K.M. Venkat Narayan: Diabetes: Has the Dragon trumped the Elephant?

venkat narayan“China pips India as the world’s most diabetic nation” ran the headlines in Hindustan Times (March 26, 2010).  It almost sounded as if India’s pride had been hurt. Such a deep sense of defeat was not expressed even when China led the world winning 51 gold medals to India’s one and only in the 2008 Olympic Games!

Never mind the Olympics. With an estimated 50 million people with diabetes, India had stubbornly held on to the infamous title of the “diabetes capital of the world”.  A recent study – of 46,000 adults from a nationally representative sample – published in the New England Journal of Medicine (March 25, 2010) has, however, estimated 92 million people with diabetes in China, and an additional 150 million with “prediabetes” and at high risk of developing it. 
These data are alarming, and are likely to totally overwhelm earlier projections by the International Diabetes Federation of 435 million people with diabetes world-wide by 2030.  What is particularly disturbing about these data is the very high rural diabetes prevalence; with 11.4% of urban residents and 8.2% of rural residents in China having the disease.

High diabetes rates have been considered an urban phenomenon world-wide, and as affecting mainly the affluent middle-class in rapidly growing emerging economies.  But these assumptions may no longer be true.  As the China study shows, diabetes does not spare rural populations or poorer people in developing countries. The forces causing the type 2 diabetes epidemic – physical inactivity, sedentary lifestyle, unhealthy nutrition – seem ubiquitous and all pervasive, as globalization spreads conferring its economic benefits and at the same time exacting its toll with diseases such as diabetes.

Why has China overtaken India to become the “world’s new diabetes capital?” 

I am not sure it has. The prevalence of diabetes in urban India is hovering around 16-18%, much higher than the 11.4% in China. Estimates of numbers of people with diabetes in India, however, have assumed far lower rural prevalence than was found in China.  Nationally representative rural diabetes data are not available for India.  With seventy percent of the population still living in rural India, small increases in rural diabetes prevalence can very substantially impact the total numbers.  A well-designed nationally representative survey is needed to accurately estimate the numbers with diabetes in India. 

More importantly, China, India, and other rapidly evolving economies need to take aggressive steps to stem the diabetes epidemic before it swamps their human and economic capital.  Policies to make environments conducive to physical activity and to reduce availability of high-calorie processed foods should be explored.

At the same time, strong evidence from several clinical trials (from the US, Finland, China, India) indicate that structured lifestyle interventions targeted at people with (pre-diabetic) high glucose levels can substantially prevent or delay progression to diabetes.  Programs to identify such high risk individuals and to deliver lifestyle interventions to them at low-cost are needed urgently.

China and India are in an exciting twenty-first century race for global stardom. This race need not be about who will be the “world’s diabetes capital.”

 To ensure that, both the Chinese Dragon and the Indian Elephant need to implement diabetes prevention and control policies soon. The clock is ticking away!

K.M. Venkat Narayan is Ruth and O.C. Hubert Professor of Global Health and Professor of Epidemiology and Medicine at Emory University Atlanta. He is a product of three continents, having lived and worked in India, United Arab Emirates, United Kingdom, and United States of America.

  • The news that China has emerged as the “Diabetes Capital of the World” is making waves as it was assumed that India had the largest number of people with diabetes in the world. I am not sure even now whether China has overtaken India as the “Diabetes Capital of the world”. If it has, it’s good news for India, from my point of view. However I feel that based on one study one cannot rush to conclusions. India needs a well designed national representative survey and such a survey is currently in progress funded by the Indian Council of Medical Research (ICMR) called as the ‘ICMR-INDIAB” study. The first phase of the study involving 4 states Tamil Nadu, Maharashtra Jharkhand and Chandigarh is nearing completion and quite soon the rest of the states will follow. It is possible that the rural diabetes rates in India are as high as in China. One should also remember that China currently has a much larger population than India – 1.32 billion compared to India’s 1.1 billion which means that the population of China is almost a quarter more than India. Hence, it will not be big surprise if China has more people with diabetes than India. It is hardly a matter of pride to be the Diabetes Capital of the World. What is needed are firm steps to halt the diabetes epidemic in its track. This needs a consorted effort of multiple stakeholders – several departments of the government (health, urban planning, youth and cultural affairs and town planning, human resources, finance and agriculture) all working together to improve the environment to provide more open spaces for people to exercise and to encourage healthy eating. The results of several prevention trials have shown that with a modest investment of time and effort, diabetes prevention is possible. However, this has not really been translated to a real world setting outside of the clinical trial scenario. What is needed is a massive effort both in India and in China to reduce the numbers of people with diabetes. Currently, at least 40% of the people with diabetes in the world live in these two countries. Unless preventive measures are taken, these numbers could swell to proportions which makes health care for the millions of people with diabetes in these two countries, unaffordable and unmanageable.

    The other major issue is that in India, and perhaps in China, diabetes affects the youth which means that the burden due to complications of diabetes could significantly rise among adults in the prime of their lives. The Madras Diabetes Research Foundation along with the Rollins School of Public Health, Emory University has taken up the challenge of addressing the prevention of early onset type 2 diabetes. A large study funded by the International Diabetes Federation under the BRIDGES programme called as the Diabetes Community Lifestyle Improvement Programme (DCLIP) is making efforts to improve physical activity through community empowerment. It is hoped that the results of this study will show that the prevention of diabetes is possible in a real life setting. The time for action is NOW.

    Dr. V. MOHAN, Chairman, Dr.Mohan’s Diabetes Specialities Centre & President,Madras Diabetes Research Foundation Chennai, India

  • Not only Indian Elephants or Chinese Dragon’s, the Bangladeshi Tigers are also approaching to a strong pace.

    Different small population based studies on diabetes in Bangladesh shows that, in 1976 the rate was only 0.003%, and it increased to 6.8% in 2007 in rural areas. In semi urban areas the rate nearly doubled between 1997 and 2007. In urban areas it was 11.2% in 2007. These are prevalence rates not far from many high income countries. There are surveys of population groups that show even higher rates for certain populations. A survey of adults age 35-70 showed diabetes prevalence among females was 17.0% in non-slum areas and 14.2% for males.

    I agree with Dr. Mohan and Dr. Venkat and would like to say that its time to act in Bangladesh too. And actions should reach the people by community based actions, rather than waiting for people to come to the centers.

    Shusmita Khan, Sr. Assistant Coordinator (NCD), Eminence (www.eminence-bd.org)