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Diabetes is considered, as well as remains, the biggest concern in India. As reported by Dr. Rajiv Gupta (2008), there were an estimated 40 million persons with diabetes in India in 2007 and this number is predicted to rise to almost 70 million people by 2025, according to Diabetes Atlas published by the International Diabetes Federation (IDF). As reported by Arora et al (2000), India remains the "Diabetes Capital of the World" with one in every fifth diabetic residing in India.
Before proceeding further, let us first understand this long-term condition. Diabetes is characterized by hyper glycaemia, an overall increase in the sugar level in the body which is generally treated by one or combination of anti-diabetic drugs and at much severe stage this therapy is combined with intra muscular administration of human insulin. Over a period of time there is a tendency that human body develops a resistant to this insulin (Valente, 2005). While medication can often be used to treat this insulin resistance, there are cases where the deterioration of the pancreas can lead to Type 1 diabetes and insulin dependence. Thus Diabetes, as explained by Mastroieni (2008), with an improper management can result in serious complications, including heart and kidney damage, blindness and loss of extremities.
Diabetes is considered to be one of the leading causes of morbidity and mortality since it has no complete medical treatment. According to WHO report (1997), shown by Indian task force on diabetes care in India, 124.7 millions of people were affected with diabetes in 1995 globally which increased to 153.9 millions in 2000 and is expected to increase to 299.1 million by 2025. Around 3.2 million deaths every year are attributable to complications of diabetes with six deaths every minute. Cardiovascular disease is responsible for between 50% and 80% of deaths in people with diabetes globally (WHO, 2010).
It was also argued that the increase in the prevalence of diabetes is seen more in developing countries than developed countries. Therefore, it is believed that developing countries like India will have more than a 200% increase in the number of diabetic patients, whilst the developed countries will have a relatively meager increase in numbers of around 45%.
Let us now discuss on demography of diabetes in Indian population considering lifestyle, age and socio-economic status. Gupta (2008) mentioned that developing countries like India have shown dramatic lifestyle changes leading to lifestyle related diseases because of a rapid growth in urbanization and globalization which led a transition from a traditional to modern lifestyle. What this means individually is, increased facilities, sedentary lifestyles, eating habits such as the consumption of diets rich in fat and calories combined with a high level of mental stress has compounded the problem further (Gupta R, 2008) to a vast level.
There are several studies from various parts of India which reveal a rising trend in the prevalence of type II diabetes in the urban areas. For example, studies conducted in Chennai as referenced by Ramachandran (2002), a city in Southern India showed that the prevalence of diabetes in adults in urban areas had increased from 5.0% to 13.9% within 16 years. According to the National Urban Diabetes Study (NUDS) conducted in six major cities of India in 2008, the average prevalence in urban India adult is 12.1%. The prevalence of diabetes in rural areas was known to be up to four to six times lower than in cities. This is due to old lifestyle habits and lower socioeconomic status of the rural population. Considering the age factor the NUD study reflects that Indians under 40 years of age have a higher prevalence of IGT (Impaired glucose tolerance) than of diabetes itself. IGT is a pre-diabetic condition with a fluctuating glucose tolerance and it is surveyed that people with IGT have a 25% to 50% risk of developing diabetes in the subsequent 10 years and hence it is evident that diabetes incidence rates are set to continue to grow in a relatively young and productive people of India.
In most of the cities studied by NUDS, the IGT to diabetes ratio is more than one. This means that there is a huge potential for an even greater rise in the prevalence of diabetes in urban areas. Considering socio-economic groups in India, the prevalence of diabetes in low-income groups is half that of high-income groups probably because the low-income groups get more physical exercise and less fast food. However as analysed by Ramchandra (2002), due to poor availability and accessibility to health services, the later complications of diabetes have been more common in the low-income groups. According to the Bangalore Urban District Diabetes Study (BUDS), the annual direct cost for routine care of diabetes in Bangalore city among lower socio-economic patients in 1998 was found to be about US$ 191, while cost per hospitalization was calculated up to US$ 208. As argued by Desai (2009) for a developing country like India with only 5% of its GDP being spent on healthcare, diabetes, especially the condition with complications has a major impact on the socio-economic status. However as suggested by Anthony (2004), further complications of diabetes can be prevented, or delayed, by modifying risk factors. As further suggested by him persons with diabetes must understand their disease and be empowered to avoid obesity, smoking and unhealthy diets, and encouraged to exercise, and control blood glucose. Good health education, health promotion and access to professional care are essential for persons with diabetes mellitus. (Anthony S., 2004)
Governments have encouraged public health policies and programs in order to gain some understanding of the causes of disease and thus ensure social stability. The goal of public health is to improve lives through the prevention and treatment of disease. Public health is "the science and art of preventing disease, prolonging life and promoting health through organised efforts of society." This definition of public health was given by Sir Donald Acheson in 1988 in England report (Department of Health, 2007). Thus focus of public health intervention is to prevent rather than treat a disease through surveillance of cases and the promotion of healthy behaviors. WHO (1975 cited by Verma 2005) points out that health is an important asset in the constitution of WHO. The widely accepted definition of health given by WHO in 1946, described as "health is a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity." However since this definition does not take into consideration major impact of environmental pollutants on human health there has been a shift in the concept of health and the global commitment is towards "Total Health' in recent past which will be described as "Health is a state of complete physical, mental, and social well being where life thrives in healthy environment devoid of pollutants; and not merely an absence of disease or infirmity." One of the goals of the WHO is to prevent diabetes and to minimize complications and maximize quality of life. The core functions of the WHO Diabetes Programme (2010) are to set norms and standards, promote surveillance, encourage prevention, raise awareness and strengthen prevention and control. Health promotion and disease prevention are being addressed both nationally and internationally. Five key action areas were identified in the Ottawa Charter of 1986 and reaffirmed by the Bangkok Charter for Health Promotion adopted on August 11, 2005. These five key action areas included building a healthy public policy, create supportive environments, strengthen community action, develop personal skills and reorient health services. Further recognition and support of the development of community-based programs together with Public Health Units and local partners to reduce the risk of developing specific conditions and improve overall health and well-being is undertaken by the governments of various developing countries including India. These initiatives include health promotion activities, public awareness programmes on non-communicable diseases, alcohol and substance abuse prevention programs, heart health, tobacco use reduction, promotion of physical activity and good nutrition, and programs such as "Best Start" and "Healthy Babies, Healthy Children," to protect and promote children's health and well-being.
More recently, India has committed to promoting healthy lifestyle and regular physical activity through the "National programme on Diabetes Cardiovascular diseases and stroke, which will be discussed further in this essay. Thus, using health promotion as a powerful strategy to address the factors influencing health inequalities, enabling people to exert control over the determinants of health and thereby improving their health are undertaken by many governments in the developing world including India.
Let us now focus on the risk factors and social determinants for diabetes in India. Some of the risk factors identified by Gupta (2008), former president of Delhi Diabetes forum, for increase in the prevalence of diabetes in Indians are age, family history, central obesity, physical inactivity and sedentary living, insulin resistance, urbanization and stress. It is evident from the analysed statistics that diabetes among the population living in India develop at a very young age, at least 10 to 15 years earlier than the western population. As I have discussed earlier that according to National Urban Diabetes Study, an early occurrence of IGT (impaired glucose tolerance) gives ample time for development of the chronic complications of diabetes. A high incidence of diabetes is seen among the first degree relatives due to high genetic risk. Also it has been found that Asian Indians are more insulin resistant as compared to the white population. Furthermore analysis by Gupta (2008) suggests that they have a higher level of insulin resistance to achieve the same the blood glucose control. Moreover, cluster of factors consisting of abnormal fats (Dyslipidemia), high blood pressure, obesity, and abnormal glucose levels known as metabolic syndrome is highly prevalent amongst Asian Indians.
Other important factor as analysed by Gupa (2008) is the vast availability and use of motorised private transport and a shift in occupations combined with an increased usage of electronic media such as internet, television, etc. reducing the physical activity in all groups of populations leading to a collection of excess body fat specially concentrated within the abdomen region which increases risk of diabetes. Urbanization can also be associated with increasing obesity, decreasing physical activity due to changes in lifestyle, diet and a change from manual work to less physical occupations. Also the physical and mental stress accompanied within the lifestyle changes has a greater impact on increasing incidence of Diabetes.
In addition to the above all factors, the most important factor identified by Deogaonkar (2004) is the health inequality due to socio-economic inequalities in India. These include unequal distribution of healthcare resources, difficulties in accessing healthcare services and primary health care and economic inequalities.
Let us discuss this aspect in more details. As reported by Deogaonkar (2004), the ratio of hospital beds to population in rural areas is fifteen times lower than that for urban areas. The ratio of doctors to population in rural areas is almost six times lower than that in the urban population. Per capita expenditure on public health is seven times lower in rural areas, compared to government health spending for urban areas. Though the spending on healthcare is 6% of gross domestic product (GDP), the state expenditure is only 0.9% of the total spending. People use their own resources to spend on their health which means only 17% of all health expenditure in the country is borne by the state, and 82% comes as 'out of pocket payments' by the people. This makes the Indian public health system grossly inadequate and under-funded. Moreover there is also a difficulty in accessing health care services which is due to geographic distance, socio-economic barriers and gender discrimination. Population living in remote areas with poor transportation facilities is often removed from the reach of health systems. Incentives for doctors and nurses to move to rural locations are generally insufficient and ineffective. Therefore socio-economic barriers include cost of healthcare, use of less nutritious and cheaper foods and social factors, such as the lack of culturally appropriate services, language or ethnic barriers, lack of education and prejudices on the part of providers.
An additional factor to be considered widely is the gender inequality. Gender discrimination makes women more vulnerable to various diseases and associated morbidity and mortality. Women are largely excluded from making decisions, have limited access to and control over resources, are restricted in their mobility, and are often under threat of violence from male relatives. In general an Indian woman is less likely to seek appropriate and early care for disease, whatever the socio-economic status of family might be. This gender discrimination in healthcare access becomes more obvious when the women are illiterate, unemployed, widowed or dependent on others. Having identified this we can also not ignore the primary healthcare and economic inequality. The growth of primary health sector is a boon providing excellent services at higher rates but at the same time unaffordable by common citizen living on an average income. The increasing cost of healthcare that is paid by 'out of pocket' payments is making healthcare unaffordable for a growing number of people. One in three people who need hospitalization and are paying out of pocket are forced to borrow money or sell assets to cover expenses. Over 20 million Indians are pushed below the poverty line every year because of the effect of out of pocket spending on health care. Thus for a large, multicultural and overpopulated country like India, undergoing rapid but unequal economic growth has adversely affected the health of under-privileged population.
So, it has become a real challenge for individuals and governments to promote healthy lifestyles. Health promotion and disease prevention strategies focus on keeping people healthy and preventing diseases from occurring. These strategies are referred to as primary prevention activities. Secondary and tertiary prevention activities focus on maintaining the health of individuals with chronic conditions, delaying progression of their conditions, and preventing complications (Guide to health promotion and disease prevention, 2006). Primary intervention like lifestyle modification that involves regular exercise or physical activity and consumption of fibre rich, low-calorie healthy diet, has been beneficial in prevention of diabetes. One of the studies, the Indian Diabetes Prevention Programme (IDPP) had randomized 531 overweight subjects with IGT with increased risk for diabetes. This study showed the relative risk reduction of 28.5% with LSM (lifestyle modification), 26.4% with metformin (anti-diabetic drug) and 28.2% with a combination of LSM and metformin indicating no additional benefit of combination. Thus, there is strong evidence that type 2 Diabetes mellitus can be prevented with an intervention as simple as lifestyle modification (Desai, 2009). However 1998 study, Chennai Urban Rural Epidemiology Study (CURES) in Chennai found that awareness of diabetes as a public health priority and knowledge of diabetes prevention by LSM is poor, especially among women and people with little education. But seven years later as reported by Siegel (2008) when the same group was studied, it was found that community empowerment can greatly increase physical activity. For example, it motivated a community in Chennai to construct a public park with its own funds for leisure time, exercise and mental relaxation which suggests that community involvement can strengthen government efforts (Siegel, 2008).
A large scale community based project, Prevention Awareness Counselling Evaluation (PACE) Diabetes Project, was carried out between the periods of 2004 to 2007 to increase awareness of diabetes and its complications in Chennai city. It was funded by the Chennai Willingdon Corporate Foundation, a non-governmental organization (NGO) based in Chennai. Awareness programs were conducted through public education, media campaigns, general practitioner training, blood sugar screening and community based program. Diabetes prevention messages reached to nearly two million people in Chennai through the PACE Diabetes Project, making it one of the largest diabetes awareness and prevention programs ever conducted in India (Somannavar, 2008). Many such community based programmes like "MARG" (Hindi for Path), CHETNA (Childrens' Health Education Through Nutrition and Health Awareness), TEACHER (Trends in childhood nutrition and lifestyle factors in India) were carried out in different parts of India to impart health education through lectures, posters, group discussions with children, parents and teachers, and by conducting health camps. (Diabetes Foundation India, 2007)
Now let us make an attempt to analyse some national and international policies implemented for the prevention of diabetes in India. Certain policies and practices contribute to India's rising diabetes rates or serve as barriers to action, but others can alleviate the diabetes burden. There are many National programmes designed for the promotion of good health and wellbeing initiated by the Minstry of Health and Family welfare (MOHFW), Government of India. One such programmes for the promotion and awareness of diabetes and other non-communicable disease is the National Program on Diabetes, CVD, and Stroke (NPCDS). This programme was launched in seven states on January 2008 with an aim to promote the awareness of non communicable diseases amongst the general population and early diagnosis and appropriate management of Diabetes and other non-communicable diseases including stroke and cardio vascular diseases.
As a part of its execution, January 2008 onwards, various measures as reported in the progress sheet (04/2008) (please refer to annexure 1) such as establishments of clinics, liaison with the local medical colleges, district hospitals and medical research centres for processing the data and treatments and appointments of the district nodal officers, are taken across the seven states. In addition, the television ads demonstrating a preventive framework (in English and Hindi) were relayed on the national and local TV channels.
The programme had a phenomenal response initially. As per the annual report (2009-10) published by the ministry of Health and family welfare, under this project, 22008 persons were screened for diabetes, and other non-communicable diseases such as hypertension, heart diseases and stroke (as reported by States; Gujarat, Kerala, Punjab, Sikkim and Andhra Pradesh) 2192 were found to be diabetic (9.95%), 3774 (17.74%) as hypertensive, 1080 (4.9%) as suffering with CVD and 101 (0.45%) had stroke. Annexure 1 refers to an overall progress of the programme as on 04/2008. Having achieved results from few areas of the country is not sufficient and yet, there needs a lot of work to be done in other parts. Updated information on progress needs to be communicated by the ministry in order to analyse the results accurately.
Let us now look at the other programmes for the diabetes awareness. As mentioned in United Nations Resolution 61/225 given by IDF(c), many children die of diabetes, particularly in low and middle-income countries. In 2007 and 2008, World Diabetes Day (14th November) focused on promoting the UN Resolution and raising awareness of the impact of diabetes on the lives of children and adolescents worldwide. In response to high consumption of junk food, in 2006 the health ministry of India proposed a ban on soft drinks and junk food in schools, colleges, and universities nationally and is consulting with other agencies regarding implementation. A massive campaign to increase children's awareness of these issues has been proposed, but the reaction in Indian civil society has been negative thus far. In 2006 the government also approved the National Urban Transport Policy (NUTP), which focuses on greater use of public transport and non-motorized modes, especially for marginal urban populations. The National Urban Renewal Mission (NURM), launched in 2005, gives the central government priority to construct bicycle lanes and pedestrian paths. A public bicycle rental program in designated areas is under study. However, capacity and resources are obstacles to implementation (Siegel, 2008). BRIDGES (Bringing Research in Diabetes to Global Environments and Systems) is a programme initiated by the International Diabetes Federation, and supported by an educational grant from Eli Lilly and Company. BRIDGES aims to fund translational research projects in diabetes prevention and treatment to provide the opportunity to translate lessons learned from clinical research to those who can benefit most, people affected by diabetes. BRIDGES is seeking the best ideas from the global multidisciplinary community interested in diabetes in the form of Requests For Proposals (RFPs) (IDF, 2007 (a)). On January 15 2010, IDF launched D-START (Diabetes, Supporting Translational Research and Twinning), an initiative that aims to support the development of innovative projects in low and middle- income countries (LMCs). D-START brings together world experts in diabetes and organisations with limited access to funding opportunities. Partnership, transfer of knowledge and sustainability will be the key goals of this new initiative and will undoubtedly contribute to its success (IDF, 2007(b)).
In-spite of interventions, various awareness programmes and policy implementations, diabetes still remains a burden for India. This may be because of ethical and social issues related to interventions and challenges and gaps in various policies for diabetes in India. Let us now focus on ethical issues with interventions considering various aspects. Bal (2000) argues that one of the ethical dilemmas is to carry out expensive treatments in diabetic patients. For example, foot gangrene is one of the dreaded complications of diabetes. It is possible to save the foot but with expensive high technology treatment. Other alternative to overcome this expense is amputation of foot which is loss of limb resulting in loss of one's employment. So it is really difficult for the family to take the decision regarding the treatment. Other factors which are prevalent in India like bureaucratic controls, corruption and a lack of motivation prevents good quality health services (Bal, 2000). Now considering Diabetes Prevention Program which was restricted to impaired glucose tolerance group with high risk of developing diabetes, there is an ethical issue in not considering low risk group. Lifestyle intervention can indeed prevent the development of type 2 diabetes in persons at high risk. However, as quoted by Williamson (2000) the effectiveness of lifestyle intervention for persons at lower risk for diabetes remain unknown.