Indian physicians around 1500 BC were among the first to identify diabetes as a deadly disease. They named it “madhumeha”, which translates to “honey” urine. The word 'diabetes', or 'to pass urine through', was first used in 250 BC by the Greeks. The first description of the two predominant forms of diabetes—type 1 and 2—was by Indian physicians Charaka and Sushruta.
Diabetes, which is considered one of the four priority non-communicable diseases (NCD), has had a steady increase in incidence and prevalence. In 2014, there were 422 million people living with diabetes, according to the World Health Organization. In 1980, it was 108 million. The global prevalence (age-standardised) of diabetes in the adult population has nearly doubled, from 4.5 per cent to 8.5 per cent.
In India, the distribution of diseases responsible for deaths and disability-adjusted life years (DALY) lost has evolved rather dramatically in the last quarter century. In 1990, communicable and nutritional diseases accounted for a major share of the disease burden in India. But, current estimates clearly demonstrate a predominance of NCDs. The burden of diabetes has also gone up. According to the International Diabetes Federation, India has nearly 73 million diabetics now and the number is expected to touch 134 million by 2045. The rather sharp increase in the prevalence of diabetes in rural India, especially in the more developed states, and the progressive lowering of the age at which people become susceptible to type 2 diabetes (in their 20s), are worrying.
Indians suffering from diabetes are demonstrably different from those in other populations. They have more abdominal fat despite being leaner, are more insulin resistant and have evidence of chronic inflammation. The differences have been attributed to the inherent differences in handling glucose and fats by the body that makes Indians more prone to resistance to the action of insulin.
Studies on south Asians living in the UK not only demonstrated differences in their bodily characteristics from those of the native population, but also suggested that a change in environment and increased chances of upward mobility in the socioeconomic ladder would make our ethnically 'at-risk' population more vulnerable to diabetes.
Rapid economic development and globalisation have resulted in the westernisation of our diet. Availability and choices of food that are high in calories, carbohydrates and fat have increased in urban areas. A high consumption of refined carbohydrates—polished white rice or other refined cereals—is thought to be the biggest culprit.
The sharp rise in the burden of all NCDs, especially diabetes, is a pan-Indian phenomenon, which is not surprising, given their association with socioeconomic development and urbanisation. But, there is a fair bit of heterogeneity in the rate of this rise and disease prevalence across the country. A study of the epidemiological transition across a span of 25 years revealed that, by 2003, the trend of disease burden in the country as a whole had changed to predominance of non-communicable diseases. However, this transition had not been uniform in terms of geography or disease type. While all states have shown a substantial increase in prevalence of all leading NCDs, the decrease in the prevalence of communicable diseases has been slow in Bihar, Jharkhand, Uttar Pradesh, Rajasthan, Meghalaya, Assam, Chhattisgarh, Madhya Pradesh and Odisha. These states continue to bear the burden of communicable as well as non-communicable diseases. A more detailed analysis can be seen in the recently published India State-level Disease Burden Initiative report, which was released on World Diabetes Day—November 14. It is expected that the information in this report would inform government policy and measures to address problem areas in each state.
One such government initiative is the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). Information, education and communication activities targeting individuals are key elements of the programme. Cell phone-based apps and video games, and websites that can provide accurate information about the disease are being encouraged. Community outreach programmes targeting special groups like mothers and schoolgoing children are also being implemented.
Launch of NCD clinics at community health centres, appointing dedicated nurses, and upgrading facilities at district hospitals and medical colleges are all part of this programme's roadmap. Basic training is being imparted to practitioners of all systems of medicine, with focus on diabetes prevention and management, and assessment of complications and rehabilitation. A pilot project linking NPCDCS with AYUSH practitioners has also been initiated.
A disease that was previously restricted to the affluent class—so much so that an editorial in The Lancet in 1907 said, “What gout is to the aristocracy of Britain, diabetes is to the aristocracy of India”—has now become an “equal opportunities afflicter”. No religion, age group, gender or socioeconomic class is immune to its inimical impact on human health. Efforts involving individuals, communities, government, NGOs and the private sector will be required to thwart the proliferation of diabetes.
Dr Tandon is professor and head of department, endocrinology and metabolism, AIIMS, Delhi.
Dr Krishnamurthy is senior resident, department of endocrinology and metabolism, AIIMS, Delhi.
