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Invited Commentary

Diabetes in India: A Dualistic Approach Beckons

Unnikrishnan, Ambika Gopalakrishnan,

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Indian Journal of Endocrinology and Metabolism: July–Aug 2021 - Volume 25 - Issue 4 - p 293-294
doi: 10.4103/2230-8210.332237
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India has over 77 million people with diabetes. The age-adjusted national prevalence of diabetes is 8.9%. About 171, 281 children or adolescents in India have type 1 diabetes. These numbers, provided and updated periodically, are obviously most important.[1] They provide a basis for assessing the disease burden on a continuous basis, thus enabling macro level modifications and course corrections to national programs focusing on diabetes.

In addition to these numbers above, there are other aspects of diabetes epidemiology that we still need to know. For instance, even as urban populations around the world become more active, rural populations are falling prey to lifestyle diseases.[2] This could be because of mechanization and urbanization in rural populations. At what rate is the incidence of diabetes changing in these rural and urban areas of India, and what factors are responsible for this? There are several other examples of unanswered questions about nationally representative data on diabetes in India. These include but may not be limited to the following: prevalence of type 2 diabetes among young adults in the country, diabetes among pregnant women in the community, diabetes in socio-economically disadvantaged populations like slum dwellers and the occurrence of type 1 diabetes in adult populations of India. These are just some situations where we need to fill in the blanks of an ever-expanding tapestry of diabetes prevalence in our country. And meanwhile, even as researchers continue to work on these aspects, the epidemic of diabetes continues to progress. Indeed, the current pandemic of COVID19 brought into focus the specter of new-onset and worsening diabetes in the post-COVID setting.[3] Not to forget, of course, the obvious associations between uncontrolled hyperglycemia, inappropriate steroid therapy and the uptick in cases of mucormycosis in the recent past.[4]

While trying to understand the diabetes epidemic in India, we need to transcend the stark, black and white quality that a single number provides (take for instance the simple diabetes prevalence value of 8.9% mentioned above). True, this number provides a foundation for planning policy. But what is simultaneously needed is a dualistic approach, that of combining the numerical narrative with a tapestry approach. In addition to focusing on broad national data, it is also important to fill up of other pieces of the tapestry jigsaw of diabetes epidemiology, to show where interventions could be planned, or where healthcare disparities could be narrowed or even prevented. It is in this light that we need to appreciate the study of diabetes, hypertension and other non-communicable diseases in a tribal population of India, published in this issue of the Indian Journal of Endocrinology and Metabolism (IJEM). This study is a timely effort to further the understanding of diabetes in this specific population, and shows the prevalence of diabetes to be about 7.4% in this tribal population.[5] Together with similar studies of special populations of our country, this study is an important step towards understanding the tapestry of diabetes epidemiology in India. In general, diabetes care needs of tribal populations have been considered similar to the needs of remote and rural communities. This is true to an extent, because problems of awareness, affordability, accessibility to specialized care and transportation are all problems common to both tribal and rural people. However, “similar” is not “same”, and diabetes care needs of tribal populations go well beyond routine problems seen in remote and rural communities.[67] These issues include those relating to genetic predisposition and socio-cultural factors impacting diabetes in these populations. In addition, recent reports of the prevalence of prediabetes among tribal populations is a matter of concern.[7] This study in IJEM, along with similar studies provide early steps to identifying the problem of diabetes in this population, thus setting a base for further research in the field.

Just like the problem of diabetes epidemiology needs to be understood beyond simple numerical measures, solutions to diabetes care at a population level too will need to transcend the traditional linear narrative, which focuses on the individual reaching targets such as the A1c. Currently, the focus of treatment, and indeed the burden of treatment seem to fall on the shoulders of the individual.[8] The onus of following diet, doing exercise, monitoring glucose and taking medications – all these activities are the individual’s responsibility. As a result, the responsibility of reaching targets such as A1c, blood pressure and optimal weight not only fall on the individual, but these targets are also (usually) the end points of large clinical trials. In order to reach these targets, study budgets have provided substantial resources. An example is the Diabetes Prevention Program, where intensive lifestyle measures were instituted via frequent coaching, supervised physical activity, adherence toolkits and motivational sessions.[9] These interventions did prevent diabetes, but their sheer scale and cost, among other factors, made it impractical to implement them at a global level.

The answer, therefore, may not lie in trying to implement individual-goal-based clinical trials at the population level. It may be equally important to recognize and approach the tapestry of factors related to diabetes occurrence at a broader level. Important among these factors that influence disease are the “Social Determinants of Health.” In the case of diabetes, at a population level, these determinants are as important as numerical outcomes such as A1c. What are the so-called social determinants of health, as applied to diabetes care? Well, they are simple, yet powerful tools for health, especially when applied to socioeconomically disadvantaged populations. Take for instance the easy availability of junk food, lack of availability of healthy food in local stores, psychological stress and the absence of avenues to exercise.[8] Are these not health issues that need to be addressed? There are more examples, such as the availability of social/family support, bringing down diabetes-related health care costs, improving access to onsite diabetes services and/or access to transportation to reach diabetes specialty centers. In the tapestry of population-level diabetes care strategies, these social determinants of health are equally powerful tools, if not more powerful than individualistic health goals.

It is important to recognize that this is not an “either-or” situation. The overarching number denoting national prevalence is very important, but so is the epidemiology of diabetes in specific populations. Similarly, there is really no need to choose social determinants over individual health goals, or vice versa. What is needed is a dual combination of both individual and community-level approaches. This dualistic approach could serve us well in developing policies for changing the health of people with diabetes. For example, development of a community-level diabetes prevention program led by community health workers could simultaneously exist with training of health care providers to give specialized diabetes care to individual people. Environmental support interventions to improve lifestyle, such as availability of healthy food and avenues to be physically active, could co-exist with individual and family support programs tailored to the setting in which they operate. Improving strategies at both individual and population levels is especially important for vulnerable populations.[10]

Traditionally, these strategies have been in the hands of policymakers and public health professionals. However, endocrinologists providing high quality diabetes care should begin to play a role here, by inculcating this dualistic approach into their practice. In addition to treating individuals visiting our endocrinology clinics, as leaders of specialty diabetes care, endocrinologists have a broader responsibility to engage with the community outside our clinic. By doing so, we as endocrinologists can spread awareness about healthy lifestyle choices and help policymakers and other stakeholders in the fight against chronic diseases. This will ultimately enable endocrinologists to continue to claim our rightful place as leaders in the fight against diabetes and obesity in the country.

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