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Epidemiology and Burden of Diabetes

 

As a country advances up the economic value chain, the profile of killer diseases changes. India is right now at the crossover point. In time, as we become a more affluent nation and spend more on healthcare, communicable disease related mortality would diminish while chronic disease mortality would occupy the space in the death ratio calculations.

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Diabetes and associated complications pose a major healthcare burden worldwide. It presents major challenges to patients, health care systems and national economies. In 2011, IDF estimated 366.2 million adult population with diabetes, which is estimated to grow by 51% to 551.8 million by 2030. China has the world largest diabetes population of 90 million followed by India with 61.3 million. 70% of the current diabetes cases occur in low or middle income countries.

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Shown here is an estimate of the number of diabetics that are currently within different regions and what their numbers would be by 2030. Most middle and low income countries would be severely affected going forward. India, which is part of South East Asia could see a 69% increase in diabetes patient numbers by 2030.

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This slide further shows some additional differentiation between regions. Interesting to note the comparative prevalence that exists between them. SEA regions having a high population base also has a high prevalence that maximum diabetic burden would be seen here, while in Europe, even though the population count is large, the % prevalence is low and comparatively that may go down in the future.

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The greatest increases in the number of people with diabetes will be in low- and middle-income countries (LMIC). 80% of people with diabetes live in LMICs. The prevalence of diabetes is higher in low- and middle-income countries than in high-income. Deaths attributable to diabetes also shows a significant number in LMIC's.

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Low-income countries in Africa have the highest estimated proportion of undiagnosed diabetes (77.9%). However, for any one region and income group, the proportion of undiagnosed diabetes was at least 27%. This is very high and likely an underestimate. Globally, half of all cases of diabetes are undiagnosed. Over 60% of all people with undiagnosed diabetes are in the Western Pacific and South-East Asia Regions.

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Diabetes is one of the major causes of premature illness and death worldwide. Non-communicable diseases including diabetes account for 60% of all deaths worldwide. The number of deaths attributable to diabetes in 2010 shows a 5.5% increase over the estimates for the year 2007.


29% increase in the number of deaths due to diabetes in the North America & Caribbean Region.


12% increase in the South East Asia Region.


11% increase in the Western Pacific Region.

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The maps show us countries where there is high spending per person with diabetes and high total spending on diabetes. The healthcare expenditures measure includes medical spending on diabetes by the health system as well as by people with diabetes. It does not include the indirect costs to society from lost productivity, absences from work and the associated costs of care. In other words, this is a big underestimate of the true cost of diabetes. It is also important to note that some of this spending is necessary as part of care. However, some studies show that families pay 40-60% of medical care expenditures out of their own pockets for diabetes, which shows a disproportionate amount of the cost is borne by people with diabetes and their caregivers.

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Prevalence of impaired glucose tolerance is high in many Asian countries, suggesting the presence of a large pool of people with potential to develop diabetes. In southeast Asia, the estimated comparative prevalence of impaired glucose tolerance was 3.0% in 2011. Estimated IGT prevalence to grow by 3.2% by 2030. An estimated 23.8 million adults with IGT in the year 2011. Projected to 38.6 million adults with IGT in the year 2030.

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Shown here is a list of Indian studies that were multi-centric in nature that were done over the years. We can see that prevalence estimates ranged from 1.8 to 13.5% across regions within India. Possible bias in these estimates also could be due to different methodologies within studies, or different definitions of diabetes used for diagnosis.

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The mechanisms underlying development of the disease are complex and varied, even within these populations. Asian populations are more insulin resistant than are people of many other races. Insulin resistance and compensatory hyperinsulinemia are reported even in children and adolescents of Asian Indian origin.These factors probably play a major part in the escalating prevalence of Type 2 diabetes in young populations in Asia.


Ramachandran A et al ,Diabetes in Asia, Lancet 2010; 375: 408-18


Ramachandran A et al Diabetes Care 2007; 30: 1828-33


Abate N, Indian J Med Res 2007; 125: 251-58


Type 2 diabetes has a strong genetic component and most Asian patients have a first-degree relative with diabetes. For e.g.: In early studies, genetic variants in the peroxisome proliferator-activated receptor-γ gene (PPARG)51 and the ATP-sensitive potassium channel Kir6・2 (KCNJ11) were reproducibly associated with Type 2 diabetes. In Asian populations, the protective effect of the PPARG*A12Ala allele on insulin resistance and risk of Type 2 diabetes was not consistently seen. (Ramachandran A et al ,Diabetes in Asia, Lancet 2010; 375: 408-18)


Indians have a lower BMI than several other populations. The cut off value for ideal BMI is also less. The healthy BMI for an Asian Indian is likely to be <23 kg/m2 Studies in India have also shown that central obesity was more strongly associated with glucose intolerance than generalised obesity. It has been hypothesised that the excess body fat and low muscle mass may explain the high prevalence of hyperinsulinaemia and the greater risk of development of Type 2 diabetes in Asian Indians. (Ramachandran.A low risk threshold for acquired diabetogenic factors in Asian Indians Diabetes Research and Clinical Practice 65 (2004) 189-195)

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Age-adjusted prevalence of diabetes diagnosed using criteria of known diabetes or fasting glucose > 7.0 mmol/L (> 126 mg/dL) was 8.3% in men and 9.0% in women. As shown in the slide, prevalence estimates differed across regions.

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The results of the Diabetes Epidemiology Collaborative Analysis of Diagnosis Criteria in Asia (DECODA) study have shown several variations in age-specific prevalence within Asian populations. Various cultures have differing peaks of DM with age. Indians seem to get DM earlier than their Chinese counterparts. A high prevalence of maturity-onset diabetes in the young has been reported in India. In China, from 1994 to 2000, there was an 88% increase in prevalence in the 35-44 years age group. Data from southern India show that the prevalence of diabetes in people younger than 44 years has increased from 25.0% of the total prevalence in 2000 to 35.7% in 2006. Factors that have contributed to the epidemic of obesity and young-onset diabetes are the rapid transition in dietary habits, reduced physical activity, changing pattern in leisure activities, longer working hours and decreasing sleep hours.

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Not only is Type 1 common with children, recent trends also show a rising Type 2 disease in them. This has been closely related to obesity among them. Sedentary lifestyle has been one of the biggest culprits for this development. The 'fast-foods' that are fat and calorie rich are easily available in the numerous food joints. It was observed that the prevalence of diabetes was almost three times higher in individuals with light physical activity compared to those having heavy physical activity. It was also noted that prevalence of metabolic syndrome and hypertension was also significantly higher among young people with light physical activity. (Mohan V, The Chennai Urban Population Study (CUPS 14). J Assoc Physicians India 2003; 51 : 771-7.)

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There are few epidemiological studies in semi-urban India and many in rural populations. In earlier years, there was a very low prevalence of diabetes in rural populations.

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India has a population of more than a billion and to extrapolate results from non-representative studies to the whole country is not scientifically appropriate. India is a vastly diverse country with many races and cultures. These come with disparities in diets and lifestyles. Risk-association studies that demonstrate that lifestyle factors such as urbanisation, socioeconomic status, stress, sedentary lifestyle, dietary calorie excess, certain specific dietary factors and generalised and central obesity are needed. Thus, there is a good need to do a countrywide, across various subgroups like age, sex, occupations and using simple lab measures like FPG do estimate the true prevalence in India. However, despite these caveats it is worthwhile examining smaller studies already done to provide an estimate.

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