In this interview, Dr. R.M. Anjana, Managing Director, Dr. Mohan’s Diabetes Specialities Centre, discusses issues surrounding the prevalence of diabetes in India and probable solution for this challenge by emphasising on the importance of ICMR-INDIAB study and its major findings.
Q. Diabetes has got us in a quandary. China, India and USA are among the top three countries with a large number of diabetic population. What makes the Indian population more vulnerable to diabetes?
Although genetic factors may play a part, the rapidity with which the diabetes prevalence has risen among these populations reflects the far-ranging and rapid socioeconomic changes to which they have been exposed over the past few decades. Traditionally, obesity and its correlate, insulin resistance, have been considered the major mediators of type 2 diabetes risk. Recent evidence shows that early loss of beta-cell function plays an important role in the pathogenesis of T2D, especially in non-obese individuals such as South Asians. Indians also have peculiar characteristics known as the ‘Asian Indian phenotype’, which increase their susceptibility for diabetes. Despite having lower prevalence of obesity as defined by body mass index (BMI), Asian Indians tend to have greater waist circumference and waist to hip ratio thus having a greater degree of central obesity. In addition, Asian Indians have more total abdominal and visceral fat for any given BMI and for any given body fat they have increased insulin resistance.
Q. The sugar disease is posing an enormous health problem to our country today. There are millions of pre-diabetes patients in India. What are the public health measures required to cut this problem at its roots?
The high prevalence of prediabetes (one in every ten individuals) as shown in the ICMR INDIAB study would mean that there is huge pool of individuals who will eventually develop diabetes in the near future. As evidence suggests, that compared to other ethnic groups, Asian Indians progress faster through the prediabetes stage to frank diabetes.
Thus the major task to curb the conversion of individuals with prediabetes to diabetes includes:
Step 1: Creating awareness about diabetes
Step 2: Screening programme to identify high-risk group
Step 3: Prevention of diabetes in high-risk individuals (prediabetes) by initiating appropriate life style modifications.
Identifying high-risk individuals at the community level and then initiating lifestyle intervention measures becomes a mammoth task which needs the involvement of all sectors, right from the primary health care centres. This greatest health challenge calls for coherent and well planned approach to confront the disease threat. As a developing nation the country also faces inadequacy of funds and workforce, this reinforces the involvement of community to ease the job. This emphasise the need for a multi-factorial and multi-sectoral
approach to empower the community.
Q. What are the major findings of your recent study (The Lancet Report: Prevalence of diabetes and pre-diabetes in 15 states of India) and how it is different from the previous studies?
The cumulative data from 15 states/UT reported represent a total adult population of 363·7 million people (51% of India’s adult population). Among the 15 states/UT studied, there was large variation in state-specific diabetes and prediabetes prevalence ranging from 4.3% in Bihar to 13.6% in Chandigarh and 6.0% in Mizoram to 14.7% in Tripura respectively. The prevalence of prediabetes in India also varies widely in different states from 6.0% in Mizoram to 14.6% % in Chandigarh. We estimated the overall prevalence of diabetes in India to be 7·3% and the prevalence of prediabetes to be 10·3% (WHO criteria) or 24·7% (ADA criteria), depending on which definition was used. However, these estimates are based on data from 15 states/UT out of a total of 31 to be studied, and cannot be considered as final, especially since the states yet to be sampled include the National Capital Territory of Delhi, Kerala (the state with the highest reported prevalence of diabetes in India so far), Uttar Pradesh (the most populous state) and Goa (the state with the highest per capita income). Our results also show evidence of an epidemiological transition, with a higher prevalence of diabetes in low SES groups in the urban areas of the more economically developed states.
QHow beneficial this study would be?
Diabetes and other non communicable disease risk factors like dyslipidemia, hypertension, obesity and metabolic syndrome are imposing a large and growing burden on public health. These conditions are preventable, but are often silent in their manifestation. Therefore the ICMR-INDIAB study will help to throw light on the large burden of undiagnosed risk factors and provide an opportunity for prevention of disease in this group of people. In addition for those with an established diagnosis of diabetes the level of control is assessed and opportunity for better control of diabetes. All participants in the study are also provided with general advice on prevention of NCDs. This will help to improve the awareness about NCDs in the population at large. Thus new initiatives like these are needed to institute prevention programmes to curb the huge strain of NCDs on the national healthcare systems. The ICMR-INDIAB study helps not only in earlier detection of diabetes through screening, but also in planning prevention programmes for the country.
Q. Diabetes, once a disease of the affluent, is now rampant among the urban poor too. Is diabetes actually attacking people from low socio-economic stratum? Do we blame genes and changing lifestyles?
In the ICMR-INDIAB study conducted in the 15 states/UT, the overall prevalence of diabetes was higher in urban areas (11.2%) than in rural areas (5.2%). Compared to earlier studies, in
the ICMR-INDIAB study, the prevalence of diabetes was higher in individuals of low socio-economic status in the urban areas of Chandigarh, Punjab, Tamil Nadu, Andhra Pradesh and
Maharashtra, which are also ranked among the more economically advanced states of India. This finding suggests that the urban areas of more affluent states have transitioned further along the diabetes epidemic, such that less affluent individuals have a higher prevalence of
diabetes than their more affluent counterparts. The results suggest that as the overall prosperity of states and India as a whole increases, the diabetes epidemic is likely to disproportionately affect the poorer sections of the society, a transition that has already been noted in high-income countries. This trend is worrying because it suggests that the diabetes epidemic is spreading to those individuals who least can afford to pay for its management. In India, economic development has drastically modified lifestyles over the course of a single generation. The two aspects of this transition are the changes in physical
activity levels and food habits. In addition to these, novel risk factors ranging from exposure to environmental pollutants, smoking, depression, short sleep duration, and built environment have also shown to be associated with increased diabetes risk.
Q. Do you think patient faithfulness to medication and lifestyle modifications can play an imperative role in diabetes management? What would you describe as good lifestyle for diabetes prevention and control?
Yes, the combination of proper medication, healthy diet, adequate physical activity, and behavioral modification is the most effective approach to healthier lives in individuals with diabetes. Diabetes occurs due to the synergistic effects of behavioral risk factors such as physical inactivity, unhealthy diets, tobacco consumption and the harmful use of alcohol. A good lifestyle for diabetes prevention/control should include good quality of the diet in addition to adequate physical activity. Healthy diets are built by combining many nutrient dense food choices in optimal proportions and these includes whole grains, legumes, fruits, vegetables, low fat dairy and nuts. Unhealthy choices such as high use of refined grains, added sugar, added salt, saturated fats and trans fats should be dished off from the diet. Reaching out both at a health clinic through diet counseling and at the community with public health nutrition awareness programme could empower people with better informed choices for healthy diet. In addition to healthy diet, to improve overall physical activity, at least 150 minutes of moderate-intensity aerobic or at least 75 minutes of vigorous-intensity aerobic activity throughout the week is recommended to reduce the risk of diabetes. Therefore, adhering to healthy diet along with increased physical activity will reduce the burden of diabetes.
Q. How in your capacity, you are improving awareness about diabetes and promoting healthy diets and active lifestyle?
Evidence shows that awareness levels regarding diabetes are still low. Ours is a tertiary care centre for diabetes control and prevention. Thus awareness and health education is a mandate for us. All our patients are educated about diabetes prevention and control. We are regularly conducting community based mass screening and awareness programmes to tackle the epidemic of diabetes. Education about diabetes, the various risk factors, complications, importance of a healthy diet, increasing physical activity levels, regular checkups and the need for screening is also provided to individuals with diabetes, their family members and those with high risk of developing diabetes (pre-diabetes) in both urban and rural areas. Low cost informational material including pamphlets, posters, a prevention booklet and CDs (In English and regional language) have been developed and distributed to impart knowledge to lay public. Awareness programmes for children and adolescents to “Catch them Young” are conducted in schools and colleges through lectures regarding primary prevention of diabetes.
Q. What are the current treatment options available?
The first line of management of all diabetic patients is diet control and exercise. Medications are used to reduce the blood sugar levels if diet and exercise fail to achieve adequate control. These can either be oral tablets (oral hypoglycemic agents or OHAs) or insulin injections. Today we have a large number of medicines to choose from and hence there is no excuse for anyone’s sugar to remain uncontrolled. Better blood glucose monitoring including use of continuous glucose monitoring and ambulatory glucose monitoring have revolutionised the management of diabetes.