As diabetes spreads among India’s urban poor, it could be pushing them over the edge

On June 23, the narrow streets of Mehrauli’s ward number two in Delhi were deserted. A day before that, residents were shocked to find that their neighbour, Upendra Shukla, a teacher, had murdered his wife and three children, including a two month-old infant, by slitting their throats. He tried to kill himself too, but survived.

Police officials told reporters that 33-year-old Shukla, who confessed to the killings, was suffering from depression and was allegedly upset about his and his wife’s deteriorating health: while she was a diabetes patient, Shukla suffers from hypertension.

The case of the Mehrauli deaths is disturbing, and it is not an isolated incident. In the past few months, several reports from different parts of India highlight similar cases of suicide and homicide by people either suffering from diabetes and related cardiovascular illnesses, or their caregivers.

In December 2018, for instance, a diabetic and depressed garment factory supervisor from Bengaluru killed his seven-year-old disabled son before killing himself. In November 2018, the wife of a railway employee in Mumbai, who had both diabetes and hypertension, committed suicide by jumping from the fifth floor of her building. And in September 2018, after a tailor in Bengaluru died of diabetes, his wife and mother committed suicide by hanging themselves from fans at home.

In all these cases, it is difficult to establish a direct correlation between the experience of suffering from diabetes and mental health deterioration. But they are a reminder of the fact that diabetes – once known as the “rich man’s disease” – is fast becoming an affliction among lower-income populations as well.

In both urban and rural areas, the proliferation of cheap sugar-rich junk food is making more and more people susceptible to obesity, high blood sugar and blood pressure and other cardiovascular ailments. According to doctors, this implies that any mental health problems linked to these illnesses are also likely to manifest themselves in low-income groups.

Changing lifestyles

Diabetes is often called a lifestyle disease, and for a long time, it was associated with the lifestyles of the affluent: a more sedentary work life, less physical exercise and the ability to afford sugar and fat-rich foods.

But the lifestyles of the less affluent have been changing rapidly in the past decade, and several countries have now acknowledged the rising prevalence of diabetes among the urban poor. In India, the most significant research study confirming this trend is the Indian Council of Medical Research’s India Diabetes study, known as the ICMR-INDIAB study for short. With a sample size of more than 57,000 Indians from 15 states, the study was conducted over seven years from 2008 to 2015.

In a report published in 2017, the study found that diabetes is twice as common in urban areas than rural areas, and that in cities, high rates of diabetes were observed even in lower socio-economic groups. In some states, like Tamil Nadu, Andhra Pradesh, Punjab, Chandigarh, Manipur and Tripura, diabetes rates were higher in urban low-income populations than in urban higher-income groups.

The study attributes this disturbing trend to lifestyle changes among urban populations: growing use of transport services, lack of physical activity and the easy availability of junk food and sugary drinks.

For the urban poor, junk food like chips or instant noodles is actually cheaper than a proper meal of vegetables, dal and rice. In 2015, non-profit organisation Ehsaas conducted a small study on the eating habits of slum children and observed that high consumption of junk food could be the possible cause of a malnutrition epidemic in Delhi slums.

In Mehrauli’s ward number two, junk food sales are high at a small general store adjacent to the place where Upendra Shukla killed his family and attempted suicide last week. Store owner Deepak Aggarwal is aware of the harmful effects that such food can have on the body – his father died of cardiovascular problems at the age of 52 last year. “But I cannot control my children,” said Aggarwal. “There is always junk food stocked up for them. They are very fond of it.”

In Mumbai, Dr Smita Chavan says she has seen a very clear rise in the numbers of diabetes patients over the past ten years. “These are all patients from slums and low-income areas, where we are also seeing more prevalence of obesity,” said Chavan, an associate professor of community medicine at RN Cooper Hospital in Andheri. “Food with bad cholesterol and bad carbohydrates are more easily available in these areas now.”

Some studies also point to the high rates of diabetes among rural populations in India, possibly fuelled by carbohydrate-rich government food rations. This has been one of the recent criticisms of the Public Distribution System under which the government disburses subsidised food grains to marginalised populations. PDS focuses on providing each family with a specific amount of calories per day, with little focus on the nutritional quality of the food. By replacing millets with rice and wheat, it has forced a dietary shift in rural India.

Diabetes and mental health

Diabetes is debilitating for patients and their families at multiple levels: it requires daily medication and strict dietary restrictions, lowers immunity to other diseases and can gradually affect the functioning of almost every organ in the body.

It is well-known that diabetes – both type 1 and type 2 – can increase risks of high blood pressure, cardiac arrests, strokes and kidney disease. But recent research also points to the correlations between diabetes and mental health problems.

A 2016 study from Romania, for instance, found that people with diabetes are two to three times more likely to suffer from clinical depression than other people. More recently, researchers in Finland studied a group of more than 400,000 people over seven years and found that among them, diabetes patients were much more likely to die of suicide, accidents or alcohol-related causes than the non-diabetic population.

The study, published in October 2018 in the European Journal of Endocrinology, indicates that diabetes affects a patient’s mental health because of the strain of having to constantly monitor glucose levels and take insulin injections, as well as the anxiety of developing more serious heart or kidney problems.

For low-income families, these physical and mental stresses come with an additional financial burden. Junk food may be cheap, but the cost of managing diabetes is high.

“Medicines may be available for free at public hospitals, but insulin is not. And insulin alone can cost up to Rs 2,000 a month for a diabetic,” said Dr Smita Chavan, who believes the impact all of these combined burdens of managing diabetes can easily affect a patient’s mental health. “I have seen diabetes patients go into depression very quickly, and this happens no matter which social class the patient comes from.”