The story so far: There was great interest in the results of the largest, long-term (2008-2020) study on metabolic factors in the Indian subcontinent as part of the ICMR-InDiab study published in The Lancet(by Anjana Ranjit Mohan et al) last week. It was launched in 2008 to estimate the country’s NCD (chronic non-communicable diseases) burden, and done over five phases between 2008 and 2020 across the country, with each phase covering five States (all seven northeastern States were covered in one phase). Individuals aged over 20 were recruited for the door-to-door survey and 1.24 lakh individuals were part of the survey.
What are the key findings?
It estimated that about 11% of the population is diabetic, and 15.3 % of the country is in the pre-diabetic stage. Given that the study was conducted in the most populous nation in the world, the actual numbers are naturally staggering. As per these estimates, 101.3 million people in the country are diabetic, and in the pre-diabetes stage, there are another 136 million people. Questions are being raised about whether this constitutes an emergent crisis in India and of the urgent methods that need to be employed to handle this situation, and control possible burgeoning of these numbers in the future. According to the World Health Organization (WHO), about 422 million people worldwide have diabetes, and 1.5 million deaths are directly attributed to the disease each year. Both the number of cases and the prevalence of diabetes have been increasing, and there is a globally agreed target to halt the rise in diabetes and obesity by 2025, according to the WHO.
What are the implications of these statistics?
The thing with metabolic lifestyle disorders, is that with some attention, it is possible to ward off severe complications and a morbid state of life; it is also possible to ensure that the 136 million at the pre-diabetic stage do not proceed to diabetes. “Prevention is key, and here is the window of opportunity,” says V. Mohan, Madras Diabetes Research Foundation, which conducted the study funded by the Indian Council of Medical Research. “There is a window of possibility open in a couple of areas and we need to seize it,” he explains. He believes the anchor of any intervention programme should be ‘prevention’ — in the case of diabetics, the aim has to be to prevent the onset of life-threatening complications; and in the case of pre-diabetics, all efforts must be taken to prevent the progress to diabetes, and in rural areas, where the prevalence is still low, the aim should be to keep it that way.
There are multiple studies that show that poor control of blood sugar leads to complications — cardiovascular disease, kidney disease, neuropathy, blindness, and lower-extremity amputation — which then become a significant cause of increased morbidity and mortality. The question is whether any nation will be equipped to provide comprehensive care to all diabetics who develop complications in the course of living with diabetes. While it is sensible to ensure that there are sufficient facilities to treat the complications, the sagacious approach would be to launch public awareness campaigns on using lifestyle modifications to keep blood sugar within acceptable limits and complications at bay, Dr. Mohan says. Education on a mass scale should be launched across the country for control and periodic check-ups, sticking to the recommended drug regimen and reinforcing health-seeking behaviour, he stresses.
Dr. Mohan explains that while doing the study, researchers encountered a strange phenomenon — that the conversion from pre-diabetes to diabetes was faster in India, in some cases even within six months. So immediate attention must be paid to promoting a healthy lifestyle that would lead to retarding the speed of progress to diabetes, or even prevent movement to diabetes. Urban India accounts for 16.4% of the prevalence while in the rural population the prevalence is 8.9%. Though the prevalence is lower now, this is an area where the possibility for prevention is greater. As traditional lifestyles change and more modern practices take over, it is essential to once again stress on maintaining a healthy diet, getting sufficient moderate to vigorous exercise and periodic testing for those with risk factors and after a certain age group, experts point out.
Periodic epidemiological screening programmes are very important, they say, to catch new diabetics and bring them into the protective net.
Were there any surprises during the study?
The impression, even among researchers, was that the prevalence was high only in metro cities, Dr. Mohan says, adding that they were quite surprised to find that it was similar, or growing in 2-3 tier cities.
In Kerala, said to be top among States with better social development indicators, the prevalence in rural areas had escalated to supersede that in urban areas.
This is a side-effect of progress, one that States should be careful to watch over, experts add.
All the northeastern States were covered in one phase, and the surprises included high prevalence in Tripura and Sikkim. While in Tripura, it was averred that the ethnic composition of the State was different from that of the other States in the region, being populated with Bengalis, leading to a high rate of 13% prevalence; in Sikkim where the prevalence of diabetes and pre-diabetes (31 %) was high, it was put down to its smaller size and relatively better socio-economic indicators there.
What is the way forward?
Dr. Mohan says there is a plan to do a cross-sectional study to gauge the actual incidence in the community. “What we did was an estimation. For example, in Tamil Nadu, we had the figures from a decade back and that was extrapolated as projections for 2020. We will now do a current study to find out how many actually are diabetic. Now we also intend to go back to the same people — people who then tested as diabetic to see how they have progressed, to assess their quality of life, and see if they have developed complications. The pre-diabetics in that study will also be approached to see how many of them have converted to the next stage, and among people who were not diabetic a decade ago, to follow up on their status now.”
Some of the islands and Union Territories that could not be covered during the study will now be included in the study.
Experts have also indicated tie-ups as part of the public-private partnership mode to involve the larger community in supporting detection and treatment for diabetes.
