Comment on: Diabetes epidemic in India ‘in a state of transition’
India is home to one-sixth of the world’s population, and to one out of every seven persons living with diabetes. Thus, data from India is vital to global diabetes care efforts.
In the ICMR-INDIAB study, RM Anjana and colleagues take on the daunting task of describing the epidemiology of diabetes in India, and do it well. In their article, which will prove to be of sempiternal value, the authors describe the prevalence of diabetes and prediabetes in 15 states of India. Their catchment area covers roughly half of the country, and provides a fair overview of the challenge that diabetes poses to India.
Unity in diversity
India is a humungous and heterogeneous nation, and ICMR-INDIAB data reflect this reality. In most aspects, ICMR-INDIAB results are concordant with those of the recently released National Family Health Survey (NFHS)-4. At times, however, trends seem to diverge. With regards to the metabolic health of Punjab and Tamil Nadu, for example, ICMR-INDIAB seems more aligned with NFHS-3. RM Anjana ’s data, collected through robust study design and implementation, should be given due weightage while making policy decisions based on NFHS-4.
Various states of the country, which enjoy differing economic and healthcare status, exhibit varying prevalence of diabetes. Punjab, which is traditionally thought to be the “heavy weight” of the nation, has the highest prevalence of diabetes, overweight, and high blood pressure among all states surveyed in the second phase.
From epidemic to endemic
Punjab also demonstrates a high diabetes: prediabetes ratio, which suggests that diabetes has become “endemic” to the state. Such endemicity is also noted in urban Gujarat and Andhra Pradesh, as well as the urban areas of highly educated states of Meghalaya and Mizoram.
By contrast, some lesser developed states, such as Assam, Arunachal Pradesh, Bihar, and Meghalaya show a low endemicity index, ie, low diabetes: prediabetes ratio. This implies that the true magnitude of the diabetes epidemic is yet to hit these states. The optimist, however, will note the window of opportunity to prevent diabetes, using focused public health campaigns, in these states.
From law of halves, to two-thirds
A law of two-thirds has recently been postulated in Indian diabetes epidemiology. This law proposes that two-thirds of all persons with diabetes are diagnosed, and two-thirds of all persons with dysglycemia have prediabetes (as opposed to diabetes). RM Anjana’s data suggest that the law of halves tends to operate in most Indian states. However, the law of two-thirds can be noted in the high proportion of persons with known diabetes, as compared to those with newly diagnosed diabetes in urban area of all states, except Bihar, and rural Andhra Pradesh, Gujarat, Manipur, and Punjab.
Drug addiction and diabetes
The high prevalence of alcohol and tobacco use in north-east India is of noteworthy importance. Given the multiple correlations between drug addictive disorders and dysglycemia, it is advisable to incorporate screening for diabetes in drug deaddiction programmes, and deaddiction strategies in diabetes care projects.
Impact on future health
The state-specific data imply that Indian diabetes epidemiology cannot be taken as a homogenous entity. Various states are in differing stages of evolution, and need unique, state-specific public health interventions to limit the impact of diabetes. The ICMR-INDIAB data, so elegantly presented by RM Anjana et al, will help policymakers and diabetes care professionals formulate appropriate strategies for each state and region of the country.