicine is not perfect and is constantly evolving. In fact, the father of the evidence-based medicine movement, the late Professor David Sackett, said “half of what you learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation. The trouble is no one can tell you which half so you have to learn to learn on your own”.

Some of this advice from the MOHFW will be based upon an outdated fear of saturated fat causing heart disease by raising cholesterol. This has now been completely debunked in the British Journal of Sports Medicine in highest impact BMJ paper published last year that I co-authored with two eminent international cardiologists.

Also as regards to eggs, this will be because of a misunderstanding that cholesterol in the egg yolk raises blood cholesterol. This is also completely false. In fact in 2015 the US dietary guidelines removed cholesterol as a nutrient of concern.

Finally, we need to ask questions about the conflicts of interest found within the panel that made up this advice. It may be that most were vegetarian because of religious reasons. While this must be respected (my own mother is vegetarian), this should not be conflated with unscientific claims about meat. In fact, eggs and lamb are two of the most nutritious foods one can eat and there is absolutely no harm from their consumption. On the other hand, vegetarian foods such as bread and rice when consumed in excess and especially when combined with sugar, is not only nutritionally devoid but a big contributor to metabolic disease.

Our greatest weapon in the fight against such health misinformation is transparency. We must make sure groups who form such advice are fully accountable--this includes ensuring they are systematic with the evidence, but also that they are free from any conflicts of interest.

The government has pledged to provide free universal healthcare, dubbed ‘Modicare’, to half a billion people by 2020. What lessons can India learn from the way the UK’s National Health System (NHS) has been managing the UK’s heart disease, diabetes and obesity crises?

This is a great initiative but there are important lessons to be learnt from the UK. India must make sure that their model of care is not an illness model--where the system focuses on diagnosing and treating, and not investing in prevention and lifestyle diseases.

The NHS needs to change from managing a chronic disease model (with largely ineffective drugs for the overwhelming majority taking them) to one of prevention through lifestyle. We also mustn’t forget that lifestyle changes improve quality of life very quickly, which modern medicine for treating conditions like heart disease, high blood pressure and type 2 diabetes cannot do.

You have said before that commercial interests in medicine have led to the demonisation of fat and spread misinformation that has contributed to a rapid increase in type 2 diabetes and related illnesses in recent decades. How can governments and related stakeholders improve transparency in medical research and the healthcare industry as a whole?

When selected and commercially biased information is used to determine health advice it will lead to poor outcomes for the population. This is at the root of the type 2 diabetes crisis. We have to collectively acknowledge that the food industry have a fiduciary obligation to make a profit for their shareholders, not look after your health.

The same applies to the pharmaceutical industry. The real scandal is that those with a responsibility to patients and scientific integrity, namely academic institutions, doctors and medical journals, collude with industry for financial gain.

They have to be more transparent when they review scientific literature, ensuring recommendations are based using the totality of data, not cherry picked selected data that suits industry interests. Additionally, the very panels making the recommendations cannot have conflicts of interests, either personal, financial or institutional.

You have recently developed the ‘Pioppi’ diet--based on the eating habits and lifestyle of the residents of Pioppi (a small town in southern Italy where life expectancy is around 90 years)--and shown its ability to improve heart health and reverse type 2 diabetes. Can you tell us more about its main principles and if they can be applied to diets across India?

To put this in to context, globally poor diet is now responsible for more disease and death than physical inactivity, smoking and alcohol combined. The principles of the diet and lifestyle plan of the Pioppi Diet are based on the root cause of heart disease and type 2 diabetes as pointed out in our BJSM editorial--insulin resistance and chronic inflammation.

The most impactful way to tackle these risk factors are through simple lifestyle changes that we highlight in the book. A diet that is free from ultra-processed food and low in starchy carbohydrates, engaging in moderate activity every day, something simple such as a 30-minute brisk walk, reducing stress through meditation and even understanding the importance of social interaction.

Social isolation and loneliness is a big risk factor for premature death. There’s no market for these messages and that’s why most people don’t realise how powerful they are. But these are the measures that will be most effective to manage type 2 diabetes, high blood pressure, heart disease and also significantly to reduce the risk of developing cancer and dementia.

Unlike medications, which have a marginal effect at best for a small minority of people that take them, they come without side effects and improve one’s quality of life. If we strived to achieve this across the population, we could reverse type 2 diabetes in India in the next 5 years.

In May 2018, the Mayor of London laid out proposals to ban junk food advertising on the transport network and there have been moves to reduce the number of adverts shown to children on Indian television. To what extent do you think this will have a real impact in preventing or reducing cases of obesity? Are there any other immediate actions that governments can take which would be more effective?

I personally know the Mayor of London, Sadiq Khan, and he’s been very supportive of my work. His proposals are absolutely correct. When the Academy of Medical Royal Colleges, which represents every doctor in the UK, gave a 10-point plan in 2012 for measure to curb obesity, banning junk food advertising was one of the proposals. I was part of the steering committee and six out of 10 recommendations specifically targeted the food environment. We were the first international medical body to call for a tax on sugary drinks which was implemented a few months ago. Such a move would certainly have an impact in India where consumption of sugary drinks is a major driver of chronic disease and tooth decay.

We also recommended compulsory education and training for healthcare professionals in the impact of nutrition on health. The public would expect doctors to understand, and be trained to understand, how different food patterns affect chronic disease. Yet I don’t remember receiving a single lecture on this in medical school. This must change.

Overturning dietary guidelines that incorrectly demonises fat, and in particular saturated fat, from foods like butter, ghee and cheese would also help. The Mayor of Manchester, Andy Burnham, who was the former secretary of state for health, endorsed the Pioppi Diet saying it had the potential to make millions of lives healthier and happier.

Only last week and with Andy’s support, Tameside (a Manchester borough) is being encouraged to follow the Pioppi Diet for 70 days to mark the 70-year anniversary of the NHS after the local hospital became the first in the country to ban the sale of sugary foods and drink from the hospital canteen. For me, this move is particularly special as I grew up in Tameside and it was my motion in 2013 calling for a ban of the sale of junk food in hospitals that made it part of policy of the British Medical Association.

(Sanghera, a graduate of King’s College London, is an intern with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

_____________________________

“Liked this story? Indiaspend.org is a non-profit, and we depend on readers like you to drive our public-interest journalism efforts. Donate Rs 500; Rs 1,000, Rs 2,000.”