A deadly sugar rush

In a corner seat on the first floor of Bir Hospital, a middle-aged kidney patient winces in pain. Next door, a lady has nerve damage, and is unable to feel the growing wound on her sole. Two floors up, a crowd of desperate patients wait for an appointment with an endocrinologist.

This week, the hospital in Kathmandu was filled with different medical complications. But many of them were related to a single disease: diabetes.

“On any given day, we see up to 200 patients in our department, and more than half have to do with diabetes mellitus,” says consultant endocrinologist Manil Bajracharya at Bir.

Diabetes mellitus is a condition where the body either does not produce enough insulin, or does not use it effectively, resulting in dangerously high blood sugar levels. Untreated, it can lead to life-threatening complications, including disorders of the cardiovascular system, eyes, kidneys, and nerves.

In Nepal, the incidence of diabetes is on the rise, with an estimated 8.7% of adults between 20-79 living with the condition in 2021. This number was 3.6% in 2011, and is expected to reach 9.4% by 2045.

“This rise most likely has to do with rapid changes in lifestyle and diet,” explains Bajracharya. “We have seen a shift from traditional cereal and vegetable-based diets to ones rich in animal products and processed foods high in fat and sugar content. This nutritional transition, combined with reduced physical activity, has significantly increased the risk of diabetes.”

Bagmati Province has a five times higher prevalence of diabetes than the Karnali. Other provinces with urban centres like Gandaki and Lumbini also have a high burden of the disease.

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“Nepalis who migrate to cities often have reduced physical activity and transition to high-calorie diets, which contribute to obesity and elevate the risk of diabetes,” says Bajracharya. City dwellers are twice as likely to develop diabetes compared to rural Nepalis.

Diabetes mellitus has no cure, but it can be managed through careful monitoring, lifestyle changes, and improving medications. Many people diagnosed with diabetes live for years without experiencing serious symptoms.

But Nepal has a huge gap: 43.5% of adults living with diabetes do not know that they have the disease. This means two out of every five cases go undiagnosed, and therefore untreated.

“If diabetes isn’t detected on time, it can become life-altering, and may even be fatal,” adds Bajracharya.

Raman Tamang did not know he had diabetes until a wound started growing on his foot. “I first thought it was just a normal cut. But it grew and started stinking. It got so bad that my family started avoiding me,” says Tamang.

When he was brought to Helping Hands Community Hospital in Chabahil, his wound had turned chronic.

A patient with long term diabetes suffers nerve damage. This results in the loss of sensation in the feet. Elevation in blood glucose also reduces the body’s ability to heal wounds.

“Minor cuts, scrapes, or wounds often go unnoticed until the body can no longer heal them on its own,” explains orthopaedic surgeon Hem Limbu at Helping Hands.

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Called diabetic foot ulcers, such wounds often persist and in the worst cases may get infected and have to be amputated. Across the globe, 85% of all amputations happen due to diabetic foot ulcers.

“We have to amputate almost half of all cases of diabetic foot because many patients come too late,” adds Limbu. Not amputating the leg can lead to infections spreading to the bloodstream.

Studies have shown that 19-47% of diabetic patients in Nepal also have diabetic retinopathy, where high-glucose blood damages blood vessels in the retina of the eye, impairing vision.

However, less than 30% of Nepalis who have diabetes know about this risk of blindness. And an additional 50% never get their eyes checked despite living with diabetes.

Diabetes also elevates the risk of kidney failure, heart disease, and stroke.

An estimated 9,000 Nepalis under 60 died due to some form of complication attributable to diabetes in 2021.

Then there are 9.2% of Nepali adults who are prediabetic with elevated blood glucose levels that could reach diabetic levels if their lifestyle does not change. “But because most don’t know they have the condition, proper screening and awareness are essential,” says Hem Limbu.

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Screening involves a blood test, and to manage high blood sugar, patients require insulin replacement therapy through injections or an insulin pump. But insulin resistance can often be managed with dietary modifications and exercise.

“Prediabetes is gaining increasing recognition as a significant health concern, and a growing number of adults are seeking assistance even for mild symptoms,” notes Bajracharya.

While this trend reflects improved awareness, it is equally vital to identify prediabetes in younger adults. Developing diabetes at a young age prolongs the duration of the condition and escalates the risk of complications.

Timely diagnosis and effective management can mitigate complications: reducing the risk of diabetic retinopathy by up to 95%, foot ulcers and amputations by 85%, kidney disease by 70%, and both cardiovascular disease and stroke by 50%.

“Prevention is better than cure for most diseases, but for diabetes, prevention and early detection are the only cures. Once the disease advances, reversing its effects becomes exceedingly challenging, necessitating lifelong symptom management,” adds Bajracharya. “So Nepal’s challenge isn’t just about forming an action plan for diabetes awareness, screening and treatment, but about implementing it in areas where essential drugs and equipment are out of reach.”

In urban cities, the challenge is different. Drugs, diagnostic services and self-monitoring equipment are accessible, but so are processed foods and sugary drinks.

“After essential healthcare services are in place, preventing and managing diabetes comes down to personal choices and attitudes. Whether or not diabetes continues to surge in Nepal, therefore, depends on each individual more than anything else,” says Bajracharya.

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