Abstract
The chronic burden of diabetes on the health of individuals has extensive economic and public health impact on the well-being of any nation. Strategies in place to curtail the growing epidemic challenges mediate their interventions through the informative and preventive programs in place. Research being done to overcome these challenges gives hope towards what one can do at an individual level. The journey towards prevention is a long road once the limitations of the healthcare industry are realized.
License
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Article Type: Research Article
EUR J ENV PUBLIC HLT, Volume 3, Issue 1, 2019, Article No: em0023
https://doi.org/10.20897/ejeph/4004
Publication date: 11 Jul 2019
Online publication date: 28 Dec 2018
Article Views: 6766
Article Downloads: 9290
Open Access HTML Content References How to cite this articleHTML Content
INTRODUCTION
Diabetes is a global public health problem whose burden is evident in developing countries such as India (Kaveeshwar and Cornwall, 2014). According to the World Health Organisation (WHO), 422 million adults had diabetes in 2014 (Kakkar, 2016). The global prevalence of diabetes is estimated to be 366 million by 2030 (Wild et al., 2004); the overall global prevalence decreasing, with India having the largest number of diagnosed individuals (Katikireddi et al., 2011). Prevalence is defined as the total number of individuals in a population who have a disease or health condition at a specific period of time, usually expressed as a percentage of the population (Harvard School of Public Health, n.d.). More than 62 million people in India are currently affected by the disease (Joshi and Parikh, 2007; Kumar et al., 2013). The rapid rise of the Indian middle class, coupled with sedentary lifestyles and a shift in dietary patterns, fuels the existing burden of this disease (Hu, 2011).
A considerable reduction in the incidence of type 2 diabetes can result from changes in lifestyle (Wing et al., 2013), or by using metformin (Diabetes Prevention Program Research Group, 2002). On the other hand, with the adoption of western dietary habits amongst the comparatively affluent urban (Ramachandran et al., 2008) populations in India (Ramachandran et al., 2001), and with increased intake of complex carbohydrates, animal lipid (Arora et al., 2014) and reduced consumption of fibre, there’s a likelihood of predisposition to diabetes (due to a high level of impaired glucose tolerance) (Abate and Chandalia, 2003). However, diabetes is not just affecting the higher socio-economic strata; even the less economically advantaged sections of society are being affected by it, owing to rapid penetration of fast food amongst all levels of society in India (Verma et al., 2012). Going by the health impact pyramid (Frieden, 2010), chronic conditions like diabetes, when diagnosed, need constant adherence when it comes to medications, and predicting compliance can be difficult (Sbarbaro, 1979; Haynes et al., 1996). Limited access to medications and treatment results in more complications from diabetes in people who have a lower socio-economic standing (Ramachandran, 2002).
Studies which suggested that smoking may have an increased risk of causing diabetes (Will et al., 2001) were later confirmed as having a true association with active smoking (Willi et al., 2007). An intervention towards cessation of smoking as a modifiable risk factor towards the risk of developing diabetes showed that initially quitting smoking resulted in weight gain (which is detrimental), but that the overall health benefits far outweigh the weight gain in terms of reduced risk of atherosclerosis (Bush et al., 2016) and ischemic heart disease in the long run (Wannamethee et al., 2001). The Framingham Study, a 20-year prospective cohort study looking at the evidence of prior diabetes and cardiovascular events, confirms the association of heart disease and diabetes (Kannel and McGee, 1979). Therefore, timely intervention is of great clinical relevance, lest diabetes causes other harms to the body (Tschoepe and Roesen, 1998). It is therefore important to know how interventions work and how effective they are.
The risk of obesity is linked to chronic heart disease and diabetes in a country like India, even though when compared to the global population, Indians tend to have a lower rate of obesity and overweight (Kaveeshwar and Cornwall, 2014). This brings to attention the fact that, on a comparative basis, the Indian population is more prone to develop diabetes, even with a lower body mass index (Misra and Khurana, 2011).
STRATEGIES
One of the major strategies in controlling diabetes is in maintaining effective glucose levels. The most recent criteria to be followed for diagnosing diabetes mellitus are as follows (American Diabetes Association, 2018):
-
Fasting plasma glucose ≥ 126 mg/dl
-
2-hour post-load glucose ≥ 200 mg/dl
-
HbA1c ≥ 6.5%
-
Random plasma glucose concentration ≥ 200 mg/dl
An effective strategy lies in primary prevention through healthy lifestyle management and reducing risk through proper drug therapy. These form the cornerstone for managing diabetes in India (Venkataraman, 2009).
PROGRAMS
The National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke (NPDCS) (A Manual for Medical Officer, 2009), launched by the Government of India in 2008, plans to implement interventions in health promotion and education for the community; early detection of cases through appropriate screening; improving existing health systems for tackling non-communicable diseases; and improving dialysis facilities (Verma et al., 2012).
RESOURCES
A valuable resource is the guide for health workers under the NPDCS. Health workers are the people who are in direct contact with the population at risk. This guide deserves applause as it mentions exactly what needs to be done, and what needs to be avoided. Its recommendations for the prevention and control of diabetes hinge on the fact that all diabetic persons, once diagnosed, should get their blood glucose estimation, kidney function test, eye check-up and foot examination regularly in conjunction with proper diet and regular exercise (A Guide for Health Workers, 2009).
PARALLEL/CONTRAST
The Building Indo-UK Collaboration in Chronic Diseases 2009 workshop held in New Delhi explored some of the challenges faced by both countries, and discussed various ideas for future solutions, as stated below:
-
The burden of diabetes in the United Kingdom (UK) presents a conundrum that, due to the slow nature of onset, there are a significant number of hidden cases. These hidden cases tend to have more complications due to lack of proper intervention at the proper time. Complications range from severe retinopathy to major amputations, kidney failure and heart problems such as ischemic heart disease, which includes myocardial infarction (ICMR, 2009).
-
By contrast, in India, which has the highest population of diabetic individuals in the world, prevalence continues to increase. One reason is that the primary health care system there has been structured and designed with the main purpose of catering to mostly acute conditions (Venkataraman, 2009). Areas for research therefore include reasons for this increase in prevalence, and differences in phenotype (ICMR, 2009).
RESEARCH AND ITS SCOPE
Areas of possible research include comparing phenotypic differences between patients of Indian and European descent towards answers in pathogenesis of disease. Research towards finding the basis of gene-environment interactions that has a flow-on effect towards disease causation is another avenue for potential investigation (ICMR, 2009). Recruiting participants for trials is another challenge faced by epidemiologists in a country like India, the reason being the hesitant nature of people when it comes to screening, due to lack of awareness (Ranjani et al., 2015).
Another area for research lies in establishing a positive association between diabetes and cancers, as type 2 diabetes and cancers are ‘common diseases’ that are ‘frequently diagnosed in the same individual.’ The risk of developing cancers of the breast, liver, pancreas, rectum and the urinary tract are increased in cases having type 2 diabetes (Adami et al., 1991; Onitilo et al., 2012).
PREVALENCE AND THE ECONOMIC BURDEN
The prevalence of diabetes in India has far surpassed the capacity to treat, and that has resulted in a large number of cases remaining undiagnosed (Guariguata et al., 2014). The history of diabetes in India dates back to 2500 BC where old Indian texts referred to it as ‘Madhumeha.’ This gives an insight that this disease was known since then, and that the prevalence may not have been as high as it is now (Anjana et al., 2011). The economic burden of diabetes is tremendous, with the cost for obesity in India being 1.1% of the gross domestic product (Popkin et al., 2001). Its prevalence is linked to the economic burden diabetes imposes on a population, as not only high-income countries are affected, but low-income countries are as well (Seuring et al., 2015).
CHALLENGES
Elimination of diabetes is perhaps improbable, because it is a chronic disease and there is no one specific cause for it. The genetic basis of this disease is most intriguing as this exerts the most pressure when it comes to the population at risk - the cohort being the South-East Asian population, with India at the forefront. Accepting the challenges of this disease is the humblest thing a country’s premier health organisation can do, and it is incumbent on its officials to formulate plans to combat and monitor the progress of disease on a national scale. The intertwining of other chronic conditions affecting the cardiovascular and urinary systems makes diabetes more debilitating if not treated, allowing the disease to progress with pride. The lack of good epidemiological data adds to these challenges in a country like India (Anjana et al., 2011). Another challenge is the inability of the national health system to work in conjunction with other global health organisations (the WHO), and this poses serious drawbacks towards fulfilling its policy-based goals (WHO, 2018).
TOWARDS PREVENTION AND HOPE
The primary question that one could pose towards prevention would be “Is there a cure for diabetes?” The answer, for now, is a disappointing “no”. The reasons all boil down to the fundamental fact that it is a largely multi-factorial disease with a genetic pre-disposition (Wolford et al., 2004). The Diabetes Research Institute Foundation in Florida is doing some exceptional work in cell- based therapy and bioengineering, and the results can have a positive impact on how the disease is dealt with in India (Diabetes Research Institute Foundation, 2016). Knowing that environmental and genetic factors are responsible for type 2 diabetes and firmly controlling for any associated risk factors, would perhaps delay its onset, or not allow it to happen at all. Cessation of smoking, limiting alcohol intake, being physically active, and following a healthy diet all count towards better control. If these are controlled, then the predicted prevalence can be significantly brought down, and the burden of disease reduced. The discovery of insulin (Bliss, 2013) was a major breakthrough in treating diabetes. Such breakthroughs certainly gives hope for a newer protocols that could one day lead to a more definitive cure in the face of this disease, keeping in mind the challenges the disease imposes on the healthcare system (Ramachandran et al., 2014).
References
- A Guide for Health Workers. (2009). National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke. Available at: http://www.searo.who.int/india/topics/cardiovascular_diseases/NCD_Resources_Training_module_for_NPDCS_for_health_workers.pdf (Accessed 26 October 2018).
- A Manual for Medical Officer. (2009). National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke. Available at: http://www.searo.who.int/india/topics/cardiovascular_diseases/ncd_resources_combined_manual_for_medical_officer.pdf (Accessed 26 October 2018).
- Abate, N. and Chandalia, M. (2003). The impact of ethnicity on type 2 diabetes. Journal of Diabetes and its Complications, 17(1), 39-58. https://doi.org/10.1016/S1056-8727(02)00190-3
- Adami, H-O., McLaughlin, J., Ekbom, A., Berne, C., Silverman, D., Hacker, D. et al. (1991). Cancer risk in patients with diabetes mellitus. Cancer Causes & Control, 2(5), 307-314. https://doi.org/10.1007/BF00051670
- American Diabetes Association. (2018). 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2018. Diabetes Care, 41(1), s13-s27. https://doi.org/10.2337/dc18-S002
- Anjana, R. M., Ali, M. K., Pradeepa, R., Deepa, M., Datta, M., Unnikrishnan, R. et al. (2011). The need for obtaining accurate nationwide estimates of diabetes prevalence in India - Rationale for a national study on diabetes. Indian Journal of Medical Research, 133(4), 369-380. Available at: http://www.ijmr.org.in/text.asp?2011/133/4/369/80127 (Accessed 4 November 2018).
- Arora, N. K., Pillai, R., Dasgupta, R. and Garg, P. R. (2014). Whole of Society Monitoring Framework for Sugar, Salt, and Fat Consumption and Noncommunicable Diseases in India. Annals of the New York Academy of Sciences, 1331(1), 157-173. https://doi.org/10.1111/nyas.12555
- Bliss, M. (2013). The Discovery of Insulin. University of Chicago Press.
- Bush, T., Lovejoy, J. C., Deprey, M. and Carpenter, K. M. (2016). The effect of tobacco cessation on weight gain, obesity, and diabetes risk. Obesity, 24(9), 1834-1841. https://doi.org/10.1002/oby.21582
- Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine, 346(6), 393-403. http://doi.org/10.1056/NEJMoa012512
- Diabetes Research Institute Foundation. (2016). Developing a Biological Cure. Available at: https://www.diabetesresearch.org/curing-diabetes. (Accessed 5 November 2018)
- Frieden, T. R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health, 100(4), 590-595. http://doi.org/10.2105/ajph.2009.185652
- Guariguata, L., Whiting, D. R., Hambleton, I., Beagley, J., Linnenkamp, U. and Shaw, J. E. (2014). Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Research and Clinical Practice, 103(2), 137-149. https://doi.org/10.1016/j.diabres.2013.11.002
- Harvard School of Public Health. (n.d.). Prevalence and Incidence Defined. Available at: https://www.hsph.harvard.edu/obesity-prevention-source/prevalence-incidence/ (Accessed 5 November 2018).
- Haynes, R. B., McKibbon, K. A. and Kanani, R. (1996). Systematic Review of Randomised Trials of Interventions to Assist Patients to Follow Prescriptions for Medications. Lancet, 348(9024), 383-386. https://doi.org/10.1016/S0140-6736(96)01073-2
- Hu, F. B. (2011). Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care, 34(6), 1249-1257. https://doi.org/10.2337/dc11-0442
- Indian Council of Medical Research (ICMR). (2009). Building Indo-UK Collaboration in Chronic Diseases. Available at: https://www.icmr.nic.in/sites/default/files/reports/Chronic_Diseases_Report.pdf. (Accessed 5 November 2018).
- Joshi, S. R. and Parikh, R. M. (2007). India - diabetes capital of the world: now heading towards hypertension. Journal of the Association of Physicians of India, 55, 323-324. Available at: http://www.japi.org/may2007/E-323.pdf (Accessed 26 April 2016)
- Kakkar, R. (2016). Rising burden of diabetes-public health challenges and way out. Nepal Journal of Epidemiology, 6(2), 557-559. http://doi.org/10.3126/nje.v6i2.15160
- Kannel, W. B. and McGee, D. L. (1979). Diabetes and Cardiovascular Disease: The Framingham Study. JAMA, 241(19), 2035-2038. http://doi.org/10.1001/jama.1979.03290450033020
- Katikireddi, S. V., Morling, J. R. and Bhopal, R. (2011). Is there a divergence in time trends in the prevalence of impaired glucose tolerance and diabetes? A systematic review in South Asian populations. International Journal of Epidemiology. 40(6), 1542-1553. https://doi.org/10.1093/ije/dyr159
- Kaveeshwar, S. A. and Cornwall, J. (2014). The current state of diabetes mellitus in India. Australasian Medical Journal, 7(1), 45-48. http://doi.org/10.21767/AMJ.2014.1979
- Kumar, A., Goel, M. K., Jain, R. B., Khanna, P. and Chaudhary, V. (2013). India towards diabetes control: key issues. Australasian Medical Journal, 6(10), 524-531. http://doi.org/10.21767/amj.2013.1791
- Misra, A. and Khurana, L. (2011). Obesity-related non-communicable diseases: South Asians vs White Caucasians. International Journal of Obesity, 35(2), 167-187. https://doi.org/10.1038/ijo.2010.135
- Onitilo, A. A., Engel, J. M., Glurich, I., Stankowski, R. V., Williams, G. M. and Doi, S. A. (2012). Diabetes and cancer I: risk, survival, and implications for screening. Cancer Causes & Control, 23(6), 967-981. https://doi.org/10.1007/s10552-012-9972-3
- Popkin, B. M., Horton, S., Kim, S., Mahal, A. and Shuigao, J. (2001). Trends in Diet, Nutritional Status, and Diet-related Noncommunicable Diseases in China and India: the Economic Costs of the Nutrition Transition. Nutrition Reviews, 59(12), 379-390. https://doi.org/10.1111/j.1753-4887.2001.tb06967.x
- Ramachandran, A., Snehalatha, C., Kapur, A., Vijay, V., Mohan, V., Das, A. K. et al. (2001). High Prevalence of Diabetes and Impaired Glucose Tolerance in India: National Urban Diabetes Survey. Diabetologia, 44(9), 1094-1101. https://doi.org/10.1007/s001250100627
- Ramachandran, A., Snehalatha, C., Vijay, V. and King, H. (2002). Impact of Poverty on the Prevalence of Diabetes and its Complications in Urban Southern India. Diabetic Medicine, 19(2), 130-135. https://doi.org/10.1046/j.1464-5491.2002.00656.x
- Ramachandran, A., Mary, S., Yamuna, A., Murugesan, N. and Snehalatha, C. (2008). High Prevalence of Diabetes and Cardiovascular Risk Factors Associated with Urbanization in India. Diabetes Care, 31(5), 893-898. https://doi.org/10.2337/dc07-1207
- Ramachandran, A., Snehalatha, C. and Ma, R. C. W. (2014). Diabetes in South-East Asia: An update. Diabetes Research and Clinical Practice, 103(2), 231-237. https://doi.org/10.1016/j.diabres.2013.11.011
- Ranjani, H., Weber, M. B., Anjana, R. M., Lakshmi, N., Venkat Narayan, K. M. and Mohan, V. (2015). Recruitment challenges in a diabetes prevention trial in a low- and middle-income setting. Diabetes Research and Clinical Practice, 110(1), 51-59. https://doi.org/10.1016/j.diabres.2015.07.013
- Sbarbaro, J. A. (1979). Compliance: Inducements and Enforcements. Chest, 76(6), 750-756. https://doi.org/10.1378/chest.76.6.750
- Seuring, T., Archangelidi, O. and Suhrcke, M. (2015). The Economic Costs of Type 2 Diabetes: A Global Systematic Review. PharmacoEconomics, 33(8), 811-831. http://doi.org/10.1007/s40273-015-0268-9
- Tschoepe, D. and Roesen, P. (1998). Heart Disease in Diabetes Mellitus: A Challenge for Early Diagnosis and Intervention. Exp Clin Endocrinol Diabetes, 106(1), 16-24. https://doi.org/10.1055/s-0029-1211944
- Venkataraman, K., Kannan, A. T. and Mohan, V. (2009). Challenges in diabetes management with particular reference to India. International Journal of Diabetes in Developing Countries, 29(3), 103-109. https://doi.org/10.4103/0973-3930.54286
- Verma, R., Khanna, P. and Mehta, B. (2012). National programme on prevention and control of diabetes in India: Need to focus. Australasian Medical Journal, 5(6), 310-315. http://doi.org/10.21767/AMJ.2012.1340
- Wannamethee, S. G., Shaper, A. G. and Perry, I. J. (2001). Smoking as a Modifiable Risk Factor for Type 2 Diabetes in Middle-Aged Men. Diabetes Care, 24(9), 1590-1595. https://doi.org/10.2337/diacare.24.9.1590
- Wild, S., Roglic, G., Green, A., Sicree, R. and King, H. (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care, 27(5), 1047-1053. https://doi.org/10.2337/diacare.27.5.1047
- Will, J. C., Galuska, D. A., Ford, E. S., Mokdad, A. and Calle, E. E. (2001). Cigarette Smoking and Diabetes Mellitus: Evidence of a Positive Association from a Large Prospective Cohort Study. International Journal of Epidemiology, 30(3), 540-546. http://doi.org/10.1093/ije/30.3.540
- Willi, C., Bodenmann, P., Ghali, W. A., Faris, P. D. and Cornuz, J. (2007). Active Smoking and the Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA, 298(22), 2654-2664. https://doi.org/10.1001/jama.298.22.2654
- Wing, R. R., Bolin, P., Brancati, F. L., Bray, G. A., Clark, J. M. and Coday, M. et al. (2013). Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. The New England Journal of Medicine, 369(2), 145-154. http://doi.org/10.1056/NEJMoa1212914
- Wolford, J. K. and Vozarova de Courten, B. (2004). Genetic basis of type 2 diabetes mellitus: implications for therapy. Treatments in Endocrinology, 3(4), 257-267. https://doi.org/10.2165/00024677-200403040-00007
- World Health Organization (WHO). (2018). Time to deliver: Report of the WHO Independent High-level Commission on Noncommunicable Diseases. Available at: http://apps.who.int/iris/bitstream/handle/10665/272710/9789241514163-eng.pdf?ua=1 (Accessed 4 November 2018).
How to cite this article
Vancouver
Mitra S. Diabetes Research, Prevalence, and Intervention in India. EUR J ENV PUBLIC HLT. 2019;3(1):em0023. https://doi.org/10.20897/ejeph/4004
APA
Mitra, S. (2019). Diabetes Research, Prevalence, and Intervention in India. European Journal of Environment and Public Health, 3(1), em0023. https://doi.org/10.20897/ejeph/4004
AMA
Mitra S. Diabetes Research, Prevalence, and Intervention in India. EUR J ENV PUBLIC HLT. 2019;3(1), em0023. https://doi.org/10.20897/ejeph/4004
Chicago
Mitra, Sayan. "Diabetes Research, Prevalence, and Intervention in India". European Journal of Environment and Public Health 2019 3 no. 1 (2019): em0023. https://doi.org/10.20897/ejeph/4004
Harvard
Mitra, S. (2019). Diabetes Research, Prevalence, and Intervention in India. European Journal of Environment and Public Health, 3(1), em0023. https://doi.org/10.20897/ejeph/4004
MLA
Mitra, Sayan "Diabetes Research, Prevalence, and Intervention in India". European Journal of Environment and Public Health, vol. 3, no. 1, 2019, em0023. https://doi.org/10.20897/ejeph/4004