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Type 2 diabetes in India: regional disparities

RAJEEV GUPTA,1 ANOOP MISRA2

Abstract Preamble

T
ype 2 diabetes mellitus epidemic in India is a result Epidemiology of diabetes in India has a long history. Charaka
of societal influences and changing lifestyles. Samhita, the ancient Indian medical treatise, describes this con-
Diabetes has been known in India for centuries as dition succinctly and suggests that being obese was a major risk
a disease of the affluent class. Epidemiological studies factor. It was commented that fat asymmetry impairs strength
in the 1960s and 1970s using random and post-load and shortens lifespan; this may have been an indication of
blood glucose estimations reported diabetes prevalence increased incidence of diabetes among the asymmetrically
varying from 14% in urban populations and 12% in obese.1 Initial data on diabetes epidemiology in India were avail-
rural populations. More standardised epidemiological able as hospital and clinic-based case-series reported in early and

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studies since the 1990s reported prevalence rates that mid twentieth century. This was followed by epidemiological

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vary from 515% among urban populations, 46% in studies that initially involved opportunistic screening and later
semi-urban populations and 25% in rural populations population based surveys. Ramaiah et al. reviewed all these stud-

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with large location-based disparities within urban and ies in 1991.2 Hospital records in Kolkata in the 1930s, and

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rural populations. There is a significantly increasing Mumbai and Delhi in the 1950s revealed that diabetes, as diag-
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trend in urban populations (exponential trend R2=0.744) nosed by glycosuria, was not uncommon (0.71% of all

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while among rural populations the prevalence is patients). Similar observations were reported by subsequent

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increasing at a slower rate (R2=0.289). At the turn of opportunistic-screening studies from Kolkata, Mumbai, Lucknow
this century diabetes in adult urban Indian populations and Vellore in the 1950s. The initial systematic study of diabetes
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varies from a low of 5.4% in a northern state to a high prevalence in India emanated from medical institutes in Delhi,
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of 12.315.5% in Chennai, South India, and 12.316.8% Chandigarh, Hyderabad and Chennai, and organised sectors
in Jaipur, Central India. This scenario is similar to other such as the armed forces and railways, but these studies used dif-
South Asian countries and evolving populations in East ferent diagnostic criteria that varied from presence of glycosuria,
PR (DI RI

Asia, Middle-East, Americas, Australasia and Pacific random or fasting blood glucose measurement and reported
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Islands. Gene-environment interactions appear to be results inconsistently.3 In recent years more epidemiologically
responsible for this rapid increase. The insulin-resistant stringent studies have been performed.
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state that was meant to be protective mechanism for


regulation of calorie and fat metabolism at times of Current diabetes scenario in India
famine has turned deleterious as affluence has The first systematic nationwide study in India was performed by
increased among these populations leading to diabetes the Indian Council of Medical Research Task Force on diabetes.4
epidemic. Population based measures to prevent the This study used a uniform methodology and sampling tech-
control of a diabetes epidemic include avoidance of niques and was performed at six centres in the country.
adiposity by enhanced physical activity and regulated Population sampling in urban areas was based on stratified ran-
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calorie intake. dom design and in rural areas on cluster sampling. Population
Br J Diabetes Vasc Dis 2007;7:1216 aged > 14 years was screened using a post 50 g oral glucose load
and capillary blood glucose > 9.4 mmol/L (> 170 mg/dL) was
Key words: non-communicable diseases, diabetes, taken as diabetes. In all, 34,194 subjects were screened and
epidemiology, glucose intolerance. prevalence of diabetes was 2.1% in urban subjects and 1.5% in
rural populations. There has been a veritable explosion in dia-
betes epidemiology studies in India in the past 20 years (table
1
Department of Medicine, Monilek Hospital and Research Centre, Jaipur, 1).5-31 However, the studies suffer from major lacunae and there
302004, India. is significant variability in various methodological issues such as
2
Department of Diabetes and Metabolic Diseases, Fortis-Rajan Dhall
Hospital, New Delhi, 110070, India. sample size, sample selection, case detection, responder-nonre-
Correspondence to: Dr Rajeev Gupta sponder status, age-standardisation, diagnostic criteria, bio-
Department of Medicine, Monilek Hospital and Research Centre, Jawahar chemical estimations, regression-dilution effects and reporting
Nagar, Jaipur, 302004, India. methods as well as multiple inherent limitations of cross-section-
Tel: +91 141 2653021, 2653023; Fax: +91 141 2652181
E-mail: rajeevg@satyam.net.in al epidemiological studies.32 Therefore, most of these studies can-
not be taken as nationally representative. India has a population

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Table 1. Recent Diabetes Prevalence Studies in India

First author Year of Location Age-group Diagnostic Sample size (n) Prevalence rate (%)
publication criteria Male Female Total Male Female Total
(Age-adjusted)
Urban populations
Verma NP5 1988 Delhi 20+ K 3,643 3,235 6,878 3.8 2.3 3.1
Ahuja MMS6 1991 Delhi 20+ K+PG 2,572 - 2,572 4.1 - 4.1
Ramachandran A7 1992 Chennai 20+ K+F+PG 457 443 900 8.3 7.6 8.3 (8.3)
Ramachandran A8 1997 Chennai 20+ K+F+PG 1,081 1,102 2,183 10.4 12.7 11.6 (11.6)
Shah SK9 1998 Guwahati 20+ K+PG 595 421 1,016 8.7 7.8 8.2 (8.2)
Asha Bai PV10 1999 Chennai 20+ K+F+PG 743 455 1,198 8.7 5.7 7.6
Zargar AH11 2000 Srinagar 40+ K+F+PG 1,038 500 538 5.4 5.0 5.2
Kutty VR12 2000 Kerala 20+ K+PG 225 293 518 16.4 9.2 12.4
Joseph A13 2000 Trivandrum 20+ K+F 76 130 206 16.3 16.3 16.3
Asha Bai PV14 2001 Chennai 20+ K 13,366 12,700 26,066 2.9 3.1 2.9 (4.9)
Iyer SR15 2001 Mumbai 20+ K+F+PG - - 520 - - 7.5
Misra A16 2001 Delhi 18+ K+F 170 362 532 11.2 9.9 10.3
Mohan V17 2001 Chennai 20+ K+F+PG 518 657 1,175 - - 12.3
Ramachandran A18 2001 National 20+ K+F+PG 5,288 5,928 11,216 13.8 14.0 13.9 (12.1)

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Gupta A19 2003 Jaipur 20+ K+F 532 559 1,091 13.2 11.5 12.3 (8.6)

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Sadikot SM20 2004 National 20+ K+F+PG 10,865 10,651 21,516 4.7 4.8 4.8 (4.6)
Gupta R21 2004 Jaipur 20+ K+F 226 232 458 17.7 14.2 16.8 (12.1)

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Mohan V22 2005 Chennai 20+ K+F+PG - - 2,350 18.0 13.4 15.5

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Prabhakaran D23 2005 Delhi 2059 K+F+PG 2,122 - 2,122 15.0 - 15.0

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Reddy KS24 2006 National 2069 K+F 6,536 3,890 10,442 11.2 8.2 10.1 (8.3/9.0)
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Semi-urban and mixed populations

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Ramachandran A25 1988 Karnataka 20+ K+F+PG 346 332 678 5.8 4.2 5.0 (5.0)

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Kutty VR12 2000 Kerala 20+ K+F+PG 2,388 2,600 4,988 7.2 6.2 6.7 (8.2)
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Singh TP36 2001 Manipur 15+ K+F+PG 884 780 1,664 5.1 2.8 4.0
Rural populations
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Ahuja MMS6 1991 Bengal 20+ K+PG - - 2,375 - - 0.8


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Ahuja MMS6 1991 Delhi 20+ K+PG - - 992 - - 1.5


Ahuja MMS6 1991 Kerala 20+ K+PG - - 1,488 - - 1.3
Ahuja MMS6 1991 Gujarat 20+ K+PG - - 1,294 - - 3.9
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Ahuja MMS6 1991 Himachal 20+ K+PG - - 999 - - 0.4


Ramachandran A7 1992 Tamilnadu 20+ K+PG 520 518 1,038 2.6 1.6 2.4
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Wander GS27 1994 Punjab 20+ K+PG - - 809 - - 4.6


Patadin S28 1994 Tamilnadu 40+ K+PG - - 467 - - 4.9
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Zargar AH11 2000 Kashmir 40+ K+F+PG 1,996 2,049 4,045 3.5 4.5 4.0
Agrawal RP29 2004 Rajasthan 20+ K+F+PG - - 882 - - 1.8
Sadikot SM20 2004 National 20+ K+F+PG 9,669 10,085 19,754 1.8 1.9 1.9 (1.9)
Deo30 2006 Maharashtra 20+ K+F+PG 449 553 1,022 9.2 9.9 9.3
Chow31 2006 Andhra 30+ K+F - - 4,535 14.3 12.0 13.2

Key: K = known; F = fasting; PG = post glucose load


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of more than a billion and to extrapolate results from non-repre- Trivandrum,12,13 Mumbai,15 Delhi,16,23 Jaipur19,21 and Gauhati9) as
sentative studies to the whole country is not scientifically appro- well as a national study in large metropolises,18 and industrial
priate. However, despite these caveats it is worthwhile examin- populations,24 diabetes prevalence among adults (> 20 years) has
ing these studies. ranged from 815%. A study from Kashmir in adults > 40 years
reported a low prevalence of 4.25%,11 but a national-wide study
Urban populations of > 21,000 subjects from big and small cities in India, also
Initial studies among urban subjects in Delhi reported on known reported a lower prevalence of diabetes as compared to the
diabetes and compared this with the diabetes prevalence in studies from large cities20 (table 1). Within urban populations
Southall, London.5 Diabetes was more prevalent among Indians there is a large heterogeneity of diabetes prevalence depending
living in Delhi and Southall compared to British whites. Other on the socioeconomic stratum studied and sampling response
studies from urban, semi-urban and specific regions of India have rates. In the late 1990s Ramachandran et al. and Mohan et al.
confirmed the high prevalence of diabetes among various popu- reported a high prevalence of diabetes (1112%) in
lations although the prevalence rates are widely different. Chennai7,8,17,22 while Asha Bai et al. reported a lower prevalence
In large cities in north and south India (Chennai,7,8,10,14,17,22 of known diabetes (4.9%) as well as overall diabetes (7.6%)

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from different parts of the same city.10,14 Variable prevalence rates


Figure 1. Trends in prevalence of diabetes in Indian urban ( ) and
in different urban populations in India is expected as there is a rural ( ) populations in India. There is a significantly
large variation in cardiovascular risk factor prevalence33 as well as increasing trend in urban populations (exponential trend
cardiovascular mortality in different Indian urban regions.34 R2=0.744) while among rural populations the prevalence is
increasing at a slower rate (R2=0.289)
Semi-urban and rural populations
There are few epidemiological studies in semi-urban India12,25,26
18
and many in rural populations6,7,11,20,27-31 (table 1). In earlier years
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there was a very low prevalence of diabetes in rural populations. 14

Percent prevalence
However, two recent studies, from Maharashtra30 and Andhra 12
Urban
Pradesh31 report very high prevalence rates similar to those in 10
urban Indian populations. Interestingly a significant correlation of 8
body mass index with diabetes has been observed in these stud- 6

ies. It has been hypothesised that although there is a significant 4


Rural
2
increase in diabetes as populations move from rural to semi-
0
urban to urban and cosmopolitan habitats, a reverse migration
1955 1965 1975 1985 1995 2005
of culture may already be taking place in Indian rural popula- Years

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tions.33 Earlier rural-urban disparities in diabetes could be due to

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a low prevalence of overweight and obesity in rural subjects
compared to urban subjects.

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Secular trends urban populations is in Kashmir11 and the highest in
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Serial cross-sectional epidemiological studies on diabetes to Chennai7,8,10,14,17,18,22 and Trivandrum.12,13 However, as these studies

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demonstrate secular changes have been rare in India. From were performed using different criteria and methodology the

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Chennai in south India a significant increase in type 2 diabetes results may not be comparable but are indicative of a rising tide
prevalence among adults has been reported.35 Using similar diag- of diabetes nationwide.
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nostic criteria (known diabetes and/or fasting and post-glucose There are few multi-site studies in India that have used uni-
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load hyperglycaemia) the age-adjusted diabetes prevalence form criteria for diagnosis of diabetes that would help to clearly
among adults in urban Chennai increased from 8.3% in identify regional disparities in its prevalence. The Indian Council
198889, to 11.6% (199495), 13.5% (2000) and 14.3% in of Medical Research studies reported relatively low and variable
PR (DI RI

200304. Similar increase was observed in prevalence of prevalence rates of diabetes6 among rural populations from
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impaired glucose tolerance from 8.3% to 9.1%, 16.8% and 0.4% in Himachal Pradesh to 1.3% (Kerala), 1.5% (Delhi) and
10.2% respectively. Increase in diabetes prevalence has also been 3.9% in Gujarat.6 Reasons for this variation were not discussed.
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reported from rural Tamilnadu.36 Serial studies from Jaipur using The Diabetes Epidemiology Study Group in India (DESI)18 investi-
slightly different criteria (known diabetes and fasting hypergly- gators reported from several urban locations in India: age and
caemia) have also reported increasing diabetes among urban gender-standardised prevalence of diabetes ranged from 9.3%
subjects.19,21 in Mumbai to 11.6% (Delhi), 11.7% (Calcutta), 12.4%
Analysis of secular trends reveals a very steep increase in (Bangalore), 13.5% (Chennai) and 16.6% in Hyderabad.
urban populations (exponential trend R2= 0.744) while among Multivariate logistic regression analysis revealed that significant
rural populations the prevalence is increasing at a slower rate determinants of diabetes were age, body-mass index, waist-hip
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(R2= 0.289) (figure 1). Although the prevalence of diabetes is rel- ratio, low physical activity and family history of diabetes.18 Most
atively low in rural populations, there is evidence of a high bur- of the regional variations in diabetes prevalence could be
den of impaired glucose tolerance.11,36 explained by lifestyle factors.
The Prevalence of Diabetes in India Study (PODIS)20 group
Regional disparities reported a low overall prevalence of diabetes in urban locations
There is substantial variation in diabetes prevalence worldwide, but did not report on regional variations or location-specific
with a prevalence of practically zero, in rural Third World coun- prevalence rates. The Indian Industrial Populations Study Group24
tries and 3750% among the Asia-Pacific Islanders and reported prevalence of diabetes in nine urban industrial loca-
American Indians. Most of the worlds broad geographical loca- tions. Age-adjusted prevalence of diabetes diagnosed using
tions include regions with both low and high prevalences of dia- criteria of known diabetes or fasting glucose > 7.0 mmol/L
betes, e.g., Mapuche Indians versus Pima Indians in USA, and (> 126 mg/dL) was 8.3% in men and 9.0% in women (table 1).
rural Australian aborigines versus the urban aborigines.37,38 India There was a very low prevalence of diabetes in eastern (Assam:
is no different (table 1): studies from north India reveal a lower men 2.8%, women 1.7%) and central India (Nagpur: men
prevalence of diabetes,5,6,16,19,21,24 compared with the southern 4.4%, women 3.8%); moderate prevalence in Pune (men 9.8%,
parts of the country.7,8,10,13,14,17,18,22 The lowest prevalence among women 7.2%), and Coimbatore (men 7.5%, women 8.1%); and

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conclusion from various studies appears to be that such risk fac-


tors tend to develop early in the lifecycle in Indian subjects and
Key messages consequently type 2 diabetes occurs at least 1015 years earlier
compared to people of non-Indian origin.41 The generalised and
central obesity levels at which diabetes occurs is also lower in
Epidemiological studies show a significant and Indian subjects compared to the white populations42 and for
escalating burden of type 2 diabetes in India South Asians a waist size of > 90 cm in men and > 80 cm in

women is now accepted as a major risk factor for diabetes and
There are large regional disparities in prevalence of
other cardiovascular risk factors of the metabolic syndrome.43
diabetes in India with low prevalence in rural and high
prevalence in urban subjects. The disease is more The influence of societal affluence levels on diabetes inci-
prevalent in southern regions as compared to northern dence in India suggest that a global solution that shall have the
and eastern parts of the country greatest impact on slowing or stopping the diabetes epidemic
lies with policy-makers and governments.44 There is a need to
The principal reason for escalating diabetes and
change the economic and environmental structure in urban
regional disparities appears to be rapidly occurring
areas of India so that physical activity and healthy dietary choic-
socioeconomic changes and affluence associated with
es are available.45
dietary excess and reduced physical activity

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