Introduction
Being born a woman is a blessing: it brings with it that extra dose of resilience
and strength, which helps one survive in a male-dominated world. Being a woman allows
one to manage the various challenges and demands of living life. Though these challenges
and demands increase manifold in patients with diabetes, women handle these responsibilities
as part of life. Irrespective of which member of the family has diabetes, it takes
a woman to manage diabetes.
I have a strong family history of diabetes and follow a strict lifestyle to keep the
“metabolic wolf” at bay. I have seen diabetes at close quarters, both personally and
professionally. Four generations of my family have diabetes, and I serve a large community
of women, men, and children with the condition. I appreciate the efforts made by colleagues
from India and abroad to study and resolve the psychosocial challenges that women
with diabetes face.[1]
[2]
[3]
[4] It is the insight gained through these experiences, which I present below.
My Grandmother
I must have been a few years old when my grandmother developed diabetes. I do not
know what oral medication she took initially, but soon she was on insulin. This was
in the mid-1970s. Milkhi Ram, a “registered medical practitioner” (RMP), would cycle
down to our house twice a day, boil her glass syringe and thick-bored metallic needle,
and inject her intramuscularly, in the hip. If these injections, delivered with blunt,
reused needles hurt her, she never complained. She was grateful for the chance to
live her life.
My grandfather also had diabetes, and life in our household revolved around this syndrome.
I doubt if my grandparents worried about chronic vascular complications back then.
Their main concerns were hypoglycemia (when the entire neighborhood would rush to
feed my grandmother sweet meats) and lack of flexibility (no overnight trips for grandma,
as no one in the family knew how to inject insulin). Another pressing issue was finance
(a significant (proportion of the monthly income was set aside for insulin).
Diabetic Diet
I think my family tried its best to follow the advice given by (well meaning) doctors
and self-styled “experts.” When I look back, however, I shudder to think what state
our metabolic health was in. Butter and clarified butter (ghee) were the center stage
of our cuisine, which was based upon carbohydrate-rich cereals. My grandparents were
not allowed to eat fruits and sweets, but there was no restriction on fried foods
and ghee.
My Mother
The strong family history, coupled with inappropriate culinary habits, did have an
impact on the next generation. One by one, most of my uncle and aunts developed type
2 diabetes. This list included my mother, who suddenly found she was losing weight
and experiencing osmotic symptoms. She began using tablets prescribed by the local
doctor, but I doubt if they helped her much.
I had become a medical student by then, but I do not think I learnt anything in college
which helped my mother improve her glycemic control. There was no awareness of the
targets for glucose control, of the need to avoid hypoglycemia, and of the importance
of cardiovascular risk reduction.
Diabetes Hearsay
Every “expert,” whether qualified or not, had a different take on diabetes cure. Newer
cuisines and recipes were suggested, all of which created an extra load on the cook,
that is, my mother. They advocated exotic treatments like concoctions of seeds and
spices of dubious values. The general dictum seemed to be this: The greater the difficulty
and expense in procuring an herbal treatment, the more beneficial its effect.
A similar scene was being played out at my uncles’ and aunts’ homes. Whenever they
met, discussion would revolve around diabetes care, especially complementary and alternative
medicine,[5] and around cost of therapy. Everyone would then refresh themselves with a hearty
meal or snack, cooked in true Punjabi style, and conclude with a philosophical “whatever
will happen, will happen” statement.
Insulin
The inevitable did happen, and within a few years, the siblings had to shift to insulin.
Insulin was a generic drug, prescribed twice daily, irrespective of the preparation.
My mother began self-injecting, inspired by her younger brother, who had taken on
the responsibility of administering insulin to their mother in her final days, after
the RMP become too old to manage his rounds on bicycle.
Armed with my “foreign” pharmacology textbook, I learnt that basal and bolus insulin
were different. It was then that my mother realized that the insulin she was using
was cloudy at times, and clear at others. This set us off on a search for the correct
doctor, who could prescribe the correct insulin regimen and preparation. This quest
meant that insulin sometimes had to be sourced from a medical college located 90 km
away from home. The responsibility of keeping our refrigerator stocked with insulin
was taken up by my sister-in-law, who added insulin to the grocery list.
Looking Back
When I look back, I am not sure if we managed diabetes to the best of our ability.
We did follow medical advice, and adhered to therapy, but did not bother about lifestyle
modification. Perhaps our doctors did not emphasize the important of diet and exercise,
perhaps we got conflicting advice which conflicting advice which confused us, or perhaps
we just chose not to listen. Certainly, we could have done much better.
Complications
Hindsight is a great teacher, they say, but it cannot change the past. In a few years
my mother (and one of her brothers) developed end-stage renal disease (ESRD). A few
months on dialysis convinced us that a kidney transplant was her only option. My brother
took 6 months off from work, and migrated to a distant city where transplants were
done. My mother came back happy, but continued to have uncontrolled diabetes. By this
time, newer insulin preparations and delivery devices had become available in our
state. Our health care providers were able to explain the basics of dietary therapy,
physical activity, stress management, and insulin usage. By following a disciplined
lifestyle, my mother was able to survive for 10 years after her transplant. She finally
succumbed to a seemingly innocuous foot ulcer, after a year-long battle. The emotional,
social, and financial impact on our family is difficult to express in words; it will
suffice to say that living with ESRD is a challenge which is better prevented, rather
than experienced.
My uncle, too, had developed ESRD; unable to obtain a transplant, he opted for continuous
ambulatory peritoneal dialysis (CAPD). The duty of handling this complex procedure
fell on his arthritic wife, who managed her responsibility for 2 years, until he passed
away. Another uncle’s diabetes was complicated by premature cardiovascular disease.
His children were not allowed the luxury of higher education, and had to begin working
after graduating from college.
My Generation
As years went by, it was time for my cousins to develop dysglycemia. Type 2 diabetes,
type 1 diabetes, gestational diabetes, and impaired glucose tolerance, all found a
place in our large family. Medical care had improved by then, and so had its acceptance.
Most of my cousins understand the importance of good glycemic control, adhere to therapy,
and are complication free. The credit goes to the women of the family, who motivate
the menfolk to exercise and follow medical advice, while ensuring a healthy larder
for them.
Generation Next
The younger members of the family, that is, my nephews and nieces, have not been spared.
Obesity, impaired glucose tolerance, and type 1 diabetes have gained a foothold in
this generation as well.[6] Their mothers struggle with competing social, emotional, and financial demand to
provide a healthy culinary experience to their families. This is easier said than
done, however.
The Triple Challenge: Triple Strength
The Triple Challenge: Triple Strength
In some cases, I find my aunt fighting a triple challenge of diabetes: type 2 diabetes
in herself, gestational diabetes in the daughter-in-law, and type 1 diabetes in the
grandchild. This triple challenge is associated with a triple burden: biomedical,
psychosocial, and financial. In spite of such heavy demands, they live life with a
smile. It is this resilience, this strength, this coping power, that is termed “woman
power.”
My Profession
As a diabetes care professional, I care for thousands of individuals with diabetes.
I see them not as individuals, however, but as families, as part of a larger society.
When a male patient presents with type 2 diabetes, I realize the effort his wife makes
to provide tasty, wholesome, and healthy food. When an overweight adolescent is diagnosed
with diabetes, I empathize with the mother’s self-blame and guilt. If a child walks
in with type 1 diabetes, I understand the pressure on her mother to learn diabetology
overnight. When I see a newly married woman with freshly diagnosed gestational diabetes,
I feel the tremors of fear of social ostracization that go through her.
In my clinic, these concerns weigh equally, alongside biomedical issues.[7] It sometimes becomes a challenge to counsel irate patients, uncooperative family
members, and “armchair diabetologist” friends. Countering diabetes hearsay,[8] and promoting salutogenic messages becomes a herculean task. Balancing biomedical
demands of an evidence-based system, with individualized psychosocial profiles also
becomes tough, especially in a resource-challenged, time-constrained clinic.
My Inspiration
At such times, I remember my grandmother, mother, and aunts. They lived with diabetes,
and yet, they smiled. They lived a full life. If they could live happily with diabetes,
I should be able to work happily with people who live with diabetes. It is this inspiration
which keeps me going. It is this inspiration which makes me confident that women will
win the war against diabetes.[9]
