High Diabetes Rates for Poorer Indians in Rich Cities, Mirroring West

Liam Davenport

June 07, 2017

The demographic pattern of the diabetes epidemic in India has shifted so that, in more affluent cities, the disease is more common among poorer people than among those with a higher socioeconomic status (SES), say Indian researchers who are calling for more effective prevention programs.

The study of more than 57,000 nationally representative individuals from 15 states showed that there is a wide variation in the prevalence of diabetes both between states and between urban and rural areas. The research was published online in Lancet Diabetes & Endocrinology on June 7.

However, it is also notable that low-SES individuals living in richer cities were up to twice as likely to have diabetes than people from higher-SES backgrounds living in the same cities.

This is a turnaround from what was observed previously.

Senior author Viswanathan Mohan, MD, president of Madras Diabetes Research Foundation, Chennai, India, noted in a Lancet statement that increasing prosperity in India means that "the diabetes epidemic is likely to disproportionately affect the poorer sections of society, a transition that has already been seen in high-income countries."

"This trend is a matter of great concern because it suggests that the diabetes epidemic is spreading to individuals who can least afford to pay for its management," added lead author Ranjit Mohan Anjana, MD, vice president of the Madras Diabetes Research Foundation.

Dr Mohan noted also that the high rate of prediabetes uncovered by their findings implies "the existence of a huge number of individuals" at risk of developing diabetes," which could "have serious implications for the country's health and socioeconomic development and highlight the urgent need for implementing effective preventative measures."

Management of Diabetes in India "Varies Widely": Blindess, Renal Failure Common

In an accompanying comment, Vijay Viswanathan, MD, PhD, MV Hospital for Diabetes, Chennai, India, notes that, currently, the management of diabetes in India "varies widely."

"Whereas some people living in urban parts of the country have access to excellent diabetes care services and can afford the out-of-pocket expenditure associated with diabetes, people living in semiurban and rural areas of the country do not have access to the diabetes centers or clinics that provide comprehensive diabetes care," he writes.

The consequence is that diabetes patients in rural areas are not screened early for microvascular and macrovascular complications, Dr Viswanathan says, adding, "This situation means that the development of advanced complications such as renal failure and blindness due to retinopathy are commonplace."

Describing diabetes as "one of the biggest challenges" in Indian healthcare, he says that addressing it will require solutions at many levels, including increased awareness of the disease and its complications throughout the country — especially in rural areas — and the establishment of cost-effective prevention programs.

Half of All Diabetes Patients Hadn't Previously Been Diagnosed

As prior attempts to study the prevalence of diabetes in India have not reflected the heterogeneity of the country and its population, for the current work, the researchers conducted a community-based study of 57,117 individuals aged at least 20 years using a stratified, multistage design.

The population was representative of 14 of the 28 states in India, with Tamil Nadu, Chandigarh, Jharkhand, and Maharashtra samples from 2008 and 2010; Andhra Pradesh, Bihar, Gujarat, Karnataka, and Punjab sampled between 2012 and 2013; and Assam, Mizoram, Arunachal Pradesh, Tripura, Manipur, and Meghalaya between 2012 and 2015.

World Health Organization criteria were used to diagnose diabetes and prediabetes based on capillary oral glucose tolerance tests, which did not allow for differentiation between type 1 and type 2 diabetes.

The mean age of the study population was 41.3 years, with little difference between states. The proportion of males ranged from 37% in Karnataka to 51% in Chandigarh, and the mean body mass index ranged from 21.0 kg/m2 in Assam to 24.3 kg/m2 in Punjab.

On the state level, there were variations in mean waist circumference, systolic blood pressure, smoking rates, and alcohol consumption. There was also wide variation in mean gross domestic product (GDP), ranging from $3433 in Chandigarh to $682 in Bihar. Overall, 20% of participants were in the low-SES stratum, while 46% were in the middle and 33% in the high strata.

Map of Indian States [click here for a larger image]

The overall prevalence of diabetes was 7.3%, ranging from 4.3% in Bihar to 10.5% in Punjab and from 5.2% in rural areas to 11.2% in urban areas (< .0001).

The researchers note that 70% of the Indian population lives in rural areas.

The prevalence of diabetes was also higher in mainland states than in the northeast of the country, at 8.3% vs 5.9% (< .0001).

In all, 47.3% of diabetes patients had not previously been diagnosed. The ratio of self-reported to newly diagnosed diabetes was 1:0.9 overall, ranging from 1:0.7 in urban areas to 1:1.5 in rural areas.

Prevention Efforts Desperately Needed

Prediabetes was identified in 10.3% of participants overall, ranging from 6.0% in Mizoram to 14.7% in Tripura. In general, the prevalence of impaired fasting glucose was higher than that of impaired glucose tolerance.

Although in rural states the prevalence of diabetes was higher among people with a higher SES, the opposite was seen in the more affluent states of Chandigarh, Gujarat, and Tamil Nadu, where an increased prevalence of diabetes was associated with a lower SES.

For example, the prevalence of diabetes in Chandigarh was 26.9% among low-SES individuals vs 12.9% in high-SES participants.

Discussing their findings, the researchers write: "The diabetes epidemic seems to be maturing in the more economically advanced states of India, with diminution of the prediabetes pool raising the likelihood of stabilization of diabetes prevalence in the near future in these states.

"However, the spread of the epidemic to economically disadvantaged sections of society is a matter of great concern in India, where most diabetes treatment expenses are borne out of pocket by patients.

"Preventive measures need to be directed at these individuals, who have previously been deemed at fairly low risk of developing diabetes, as well as to rural areas where diabetes awareness remains low," they stress.

The study was funded by the Indian Council of Medical Research, New Delhi and the Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi. The authors report no relevant financial relationships.

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Lancet Diabetes Endocrinol. Published online June 7, 2017. Abstract, Editorial

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