The panel discussion titled ‘Diabetes as an interlinked disease: The CKM approach to NCDs. Decoding India’s NCD burden’ focused on one of India’s rapidly evolving health challenges. Moderated by Pooja Biraia, THE WEEK’s Principal Correspondent, the session brought together Dr Pankaj Bhardwaj, director of ICMR-NIIRNCD; Dr Rajesh Khadgawat, professor of endocrinology at AIIMS; and Dr Naveen Garg, professor of cardiology at SGPGIMS Lucknow, who collectively argued that the cardiovascular–kidney–metabolic (CKM) model offers India a more effective path to address non-communicable diseases. Excerpts:
Pooja Biraia/ Let us start with the exhaustive study done by the Indian Council of Medical Research (ICMR), which highlights how bad the situation really is. Please tell us about the study, how it started and what the findings are.
Dr Pankaj Bhardwaj/ This study was started in 2008 at the national level. It is a large study where entire states were covered in a phase-wise manner, and screening was done in individuals above 20. The sample size was around 1,13,000, and the data that was generated was quite surprising. It says that diabetes in India is currently at 11 per cent, but that ranges from states like Uttar Pradesh, where it is 4 or 5 per cent to places like Goa, where it is 10 per cent. Interestingly, one aspect we looked at was abdominal obesity. When we say obesity, it is just about BMI, but when it comes to cardiometabolic kidney problems, then it is more about abdominal obesity. So though obesity it 29 per cent in India, abdominal obesity is 39 per cent.
The study also tells us about pre-diabetes, which is also very important. About 15 per cent in the study were pre-diabetic. Sometimes, as we say in epidemiology, there is always a plateau and you see the prevalence of the disease then coming down. But, in this case, this is not going to happen because of the higher level of pre-diabetics.
Biraia/ There are also some startling statistics from the National Family Health Survey (NFHS) 5 that shows that 25 per cent Indians are overweight or obese, while 40 per cent women have abdominal obesity. So, please throw light on this survey and what we can do about it.
Dr Rajesh Khadgawat/ Most of the time, we think that the maximum increase (in diabetes) has come where people are obese or are becoming obese. Yes, there is an increase there, but the maximum increase has happened in poorest and poor segments, in the rural areas, and in those whose BMI is in the normal range, but it has increased within that range. The unfortunate thing is that this is happening in areas where our health infrastructure is not that robust.
Biraia/ That brings me to another important aspect, which is that these numbers not only focus on blood sugar, but also bring in the cardiovascular-kidney-metabolic (CKM) paradigm, where multiple organs are involved.
Dr Naveen Garg/ Diabetes and obesity are not simple diseases. They are associated with multiple problems such as cholesterol, lipid irregularity, hypertension and fatty liver, which can ultimately lead to cirrhosis. They can also lead to chronic kidney disease, cerebrovascular accidents, stroke and heart attack. So, one should take a holistic approach towards the management of diabetes and obesity. We should have a healthy diet and exercise, ensure mental relaxation and avoid risk factors such as smoking and alcohol.
As far as management is concerned, the bottom line is control of blood sugar. The second aim of management is avoiding complications. For this, we should use medication that can be useful not only in the control of diabetes and obesity, but which can also prevent the development of complications. One of the agents is GLP-1 agonist, which is now available in our country and one of the very good agents is semaglutide.
Biraia/ That also brings us to the important aspect of childhood obesity. Tell us about the figures at AIIMS and what people come to you with.
Khadgawat/ Apart from hospital-based prevalence of childhood obesity, we have gone to Delhi schools and carried out a study in one lakh children.
In the initial studies we did in 2009 and 2010, we found that 5 per cent of them were obese and 15 per cent were overweight. In government schools, obesity was less than 1 per cent. Then, after 2015, we went to the same schools again. On average, childhood obesity remained less than 1 per cent in government schools, but it increased from 5 per cent to 7 per cent in private schools.
We then went back to our original data (2009-10), and found that 80 per cent of those children had become obese adults.
We have to start preventive measures at the school level, like introducing chapters on healthy nutrition, providing them more playgrounds, having teachers who can guide them, and allotting an hour of dedicated play time.
Biraia/ Could you explain to us in layman’s terms the connect between diabetes, obesity and the heart?
Garg/ Actually, diabetes and obesity are associated with hypertension and dyslipidaemia (unhealthy level of lipid—fats—in the blood). Whenever there is a multiple-risk factor, it ultimately leads to cardiovascular disease. So there is involvement of the heart and the patient could have a heart attack.
Second, it involves the heart muscles and can lead to heart failure and could ultimately lead to problems with the kidney. There is a connect between the heart and kidney. And because atherosclerotic diseases (related to build-up of plaque in the arteries) can affect the arteries that supply blood to the brain, it could also lead to a stroke.
So, they are all interrelated. And that is why we should have a holistic approach to diagnose patients early in the development of complications. Suppose any patient with diabetes and obesity comes to any physician, we should investigate for any silent involvement of the heart, kidney or brain. If we can pick up those patients early, before development of full-fledged complications, we can have a good outcome.