06- October-2023-Special-Article

DIABETES: THE TICKING TIME BOMB

Diabetes: Scenario in India

11.4% of India’s population or 10.13 crore people are living with diabetes and 15.3% of the population or an additional 13.6 crore people are pre-diabetic.

It also found that 28.6% of the population would be considered to be obese as per the BMI measure.

Consumption of ultra-processed foods

According to the World Health Organization, a major reason for this is the consumption of unhealthy ultra-processed foods and beverages.

Food and Beverages: The Culprits

Such food includes carbonated drinks, instant cereals, chips, fruit-flavoured drinks, instant noodles, cookies, ice cream, bakery products, energy bars, sweetened yogurts, pizzas, processed meat products, and powdered infant formulas.

Scientific evidence shows that diets heavy with ultra-processed food and beverages or high in sugar, fat, and salt are risky and can lead to diabetes.

A 10% increase in the consumption of ultra-processed food a day is associated with a 15% higher risk of type-2 diabetes among adults.

When food is ultra-processed, its structure is destroyed and cosmetic additives, colours, and flavours are added.

This makes people eat more, gain weight, and heightens the risk of diabetes and other chronic diseases.

Further, obesity and diabetes are key risk factors for heart disease and deaths.

Gestational Diabetes

Gestational diabetes occurs in about 5 to 10% of pregnant women, and usually goes away after the birth of the baby. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later on.

The management of gestational diabetes includes seeing a dietitian to assist with healthy eating strategies to help manage blood glucose levels. Where possible, regular exercise such as walking also helps.

Measuring blood glucose levels with a blood glucose meter gives information about whether these management strategies are able to keep blood glucose levels in the recommended range.

Some women may need to also inject insulin to help manage their blood glucose levels until their baby is born.

Insulin for diabetes

Insulin is a hormone our body makes to keep our blood glucose levels within the normal range. It is made by beta cells in the pancreas.

Insulin’s main job is to move glucose from our bloodstream into the body’s cells to make energy. If you don’t have enough insulin, glucose builds up in your bloodstream rather than getting into your cells to provide energy.

With type 1 diabetes, the body does not make any insulin and therefore insulin has to be injected regularly every day to stay alive.

With type 2 diabetes, the body does not make enough insulin, or the insulin that is made does not work well. Insulin injections are sometimes needed to manage blood glucose levels.

India: A playground for the food industry

It is reported that the sale of sugar-sweetened beverages has fallen in the last 20 years in many high-income countries. To compensate for the loss of sales, companies are now focusing on low- and middle-income countries.

India is a playground for the food industry. Billions of rupees are spent on marketing and advertising ultra-processed food and beverages.

Marketing targets younger generations and the growing middle class, making it hard for an individual to choose healthy food options.

Children in particular are exposed to cartoon characters and given incentives and gifts. Celebrity endorsements also determine their consumption decisions.

In such a context, policy and regulatory actions are warranted.

The Food Safety and Standards Authority of India has shown a lacklustre response to the crisis and allowed a dominating role to the food industry while suggesting front-of-package labelling, which is still not in place.

Many say that people should exercise. While this is good for health, it should be in addition to a regulatory policy on restricting the marketing of ultra-processed foods and providing warning labels on junk food and beverages.

Burden of Diabetes on Indian Population:

Madras Diabetes Research Foundation and Indian Council of Medical Research Findings

1. More than a quarter of the population was either diabetic or in pre-diabetic stage.
2. 4% of India’s population or 101 million people are living with diabetes. Whereas 15.3% of the population or an additional 136 million people are pre-diabetic.
3. The prevalence of hypertension or high blood pressure was found to be higher still in the country.
4. This is because Indians tend to gather fat in the abdominal region and despite the BMI being normal people might be at a higher risk of diseases of obesity.
5. The study found that 6% of the population would be considered to be obese as per the BMI measure, 39.5% of the population or 351 million people had abdominal obesity.
6. The study also found that 24% of the population or 213 million people were living with hypercholesterolemia — a condition where the bad cholesterol or LDL levels are high.

How do the study findings help in developing policies?

With granular data available from each of the states, it can be used by the state governments to device their health policies.

For example, the high prevalence of pre-diabetes shown in rural India by the study would mean that governments would need to focus there.

Screening for the NCDs and medicines for those who get them have already been included in 1.5 lakh government health and wellness centres.

India: Diabetes capital of the world

India is often referred to as the ‘Diabetes Capital of the World’, as it accounts for 17%percent of the total number of diabetes patients in the world.

There are currently close to 80 million people with diabetes in India and this number is expected to increase to 135 million by 2045.

Prevalence

Diabetes is primarily a lifestyle condition that has increased alarmingly across all age groups in India.

The prevalence of diabetes in India has increased by 64 percent over the quarter-century, says a 2017 report.

About 98 million Indians could have diabetes by 2030 — these projections come from the International Diabetes Federation and the Global Burden of Disease project.

Worryingly, in India, a large number of children are also impacted by diabetes. Children are developing obesity and metabolic syndrome early because of the change in diets to more processed and fast foods.

According to a World Health Organization (WHO) fact sheet on diabetes, an estimated 3.4 million deaths are caused due to high blood sugar in the world.

Why Indians are more prone to diabetes?

The rapid change in dietary patterns, physical inactivity, and increased body weight, especially the accumulation of abdominal fat are some of the primary reasons for increased prevalence.

Ethnically, Indians seem to be more prone to diabetes as compared to the Caucasians.

At the same time, the increased ‘westernization’, especially in the metros and the larger cities, has led to a drastic change in our lifestyle with changes in our traditional diets and decrease in physical activity.

With the increasing availability of machines to do our work, there’s also a substantial drop in day-to-day activities.

Stress, of course, does play a role, but it’s difficult to quantify.

Currently, India is undergoing a rapid epidemiological transition with increased urbanization.

The current urbanization rate is 35% compared to 15% in the 1950’s and this could have major implications on the present and future disease patterns in India with particular reference to diabetes and coronary artery disease.

Environmental and lifestyle changes resulting from industrialization and migration to urban environments.

Obesity, especially central obesity and increased visceral fat due to physical inactivity, and consumption of a high-calorie/high-fat and high sugar diets, thus become major contributing factors.

Another factor that is not under our control is that we Indians have a greater degree of insulin resistance which means our cells do not respond to the hormone insulin.

Managing Diabetes

India has a challenge to face undoubtedly. However, medical experts feel that timely detection and right management can go a long way in helping patients lead a normal life.

Though a chronic medical condition, Diabetes can be curbed at the initial level by introducing lifestyle changes which include maintaining ideal body weight, regular physical activity, cessation of tobacco smoking, stopping/ minimum alcohol intake.

Role of Policy Makers for Prevention of Type 2 Diabetes in India

There is an urgent need for the government to address these issues and provide adequate healthcare facilities, particularly for the lower economic status of the society.

An integrated national system for early detection and prevention of diabetes must be developed in order to minimize an individual’s risk of Type 2 diabetes and its complications.

Three key goals for Healthcare Policymakers:

Policy Goal 1:

1. The starting point for policymakers is to ensure continual improvements in disease management for their population with diabetes. In turn, this will ease the pressure on the health system and reduce overall spend.
2. Improving diabetes care lies firmly in the control of health ministries.
3. The basic means to achieve improvements are well-evidenced in global and national clinical guidelines.

These include:

1. Access for people with diabetes to medicines and medical treatment.
2. Deliver comprehensive screening for people with diabetes.
3. Provide comprehensive patient education and self-management programs.
4. Creating incentives for healthcare providers to achieve improved outcomes.
5. Improving the efficacy and cost-effectiveness of self-management.
6. Delivering interventions to hard-to-reach patients by exploring innovative low-cost models of delivery.

Policy Goal 2:

1. Establish effective surveillance to identify and support those at risk of Type 2 diabetes.
2. Intuitively, screening for diabetes makes sense.
3. The key for policymakers is to make screening more accessible and appealing for people and at a sustainable cost.

Some of the innovative ways to achieve this aim can include:

1. Providing incentives for people to be screened.
2. Targeting healthcare providers to encourage take-up.
3. Tailoring screening to cultural circumstances.
4. Sharing the cost and inconvenience by screening for other diseases at the same time.
5. Targeting high-risk populations.
6. Offering incentives to healthcare providers

Policy Goal 3:

1. Population-level behavior change aimed at encouraging societies to attend more conscientiously to their health, be less sedentary and have better nutrition.
2. Policymakers need to commit to creating an environment focused on prevention – one that supports healthy choices and encourages healthy behaviours.

The core-steps and innovative action steps for policymakers may include:

1. Articulating a clear case of change – including both health and economic consequences.
2. Committing to ambitious targets and timescales.
3. Assigning responsibility for leading and coordinating initiatives to create an environment focused on prevention.
4. Exploring the full range of preventive interventions- from information to nudges and legislation.
5. Building a cross-disease coalition to support a preventive health and wellbeing approach.

Creating an improved prevention-focused environment is not an easy task. People have hundreds of opportunities to make less healthy choices every day at home, work, school and while travelling, shopping or engaging in leisure pursuits.

Each decision is shaped by a wide range of factors viz., the information available, incentives, peer pressure and social norms.

Mandatory provisions

The only way the government can safeguard people from the manipulative strategies of the food industry is through a legal framework or even an ordinance (Article 123 of the Constitution) with the objective of reducing/halting the consumption of ultra-processed foods.

It could also include defining ‘healthy food’, a warning label on unhealthy food, and restrictions on the promotion and marketing tactics of unhealthy food and beverages.

Conclusion

The people must be informed of the risk of consuming such food. In this process, there is no reason to partner with the food industry that is responsible for ill health.

The governments of South Africa, Norway, and Mexico have recently taken similar actions.

The Infant Milk Substitutes, Feeding Bottles, and Infant Foods Act flattened the growth of commercial baby food.

The proposed new law could do the same to unhealthy foods and beverages. This is an idea whose time has come.

The Government of India can show its strength to regulate food labelling and marketing. Such a law will be a clear demonstration of the will of the government.

Mains Questions

1. India is being termed as ‘Diabetic Capital of the World’, which is worrisome. In background of this statement, enumerate the reasons for the same and also suggest way out? (250 Words) 15 Marks