More than a sweet problem: What really drives diabetes beyond sugar

For years, the standard advice for people at risk of diabetes has been familiar - cut down on sweets, avoid sugary drinks and watch what you eat. But doctors say this understanding of diabetes is dangerously simplistic. A person can avoid sugar, maintain an apparently normal weight and still be heading towards Type 2 diabetes.

The reason lies in a much larger problem, one that involves insulin resistance, often accompanied by excess visceral fat, physical inactivity and other metabolic abnormalities.

As India grapples with an estimated 101 million people living with diabetes and another 136 million with prediabetes, according to the ICMR-INDIAB study, experts say it is time to rethink how the disease is understood and prevented.

"Diabetes is not simply about how much sugar a person consumes. It is about how the body processes glucose and how effectively insulin works. Genetics, abdominal fat, physical inactivity and dietary patterns all contribute to this process," says Dr Ramesh Shah, a family physician based in Mumbai.

One of the most misunderstood aspects of diabetes is the relationship between body weight and metabolic health. Many Indians develop Type 2 diabetes despite not being classified as obese by conventional BMI standards.

South Asians are particularly susceptible to abdominal fat accumulation and insulin resistance. This means a person may appear relatively slim but have excess visceral fat, the fat deposited around internal organs.

This is why doctors increasingly recommend looking beyond the weighing scale and considering waist circumference, blood pressure, cholesterol and blood glucose levels when assessing metabolic health.

"People often assume that if they are not overweight, they cannot develop diabetes. This is a misconception. We see individuals with relatively low BMI developing insulin resistance and Type 2 diabetes, says Dr Phulrenu Chavan, endocrinologist at Hinduja Hospital, Mahim in Mumbai. She further adds that diet, physical activity, sleep, stress and even exposure to factors such as air pollution can interact with our genetic pathways. "In other words, our genes may load the gun, but our environment and lifestyle can influence whether it gets fired."

Another lesser-known connection is between diabetes and fatty liver disease. Metabolic dysfunction-associated steatotic liver disease (MASLD), earlier known as non-alcoholic fatty liver disease, is closely associated with insulin resistance and Type 2 diabetes.

Excess fat accumulation in the liver can progress to inflammation and fibrosis in some individuals. Conversely, fatty liver can also worsen insulin resistance, creating a vicious metabolic cycle.

The heart and kidneys are equally vulnerable. Diabetes significantly increases the risk of cardiovascular disease and chronic kidney disease. In many patients, these complications can develop silently, without obvious symptoms.

This is why specialists increasingly advocate a whole-body approach to diabetes management, assessing cardiovascular risk, kidney function and liver health alongside blood glucose.

There is also a tendency among patients to consider diabetes controlled simply because their HbA1c has improved. While HbA1c remains an important measure of average blood glucose over approximately three months, it does not capture every aspect of metabolic health.

A person with diabetes may have acceptable glucose readings but continue to struggle with hypertension, abnormal cholesterol, excess weight or kidney-related complications.

Doctors therefore stress that diabetes management must go beyond a single laboratory number. Depending on individual risk, patients may need regular kidney function tests, urine albumin assessment, eye examinations, lipid profiling and cardiovascular evaluation.

Treating diabetes cannot mean chasing an HbA1c number alone, say diabetologists. The patient's overall metabolic and cardiovascular health must be considered and treated before complications develop.

Perhaps the most important intervention is identifying people before they develop diabetes. Prediabetes offers a window during which lifestyle changes, weight management and physical activity can help prevent or delay progression to Type 2 diabetes.

But prevention needs to be more nuanced than simply asking people to stop eating sweets, say experts. Regular physical activity, adequate sleep, reducing abdominal fat, improving dietary quality and periodic screening are all important.

On World Diabetes Day, the message is clear: diabetes may show up in a blood test, but its origins and consequences extend far beyond blood sugar. And perhaps the most important question is whether we are paying enough attention to our metabolic health.