Lessons in prevention from some community-based studies.
According to the World Health Organisation (WHO) and the International Diabetes Federation (IDF), India leads the world in terms of the number of people with diabetes: 41 million in 2007. This number is set to increase to 70 million by 2025. This, unfortunately, makes India the “diabetes capital of the world.”
Traditionally diabetes was considered a disease of the rich and the elderly. These assumptions are no longer true. In 1998, the Chennai Urban Population Study (CUPS) was carried out by this writer and his colleagues in two colonies representing middle and low income groups respectively. The study showed that 12.4 per cent of the middle income group had diabetes. In contrast, the low income group (living in a slum) had only 6.5 per cent prevalence rate. We therefore decided to share the results with the middle income group colony residents in order to empower them regarding diabetes and the need for prevention. This subsequently led to a park being built by the residents, which resulted in a 300 per cent increase in the number of people in the colony who took up some form of exercise.
Ten years later, a re-survey of both colonies was done — which showed astonishing results. Compared to the rest of Chennai, where the prevalence rates have now increased to over 18 per cent, in the colony where the intervention was introduced through community empowerment, the prevalence rate had only marginally increased to 15.4 per cent. Meanwhile, in the low income colony which had much lower prevalence rates in 1998, it had increased to 15.3 per cent.
What lessons has this experiment taught us? First, it demonstrates that that by making a modest investment of money (the building of a park) and time (physical activity in the form of walking for about 30 minutes a day) diabetes can be prevented in a substantial proportion of people. If this finding is extrapolated to the whole of India, a 3 per cent reduction in prevalence of diabetes in a population of a billion people would mean that millions of people in India would be saved from diabetes. What is more creditable is that all this was achieved by the community taking up the responsibility for its own health, albeit through empowerment provided by a research team.
This is obviously a model for the rest of India and if implemented on a large scale can help prevent diabetes per se and its dreaded complications that affect the eyes, the kidneys, the heart, the feet and the nerves. It can potentially save crores of rupees to the exchequer, and benefit the individual, family and society as a whole.
But let us return to the lower income colony, where no prevention measures were advised because of the prevailing conditions there at that time – low prevalence and the fact that people had sufficient exercise. No one could have imagined that the situation would change so dramatically in a matter of 10 years, and that the prevalence among the poorest of the poor would match that seen in more affluent colonies. Why, and how, did this happen? With increasing incomes, people in the lower income groups started adopting unhealthy lifestyles. They now eat ‘junk’ foods with high calorie, fat and sugar levels. They have drastically reduced their exercise levels and use motorised vehicles for transport. This has led to sharp increases in diabetes rates as also of obesity, hypertension and heart disease.
Recent studies confirm that just as the rich-poor divide for diabetes has vanished, the urban-rural divide is disappearing. Prevalence rates in India’s rural areas which were around 1 per cent in the 1970s have increased to 6 per cent to 16 per cent in different parts. The southern States have recorded the fastest growth rates, obviously due to better socio-economic development.
The Chunampet model
This does not augur well for India, as 72 per cent of India’s population now lives in rural areas. Moreover, when diabetes affects the poor, the burden of the disease will be heavier. It is estimated that a poor person spends 20 to 30 per cent of his income for the treatment of diabetes. If one happens to develop complications, the costs will increase proportionately.
Moreover, currently, diabetes health care is not available or accessible in rural areas; nor is it affordable. Some 70 per cent of doctors practise in the urban areas. With the help of the World Diabetes Foundation, the Indian Space Research Organisation and the National Agro Foundation, two years ago we took up the Chunampet Rural Diabetes Project. Using telemedicine we successfully screened 42 villages in Tamil Nadu’s Kancheepuram district covering a population of 43,158 people. Using a suitably equipped van, free screening of complications was done for all people with diabetes in these villages. A rural diabetes centre was set up. Within two years, a remarkable improvement in blood glucose level control was achieved in a rural area where such care was just not available. The Chunampet Rural Diabetes Project could serve as a model for delivering diabetes health care to rural India.
What, then, should be done to control the epidemic in India? It will need a multi-pronged attack. First, we should increase awareness about diabetes through educational programmes.
Secondly, community empowerment, as in the example cited above, which led to the building of the park by the residents themselves, is necessary. Once the onus is placed on the community, people will rise to the occasion. A community-based programme to prevent diabetes, called D-CLIP, funded by the International Diabetes Federation is being carried out by the author and his colleagues along with Emory University, Atlanta. The programme is entirely driven by volunteers from the community who are designated as Dia-Ambassadors.
Thirdly, the government should subsidise healthier food options like fruits and vegetables, making them cheaper for the common person. Conversely, taxing unhealthy food options could lead to decrease in their consumption. Excess consumption of white rice has been shown to be a risk factor for diabetes. The introduction of whole grain products like brown rice, or whole wheat, is necessary. Facilities to increase physical activity must be encouraged in the urban town planning process: separate pathways for pedestrians and cyclists is one example. Workplaces should be made healthier than they are now.
For the millions of people who already have diabetes, the government must ensure availability of low-cost testing tools and treatment, for example, affordable blood glucose meters and strips, insurance cover and cheaper tablets and insulin. Capacity-building with the training of large numbers of doctors and paramedical personnel (for example, diabetes educators) can help deliver quality and affordable health care to millions of people with diabetes. The time to act is now.
( Dr. V. Mohan is Chairman and Diabetologist of Dr. Mohan’s Diabetes Specialities Centre, Chennai, which is a WHO Collaborating Centre for Noncommunicable Diseases and an IDF Centre for Diabetes Education.)