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The burden of diabetes in India
The Lancet Global Health
The India State-Level Disease Burden Initiative Diabetes Collaborators (December, 2018)1 provide a comprehensive overview of the diabetes burden in India. The authors point out some limitations in estimates due to inadequacies in the data. Nevertheless, on the basis of my field experience in India, I would like to address a few crucial points that I felt were missing in the Article.
The Government of India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in 2010. As of March, 2017, non-communicable disease Cells (small centres which help with planning, monitoring, and reporting activities) have been established in 390 (55%) of 719 districts,2 which means that nearly half of the country still remains uncovered. Further, the availability of staff and basic drugs like metformin remains inadequate in many areas, especially in rural parts of India. Because of weak implementation of the national programme and the unavailability of treatment for chronic cases, the majority of patients with diabetes have no option but to seek help from the private sector, incurring considerable out-of-pocket expenditure on treatment. This problem is further aggravated because of substantial variation in the prices of drugs in the Indian pharmaceutical market.3 Because diabetes is not a notifiable condition, there are few data available on patients treated in the private sector, and thus its actual burden is unknown. As a result, the burden of diabetes in India might be underestimated.
Another issue is the definition of diabetes, which is defined in the Article as fasting plasma glucose (FPG) greater than 7 mmol/L or being on diabetes treatment. However, patients sometimes do not disclose food ingestion before they are tested, and therefore FPG might not always be a reliable indicator for diagnosis; instead a glycated haemoglobin A1c (HbA1c) value is preferable.4
Lastly, the Article reports a high prevalence of diabetes in economically and epidemiologically advanced states such as Tamilnadu and Kerala. Many renowned diabetes research institutes, which conduct prevalence studies periodically and can offer estimates and trends on the disease, are located in Tamilnadu and south India. An unpublished systematic review of studies on the prevalence of type 2 diabetes in India, based on a PubMed search for literature published between 1994 and 2018, supports this assertion. It showed that 28 of 36 selected studies in the review were from South India, and of these 28, 15 studies were from Tamilnadu and four were from Kerala, whereas the remaining states had less than three studies and no studies were found from the other 12 states, which might indicate little prevalence data from there. Hopefully, the issues addressed here will be helpful for policy makers in designing effective strategies for India's diabetes control.
Atre, S. The burden of diabetes in India. The Lancet Global Health. April 1, 2019. DOI:https://doi.org/10.1016/S2214-109X(18)30556-4