India Cannot Afford To Ignore The Epidemic Of Diabetes

Diabetes scares me. It haunts me. I lost my father to diabetes in the 1980s, when I was still a kid in India. I grew up watching my mother boil glass syringes and reuse metal needles for his insulin shots. I saw the disease disable him first with foot ulcers, then diminish his eye sight, before shutting down his kidneys. We sold our house and borrowed money for his dialysis treatments and kidney transplant. He died soon after the surgery. He was 51 years old. It took my family years to recover from his sudden death, and decades to repay our debts.

Today, I live with prediabetes and constantly worry that I will end up fighting my father’s demons. There are millions like me in India, where a new study estimated the prevalence of diabetes and prediabetes to be 101 million and 136 million, respectively, much higher than earlier reported figures. The overall weighted prevalence was 11·4% for diabetes, and 15·3% for prediabetes. Nearly half the population had raised blood sugar levels, and hypertension was identified in more than one-third of the population, and obesity in nearly a third of the population. India is a ticking time bomb when it comes to non-communicable diseases (NCDs).

“The ICMR-INDIAB study is one of the largest epidemiological studies on diabetes,” said Anjana Ranjit Mohan, the lead author of the study, and President of the Madras Diabetes Research Foundation (MDRF). “Our study shows the huge burden of diabetes and other metabolic NCDs in India and also brings to light significant inter-state, regional and urban -rural differences in prevalence of NCDs in India,” she explained.

“What we are really worried about is the burden due to complications of diabetes, for example it could mean several million people with kidney complications of diabetes,” said Viswanathan Mohan, Chair, MDRF, and a leading diabetologist in India.

Sonia Anand, an NCD and global health expert and professor at McMaster University echoes these concerns. “When projected to the 2021 population of India, there are more than 230 million individuals with prediabetes or diabetes, 315 million with high blood pressure, and 350 million with abdominal obesity,” she explained. “These absolute numbers are staggering, and the implications go far beyond the individual impact of a shortened life expectancy if risk factors go untreated, to the unprecedented impact on India’s health system to care for these numbers of patients and the related micro and macrovascular complications including kidney failure, heart attacks and strokes,” she added.

Rural India is not spared

The ICMR-INDIAB found uniformly high prevalence of prediabetes in rural areas, with the study authors expressing grave concern about lack the infrastructure to care for increasing numbers of people with diabetes and its complications in rural parts of India.

“I am seeing alarming numbers and trends,” said Usha Sriram, Head of Diabetes and Endocrinology at Voluntary Health Services in Chennai. “My concerns are that the prevalence has escalated among individuals from resource poor settings especially the urban poor, and the urban rural divide has blurred. Gestational diabetes is at an all time high with significant trans-generational and multi-generational impact in addition to putting women at higher risk for diabetes and NCDs,” she explained.

NS Prashanth, Director of Institute of Public Health in Bangalore works in rural and Indigenous communities. “Our ongoing work also confirms the pattern of comparable or even sometimes higher burden of diabetes and hypertension, but also stroke and various other chronic conditions among Adivasi and rural communities,” he said. He worries that primary healthcare has been neglected in rural areas, since all the attention is on hospitals, tertiary care, urban areas, and insurance programs.

What explains India’s staggering diabetes burden?

“A lack of dietary diversity, dependence on high carbohydrate and processed foods, lack of physical activity and possibly environmental risks like air pollution have contributed to the high diabetes rates in India,” said Soumya Swaminathan, Chair, MS Swaminathan Research Foundation, and former Chief Scientist, WHO.

According to Jaime Miranda, a Peruvian NCD expert and Head of the University of Sydney School of Public Health, the trends seen in India is happening in other low- and middle-income countries (LMICs) as well. He has argued that people in LMICs face dual challenges in their “metabolic capacity,” as well as a range of factors that impose an excess ‘metabolic load’ that challenges homeostasis. Metabolic capacity, the ability of our body to metabolize and maintain normal levels of blood sugar or lipids, for example, is diminished in people with low birth weight, repeated infections, malnutrition, or obesity, while excess metabolic load comes from factors such as sedentary behavior, diets high in sugar or fat, psychosocial stress, and smoking.

“Whilst infants in LMICs are overcoming the challenge of child survival, they are not reaching their full developmental potential, which includes metabolic capacity,” he explained. “Because of this limited metabolic capacity, compounded with external load or stressors (e.g. poor exercise, physical inactivity and poor diets), we see metabolic and other cardiovascular failures at earlier ages in LMICs,” he added.

Diabetes in India is an excellent reminder that the communicable vs non-communicable diseases dichotomy is a false one. Often people have both. Infections are strong associated with NCDs, and NCDs greatly predispose to infections. For example, diabetes is a strong risk factor for infections such as tuberculosis, sepsis, and fungal infections. Infectious agents are well known to cause cancers (e.g. Human Papillomavirus is a cause of cervical cancer). Covid-19, we now know, increases the risk of diabetes. India’s massive Covid-19 waves may well have left millions more vulnerable to prediabetes and diabetes.

India needs a plan to tackle diabetes

India urgently needs a comprehensive, well-funded plan to deal with diabetes and NCDs. And the plan must include people with lived experience of diabetes. Apoorva Gomber has been living with type 1 diabetes for 15 years. She is a physician-researcher and Associate Director of Advocacy at the Center for Integration Science in Global Health Equity affiliated with Harvard Medical School and Brigham and Women’s Hospital, Boston. “Raising awareness and active engagement with community members living with diabetes is imperative for gaining a comprehensive understanding of their individual challenges and developing culturally appropriate equitable solutions,” she emphasized.

India needs to take care of the 100 million people who already have diabetes and its complications, and simultaneously work hard to prevent diabetes among the 136 million people with prediabetes and other risk factors (e.g. obesity). This will require India to invest more in health, and build a universal and comprehensive healthcare system. It is critical for the government to strengthen the public health system, and make essential technologies like blood sugar testing, oral hypoglycemic medicines, and insulin easily available. India will also need a plan for increasing access to newer innovations such as semaglutide. Currently, millions of people with diabetes pay out of pocket for medications, and this is untenable for those who live in poverty.

“The large number of people with prediabetes presents a window of opportunity to prevent diabetes,” said Viswanathan Mohan.

“We can reverse prediabetes,” said Sathyavani Prabhakar, an endocrinologist and diabetes expert at Lifestyle Health, Beth Israel Lahey in Burlington, Massachusetts. She believes greater awareness about prediabetes, early detection using tests like HbA1c, and treatment are key. “Education about lifestyle changes can play a huge role in preventing progression of prediabetes to type 2 diabetes. Primary care and family physicians in India will need to play a big role in diagnosing and managing prediabetes,” she added.

India’s nutrition policy must evolve to account for the diabetes epidemic. “We need a transformation in our food system to ensure that all Indians have access to a nutritious and balanced diet,” said Soumya Swaminathan, Chair, MS Swaminathan Research Foundation, and former Chief Scientist, WHO. “Nutrition literacy especially among school children and behavioural nudges to change dietary preferences will be needed, in addition to policy (expanding the public distribution system basket to include pulses, millets, fruits and vegetables) and regulatory (e.g. front of pack labelling) interventions,” she explained.

“As diabetes sweeps India with 101 million people already affected, it also presents an opportunity for the country to heavily invest in world-class collaborative science and technology to solve and cure the disease,” said KM Venkat Narayan, a professor of global health and epidemiology at Emory University. His team has argued that India offers a “fertile environment for shifting the paradigm from imprecise late-stage diabetes treatment toward early-stage precision prevention and care,” and have proposed a strategic research framework that could help.

Christine Ngaruiya, an Associate Professor at Yale University and a global NCD expert sees India as a wake up call for the rest of the world, an illustration of what a lack of attention to the NCD pandemic has done. “The global health community, strategic partners and funders – in particular – can no longer afford to neglect NCDs as priority in all areas. This goes for funding priorities as well; the lag in funding for NCDs is even more costly than we could have thought. Something must be done, and it must be done urgently,” she explained.

This then is a huge challenge ahead for India. Will the country invest adequately in health, tackle poverty, malnutrition, and other social determinants, and prevent the NCD pandemic from reaching unmanageable proportions? More importantly, can India afford the consequences of inaction?