Nov 14, 2008

Health - Diabetes prevention as a priority

V. Mohan

A call to focus on tools and strategies to counter the disease in a preventive mode, on World Diabetes Day, today.

Diabetes poses a huge economic burden on India

Prevention can be undertaken at four levels: primordial, primary, secondary, tertiary

India faces a double burden on the health front. Communicable diseases (CDs) such as tuberculosis and malaria are still rampant. Meanwhile, chronic lifestyle-related or non-communicable diseases (NCDs) have emerged as an even bigger hazard. According to the World Health Organisation report 2005, NCDs (excluding injuries) contributed to 52 per cent of all deaths in India, and the figure will rise to 70 per cent by 2025. These include diabetes, obesity, hypertension and coro nary artery disease, which are referred to as “metabolic NCDs,” and chronic obstructive respiratory disease, cancer, mental illness and injuries, classified as “non-metabolic NCDs.” The metabolic NCDs, specifically diabetes which can be taken as a model of metabolic NCDs as most of the risk factors are common to the metabolic NCDs, are in focus here.

Worldwide, there are an estimated 246 million people with diabetes, and this number is set to reach 380 million by 2025. Diabetes was traditionally considered to be a disorder affecting the affluent and the elderly. This is no longer true. By 2025, more than 80 per cent of all deaths will be in the developing countries. India holds the unenviable position of being the world leader with 40 million diabetics in 2007. This number is set to reach 70 million by 2025. This will represent almost 20 per cent of all cases of diabetes in the world.

Population-based studies done by the author and his colleagues in Chennai have shown that nearly one in five of all patients with diabetes has one or more complications arising from the disease. It has emerged as a leading cause of blindness, kidney failure, amputations and heart attacks in India. Recognising the gravity of the situation, the United Nations General Assembly passed a historic declaration on diabetes in December 2007. The only other disease for which the U.N. has passed a declaration is HIV/AIDS: that was almost a decade ago.

Diabetes poses a huge economic burden on India. A recent paper showed that of five countries studied, namely the U.S., the U.K., Finland, China and India, India spends the highest share of GDP on diabetes. But more than the economic impact, it is the social impact that is of greater concern. The age at onset of Type 2 diabetes is progressively decreasing and the disorder now affects a significant number of adolescents and children. The onset of diabetes-related complications typically occurs 10 to 20 years after the disorder is diagnosed. Thus, if the onset occurs in an individual at 50 years, one needs to worry about its complications around the age of 65-70 years. Considering that life expectancy in India today is around 68 years, perhaps this will not be a matter of grave concern. However, if the onset occurs around age 20, the possibility of people in their 30s and 40s developing complications is high. This will be a disaster not only for the individual and his or her family but also to society and the nation at large. The adage, “prevention is better than cure,” is apt in the case of diabetes.

Prevention can be undertaken at four levels. Primordial Prevention refers to reduction of risk factors such as obesity, physical inactivity and stress, thereby reducing the risk. Primary Prevention refers to prevention (or postponement) in those in a pre-diabetes stage such as impaired glucose tolerance. Secondary Prevention refers to prevention of complications in those who have developed diabetes. Tertiary Prevention is used to describe limiting physical disability and preventing progression to end-stage complications in those who have developed diabetic complications.

Doctors mostly focus on secondary and tertiary prevention, for that is the stage at which patients come to hospitals or clinics. They rarely attempt primordial or primary prevention as this would mean screening a healthy population and instituting preventive measures. Doctors simply do not have the time for this, already overworked as they are attending to sick patients.

Identification of high-risk individuals is the first step in primary prevention. This requires screening of a healthy population, which is a challenge as the disorder is totally asymptomatic at this stage. This is where public health or community medicine specialists and non-governmental organisations (NGOs) can play a role.

How can we identify those at risk? This can be done by using a simple tool called the “Indian Diabetes Risk Score (IDRS)” developed at the Madras Diabetes Research Foundation. To use this, one needs to answer three questions: what is your age, does your father, mother or both have diabetes, and do you have adequate physical activity. In addition, a waist measurement needs to be done with measuring tape. IDRS, which costs virtually nothing, can help identify the risk of developing diabetes with a high degree of accuracy. Once the high-risk individuals are identified, they can be screened with blood sugar tests to identify subjects with diabetes or pre-diabetes. This is a cost-effective strategy for primary prevention.

There is evidence to show that Type 2 diabetes can be prevented in up to 60 per cent of individuals with “pre-diabetes” by means of simple lifestyle modification steps such as going for a healthy diet, doing exercise and achieving modest weight reduction. The Prevention, Awareness, Counselling and Evaluation (PACE) Diabetes Project carried out by us with the support of the Chennai Willingdon Corporation Foundation has demonstrated how awareness levels could be improved in a whole city (Chennai) through massive education programmes, with media support.

However, if primary prevention is to become a reality in India, a multi-sectoral approach involving several stake-holders is needed. This should include measures such as improving urban infrastructure with more pathways for bicycles and pedestrians, more open spaces or parks to increase physical activity, encouraging healthy eating with increased consumption of fruits and vegetables, and involving governmental and non-governmental organisations to reach the right message to the masses. Prevention of diabetes and other metabolic NCDs can only happen if the youth are targeted and compulsory physical education is introduced in schools and colleges. Workplaces should be made healthier with the introduction of healthier diet options in canteens. Physical activity and stress reduction programmes should be introduced for employees. Incentivising weight reduction in obese patients has proved successful in some organisations.

Ultimately, diabates prevention needs “political will,” societal and community support and behavioural change on the part of individuals and their families. Now is the time for India to wake up to the imminent problem of diabetes and NCDs and act — before it is too late.

(Dr. Mohan’s Diabetes Specialities Centre in Chennai is a WHO Collaborating Centre for Noncommunicable Diseases.)

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