South Asia, especially India, is at the cusp of being called the ‘sugar hub’ of the world. It's not because of the sugarcane we grow, but due to the soaring numbers of individuals with Type 2 diabetes—a condition in which the pancreas does not produce enough insulin cells or the cells of the body do not respond to the insulin produced. It is a disease that progresses with time unless managed and has a strong link to genetic or family history. Treating diabetes is expensive with reports suggesting an average cost of Rs. 6000-10000 incurred annually by patients. Uncontrolled diabetes is expected to cost India US$ 150 billion before 2030.
In a series of studies published in The Lancet Diabetes and Endocrinology journal, researchers from India, UK and Australia, have provided an up-to-date account of the growing epidemic of type 2 diabetes, its prevalent clinical care, and the challenges faced by the public health system challenges in the countries of Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. These countries share the same cultural and socio-economic conditions which contribute to the similar pattern of disease occurrence.
The first part of the series touches upon the causes that could have led to the diabetes epidemic in these countries. The researchers point out that a decline in nutrition quality, reduced physical activity, lack of necessary medical care and increased sedentary behaviours are to be blamed. According to the 2017 Diabetes Atlas published by the International Diabetes Federation, about 4%-8.8% adults in South Asia have diabetes, with Indians being the highest. About 16·7% to 26·1% individuals are overweight, and 2.9% to 6·8% are obese.
“An increasing proportion of children, adolescents, and women are overweight or obese, leading to a heightened risk of type 2 diabetes”, say the researchers.
In India, approximately 7.2 crore adults have diabetes today, compared to just 2.6 crores in 1990. This number is predicted to swell to 13 crores by 2045! Another study, published in the journal Lancet, reports that this rise shows a clear correlation between the prosperity of states and disease prevalence. A majority of individuals with diabetes hail from the more prosperous states of Tamilnadu, Kerala and Delhi. Although diabetes has increased in every state of the country in the last 20 years, the relative rate of increase is highest in some of the least developed states, which is a matter of grave concern, says the study.
The other factor in play is the genetic trait, sometimes called the South Asian or Indian phenotype, which puts the South Asian ethnic group at a higher risk of diabetes even with a lower BMI (Body Mass Index). This factor results in the onset of diabetes at a very young age and progresses rapidly leading to complications. The researchers argue that since there are multiple risk factors, programmes targeting prevention of diabetes is the need in South Asia.
In the second part of the series, the researchers look into how diabetes is being clinically managed in South Asia and suggest ways to improve clinical care for those affected. According to this study, the risk of diabetes in South Asia is further complicated by poor awareness of the disease, delay in diagnosis and inadequate treatment. Since many individuals resort to ineffective and often harmful alternative medicines to battle diabetes without complying with the suggested changes in lifestyle and drugs, they become vulnerable severe complications at a young age and die.
“The treatment of diabetes in South Asia needs to be individualised based on diverse and heterogeneous lifestyle, phenotype, environmental, social, cultural, and economic factors”, say the researchers. Dr. Anoop Misra, Chairman at the Fortis Center of Excellence for Diabetes, Metabolic Diseases and Endocrinology and a lead author of the second part of the series, suggests an active lifestyle early on to keep diabetes at bay.
“One must start as early as 5th standard in school, to prioritise physical activity and nutrition. Young adults, who are going to be married, should undertake a short course on correct lifestyle and nutrition practices, which would result in the right nutrition in children and whole family”, he says.
Although a ‘one size fits all’ approach may not be effective in all countries, the researchers suggest that strengthening of primary care, early diagnosis, improvement of physicians’ skill and training healthcare staffs on clinically handling diabetes can go a long way in mitigating, if not wholly eradicating, this disease.
The final part of the series focuses on the role that public health care systems can play in managing diabetes. Since treating the disease is expensive, many individuals living in the South Asian countries cannot afford it. However, the good news is that diabetes is preventable with lifestyle changes and long-term healthcare management. The researchers advocate strategies for prevention of diabetes in prenatal, infancy, childhood and adolescent stages of individuals.
The study argues that in resource-strapped countries like those in South Asia, following a bottom-up approach would result in a higher success in managing diabetes. “A concerted focus on education, training, and capacity building at the community level would ensure the more widespread use of non-physician care, including community health workers”, say the researchers. However, for all that to happen, the governments need to play a significant role and cannot shy away from allocating the necessary funds for the prevention and management of this diabetes.
When the problem is so big, solutions cannot be any easy. Although diabetes affects all, the three most vulnerable groups are the people in low and middle socio-economic strata, women and children, says Dr. Misra. Innovative diets to prevent and control diabetes based on local ethnic foods, community engagements and a large-scale campaign with multiple messages through traditional and social media are the need of the hour.
“This awareness campaign has to be persistent for at least a decade to make any significant dent in the diabetes epidemic”, signs off Dr. Misra.