Diabetes in the Undernourished: Coincidence or Consequence?

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Abstract
Introduction DIABETES is recognized as a disease that is closely linked to nutrition, both in etiology and treatment. Overnutrition was the first risk factor for diabetes to be identified. In the sixth century A.D., Hindu physicians described two forms of the disease, one hereditary and the other acquired, and two types of patients, one lean and emaciated, and the other obese, observing that the acquired type was a disease brought on by “nonconducive foods and habits,” chief among which were the gluttonous ingestion of “foods which are sweet and/or fatty, a lack of exercise, laziness and lethargy” (1). The modern concept of diabetes owes much to the clinical observations of Joslin (2). He clearly recognized the importance of obesity in the etiology of diabetes, noting that “Diabetes is largely a penalty of obesity, and the greater the obesity, the more likely is Nature to enforce it” (2). Subsequently, several epidemiological studies have confirmed his clinical observations, with the exception that the duration of obesity, rather than its severity, is thought to be the determinant (3). In the words of Kelly West (4), “Obesity is the most important environmental risk factor for diabetes. Indeed there is some evidence that its importance equals or exceeds the strong influence of diabetes related genetic factors” (4). Observations such as these, although valid in themselves, have served to propagate a singularly one-dimensional view of the relationship between diabetes and nutrition. In the clinical context this view is undeniably supported by the facts: the majority of obese individuals are glucose intolerant (5–8), more than two-thirds of adult-onset diabetics in the developed world are obese (9), and weight reduction in both groups of patients can substantially improve, or even normalize glucose tolerance (8).

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