India currently faces an uncertain future in relation to the potential burden that diabetes may impose upon the country.

Many influences affect the prevalence of disease throughout a country, and identification of those factors is necessary to facilitate change when facing health challenges.

The etiology of diabetes in India is multifactorial and includes genetic factors coupled with environmental influences. Rapid urbanisation and industrialisation have produced advancement on the social and economic front in developing countries such as India, which have resulted in dramatic lifestyle changes leading to lifestyle related diseases. The transition from a traditional to modern lifestyle, consumption of diets rich in fat and calories combined with a high level of mental stress has compounded the problem further.

Risk factors for diabetes in Indians: 

  1. Indians develop diabetes at a very young age, at least 10 to 15 years earlier than the western population. Obesity is one of the major risk factors for diabetes, however, despite having lower overweight and obesity rates, India has a higher prevalence of diabetes compared to western countries. This suggests that diabetes may occur at a much lower body mass index (BMI) in Indians compared with Europeans. Therefore, relatively lean Indian adults with a lower BMI may be at equal risk as those who are obese. Indians also happen to be genetically predisposed to the development of coronary artery disease due to dyslipidemia and low levels of high-density lipoproteins (HDL). Indians therefore are more prone to development of the complications of diabetes at an early age (20-40 years) compared with Caucasians (>50 years). These findings highlight the need for careful screening and monitoring for diabetes regardless of age(1).
  1. Insulin Resistance: Asian Indians have been found to be more insulin resistant as compared to Caucasians. Insulin resistance is associated with type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD). These abnormalities have been aggravated because of imbalanced and excess nutrition in developed countries, and rapid nutritional and lifestyle transition occurring in developing countries(2).

Challenges for the Indian population:

  1. HbA1c (a Glycated/Glycosylated Hemoglobin) test checks your average blood sugar level in the past 3 months, which is the gold standard test for management of DM, is not easily available in India. There is also a lack of awareness regarding the same. Moreover, higher values of HbA1c increase the risk of diseases related to heart, kidney, nerve, brain and eye(3). According to the DAWN2 global study, which surveyed psychosocial challenges faced by people with diabetes and caregivers in 17 countries, including India, living with diabetes presents a significant psychological burden. Yet, only 23% of diabetes patients and 18% of family or caregivers in India had participated in a diabetes education program(4).
  1. There is a clinical inertia for commencement of insulin therapy amongst the patient and the clinician populations. The DAWN2 study also revealed that only 30% of surveyed healthcare professionals believe that healthcare is well organized for treatment of chronic conditions, and 79% believe that diabetes should be given higher priority(4).
  1. Lack of insulin guidelines prevents the primary care physicians from initiating insulin therapy. Studies have shown that often doctors wait until the patient’s HbA1c level is higher than 9% to start insulin therapy, which often results in months or years of high blood glucose and an increased risk of developing complications later on. One unfortunate reality is that many busy medical practices are not set up to address the needs of people who take insulin. Starting insulin requires education and easy access to health-care providers who are knowledgeable about insulin therapy, including diabetes nurse educators, pharmacists, and doctors(5).
  1. Lack of focus on exercise and physical fitness has contributed to obesity, dyslipidemia and type 2 diabetes. According to a very recent study published in the European journal Diabetologia, an extra hour of sedentary time was associated with a 22% increased odds for type 2 diabetes and a 39% increased odds for the metabolic syndrome. The pattern in which sedentary time was accumulated was weakly associated with the presence of the metabolic syndrome. These results reinforce how a sedentary lifestyle plays a significant role in the development and prevention of type 2 diabetes(6).
  1. There is no initiative taken up by the Government to curb the inflation of this epidemic at the grass root level.
  1. There is high reluctance amongst patients for self-monitoring of blood glucose (SMBG). Visits to the diabetologist are few and far between. As a result of this, the sugar levels remain unchecked for prolonged periods of time.  80% of Healthcare professionals surveyed as part of the DAWN2 study believe that improving the availability of diabetes self-management education will help reduce the burden of diabetes(4).

Dr Shabbir Baldiwala is a practicing diabetologist consulting at Saifee Hospital, Wockhardt Hospital, New Leaf Clinic & Metro Healthcare in Mumbai.

References:
  1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920109/
  2. http://www.ncbi.nlm.nih.gov/pubmed/19675375
  3. Glycated Hemoglobin (HbA1c or A1c) Calculator | Medindiahttp://www.medindia.net/patients/calculators/bloodsugar-hba1c-convertor.asp#ixzz40mSEIoHX
  4. http://www.dawnstudy.com/content/dam/Dawnstudy/AFFILIATE/www-dawnstudy-com/Home/DAWN2/country-profile/india-country-profile.pdf
  5. http://www.diabetesselfmanagement.com/managing-diabetes/treatment-approaches/type-2-diabetes-and-insulin/
  6. http://link.springer.com/article/10.1007/s00125-015-3861-8/fulltext.html