For a State which takes immense pride in consistently coming at the top in the health index rankings of NITI Aayog every year, the findings of the ICMR-INDIAB study, which puts Kerala right on top with the worst overall indicators for long-term morbidity and mortality due to non-communicable diseases, has undoubtedly come a cropper.
A current diabetes prevalence of nearly 24%, pre-diabetes at 18.1% and hypertension prevalence at a whopping 44%, is certainly not the picture of a healthy State. With more than half the State’s population having high cholesterol levels and abdominal obesity, the incidence of cardiovascular diseases and chronic kidney diseases could skyrocket in the near future and have significant impact on the State’s health expenditure as well as private spending on catastrophic illnesses.
Kerala has known since the mid or late 90s that NCDs are going to be its biggest health challenge, thanks to the population-based studies led by public health experts like the late Dr. C. R. Soman, who warned about the imminent catastrophe of heart attacks and other chronic diseases in the population because of the unhealthy, carbohydrate -heavy diet and sedentary lifestyle of Keralites.
Public health experts are now raising pertinent questions on where the decade-long NCD control programmes in Kerala have been going. Crores are being pumped in annually for the supply for NCD drugs free of cost through primary health centres. However, the fact that the mean HbA1c levels in the State is 8.3mg/dl indicates poor glycaemic control in general, which again points to poor monitoring and follow-up of patients on NCD drugs at the ground-level.
Experts point out that the high incidence of CKD in the State is a direct consequence of the spiraling levels of hypertension, which again is a result of poor adherence to the drug protocol, apart from factors like unhealthy diet and sedentary lifestyle.
Yet, the State Health department’s sole focus seems to be on devising newer screening programmes to detect disease prevalence in the population. The official website marks the number of cases of diabetes or prediabetes detected as the ‘achievements” of the State NCD Control programme.
Identifying the scope of the problem and documenting it is the easy part. But stepping in with effective interventions to increase public awareness about NCDs and its long-term consequences and improving primary prevention of diabetes and hypertension through the promotion of a healthy lifestyle is where most health systems falter.
The problem is not unique to Kerala. It is a huge challenge to health systems to create, implement and sustain programmes for the promotion of healthy lifestyles because it is not easy to change people’s attitudes towards self care, their long-term food habits and food choices or to inculcate new habits like daily exercise.
Researchers have in the past come up with several small-scale diabetes prevention and care models like the Kerala Diabetes Prevention Programme (2018) or the India Diabetes Prevention Programme, which showed that implementing standard treatment guidelines for disease prevention and management; engagement of family/ community and peers in health education and awareness creation; use of innovative technologies (IDPP used mobile phone messaging) and improved training of field-level health workers can significantly improve promotion of lifestyle modifications and healthy habits.
Diabetes management requires the patient to have fair awareness on what makes the blood sugar spike. It all comes down to healthy eating and knowing how and what type of food can affect the blood glucose levels. Limiting carbohydrates, improving nutrition through the increased consumption of vegetables and fruits and daily physical activity are important lifestyle interventions that patients need to imbibe.
Patients also have to be given affordable choices when it comes to diet and medication advice. Adherence to medication has to be ensured through consistent follow-up and people have to be motivated continuously to ensure that the changes they embrace become a part of their lifestyle.
Health experts point out that these are areas where health systems need to focus to prevent the cascade of chronic diseases in the population. Health workers or ASHAs in the field need to be trained better to impart awareness at the grassroots, to follow-up patients rigorously and they should be offered attractive incentives for the same.