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Current Diabetes Reviews, 2017, 13, 65-80 Obesity, Diabetes and Cardiovascular Diseases in India: Public Health Challenges Send Orders for Reprints to [email protected] 65 Current Diabetes Reviews, 2017, 13, 65-80 REVIEW ARTICLE ISSN: 1573-3998 eISSN: 1875-6417 Obesity, Diabetes and Cardiovascular Diseases in India: Public Health Challenges BENTHAM SCIENCE U. Shrivastava1-3, A. Misra*1-4, V. Mohan5, R. Unnikrishnan5 and D. Bachani6 1Centre for Public Health India, New Delhi, India; 2National Diabetes, Obesity and Cholesterol Foundation, New Delhi, India; 3Diabetes Foundation (India), New Delhi, India; 4Fortis C-DOC Hospital for Diabetes, Metabolic Diseases and Endocrinology, New Delhi, India; 5Dr. Mohan’s Diabetes Specialties Centre and Madras Diabetes Research Founda- tion, Chennai, India; 6Ministry of Health and Family Welfare, Government of India Abstract: Non-communicable diseases (NCDs; including coronary heart disease and type 2 diabe- tes) are rapidly increasing in India causing nearly 5.8 million deaths per year. Primary reasons for rise in NCDs in India are nutrition and lifestyle transitions. Further, presence of higher body fat, ab- dominal fat, liver and pancreatic fat and lower lean mass than whites, contribute to heightened meta- bolic and cardiovascular risk in Asian Indians. Importantly, conversion from pre-diabetes to diabetes A R T I C L E H I S T O R Y occurs more rapidly, and reversion to normal glucose regulation with appropriate lifestyle measures Received: May 30, 2016 is more difficult in Asian Indians than white population. Huge number of patients with diabetes and Revised: July 11, 2016 Accepted: July 28, 2016 with complications increase morbidity, mortality and pose substantial economic burden. It is diffi- cult, though not impossible, to decrease pace of rapidly expanding juggernaut of NCDs in India. DOI: 10.2174/1573399812666160805153 Only concerted efforts from multiple stakeholders, consistently sincere efforts and intensely focused 328 attention from health officialdom and clear political will may help counter this increasingly difficult challenge. Finally, all prevention and management approaches should be cost-effective, pragmatic, and focused on children and underprivileged populations. Keywords: Asian Indians, diabetes, cardio-vascular diseases, hypertension, metabolic syndrome, obesity. BACKGROUND contribute to 52% of mortality in South Asia, and have been projected to account for 72% of total mortality in this region NCDs have emerged as a major public health threat for by 2030 (Fig. 1) [1]. all strata of the society worldwide. They account for 38 mil- lion deaths in 2012, and this number is expected to rise to 52 million by 2030 [1]. In 2014 alone, 1.9 billion adults were SEARCH STRATEGY overweight (>=25 kg/m2) of whom 600 million were obese A literature search was conducted in the electronic data- (>=30 kg/m2) [1]. As of 2015, more than 415 million people bases (PubMed, Embase, and Google Scholar) and was lim- worldwide have diabetes. Globally, diabetes accounted for ited to articles published in English. The search terms in- 4.9 million deaths in 2014 [2]. Finally, cardiovascular dis- cluded “diabetes”, “cardio-vascular disease”, “obesity” and eases (CVD) accounted for 31% of all global deaths (17.5 “India”, in combination with “risk factors”, “economic con- million) in 2012 [1]. sequences” and “prevention”. This process yielded 284 ref- South Asian region, which is home to more than 1.7 bil- erences, including reports from national and international lion people, is currently experiencing marked demographic organizations, government reports, review articles and re- transition characterised by declining birth and death rates search studies. After further review, of these, 123 references and an increasingly aging population [3]. This increase in were selected by US, VM, RU, DB and AM. The final re- longevity has led to a rapid increase in the prevalence of view of the articles was performed by AM. NCDs like CVD, diabetes (78 million cases in 2015), cancer, and chronic pulmonary disease, due in large part to increas- MAGNITUDE OF NCDs IN INDIA: SOME FACTS ing lifetime exposure to risk factors. NCDs already In India, NCDs accounted for 60% of all deaths and 44% of disability-adjusted life-years (DALYs) lost in 2011 [1]. They were estimated to be responsible for 40% of all hospi- tal admissions and 35% of all out-patient visits in 2004 in *Address correspondence to this author at the Fortis-C-DOC Hospital for India [4]. Estimates from the Global Burden of Disease Diabetes, Metabolic Diseases and Endocrinology, B-16, Chirag Enclave, New Delhi, India; Tel: +011-493-01222; Fax: +011-493-01200; Study 2013 have shown increase in number of deaths for E-mail: [email protected] most of the leading NCDs increased by 42% between 1990 1875-6417/17 $58.00+.00 © 2017 Bentham Science Publishers Current Diabetes Reviews 66 Current Diabetes Reviews, 2017, Vol. 13, No. 1 Shrivastava et al. Mortality in 2008 Mortality in 2030 11.9% 10% 24% Injuries Cardio-vascular diseases 12.1% 35.9% Cancers Respiratory diseases 6% 37% Diabetes Other NCDs 19.1% 11% Communicable, maternal, perinatal, 2% and nutritional 10% conditions 21.0% Fig. (1). Non-communicable diseases and proportional mortality in India 2008 and 2030. Reproduced with permission from [1]. and 2013 (from 27·0 million [UI 26·3-27·6] in 1990, to 38·3 [8, 9]. Obesity affects more than 135 million individuals in million [37·2-39·4] in 2013) in India. The common NCDs India. Prevalence rates of obesity in India differ depending are interlinked; for instance, it is estimated that about 44% of on various factors including age, gender, place of residence, the diabetes burden and 23% of the CVD burden can be socio-economic status, and criteria used for the measurement attributed to overweight and obesity in India [5-7]. of obesity (Table 1) [11, 12]. According to the nationwide, population-based Indian Council of Medical Research-India OBESITY Diabetes (ICMR-INDIAB) study, the prevalence of general- ized obesity (defined as BMI 25 kg/m2), varied from 11.8% Serial National surveys in India have demonstrated an in- in Jharkhand (east India) to 31.3% in Chandigarh (north In- creasing trend in the prevalence of obesity (NFHS 2 and 3) dia) [10]. The urban population has higher prevalence rates Table 1. Prevalence of Obesity in Asian Indians residing in India. Location (geographical Sample populationCriteria of obesity Diabetes Prevalence (%) Studies Age (year) 2 and urban/rural) Males Females (BMI in kg/m and WC in cm) Males Females Dhurandhar et al. 1992 West India (Urban) >15 791 791 BMI: >30 4.8 7.8 [21] Gupta et al. 2003 [22] North India (Urban) 20 532 559 WC: >102 (M), 88 (F) 21.8 44.0 Misra et al. 2001 [7] North India (Urban) ** >18 170 362 BMI: >25 13.3 15.6 Gupta et al. 2004 [23] North India (Urban) >20 960 840 WC: 102 (M); 88 (F) 25.6 44.0 Prabhakaran et al. 2005 North India BMI: >25 35.0 * 20–59 2935 * [24] (industrial population) WC: 90 (M); 80 (F) 43.0 * Misra et al. 2005 [25] North India (Urban) 38.9 640 * WC: 90 (M); 80 (F) 10.1 25.9 Mean: Gupta et al. 2007 [26] North India (Urban) *** 43.2 (M) 226 232 BMI: 30, WC: 102 (M); 88 (F) 20.8 34.5 44.7 (F) Chow et al. 2008 [27] South India (Rural) 20–90 4535 * BMI: >25 WC: 90 (M); 80 (F) 32.4 41.4 Bhardwaj et al. 2011 [20] North India (urban) >18 217 242 BMI: >25, WC: 90 (M); 80 (F) 50.2 50 Gupta et al. 2012 [13] West India (Urban) 35–70 4621 WC: 102 (M); 88 (F) 14.4 South India (Tamilnadu) 1047 2521 20.6 28.4 West India (Maharashtra) ICMR-INDIAB-3 [10] 20 1215 2594 BMI25 15.7 17.6 East India (Jharkhand) 921 2286 14.7 19.1 North India (Chandigarh) 880 2336 24.2 38.7 22.5# 45.6 @ Mohan et al. 2016 [14] Multi-centric 35-70 6853 BMI25 57.4@@ *: Overall including male and female; ** Data from urban slum population of New Delhi, north India; *** Data from Punjabi Bhatia community in north India; M, Male; # Rural; @ Urban poor; @@ Urban middle class; F, Female; BMI, Body mass index; WC, Waist circumference; ICMR-INDIAB, The Indian Council of Medical Research–India Diabetes. Adapted from reference 12, with additional data from references 10 and 14. Obesity, Diabetes and Cardiovascular Diseases in India Current Diabetes Reviews, 2017, Vol. 13, No. 1 67 250 *p < 0.05 *p < 0.01 *p < 0.01 200 3 *p < 0.01 150 *p < 0.01 *p < 0.01 100 50 Abdominal fat & pancreatic volume (cm ) 0 s ta o a dn bcu a e u rp ioe r su t n o s subcut neous t subcut neous Intra-peri one l sct r Ret o er t n al To al ab omi all ub u aneou Live span (mm) Pancreatic v lume Deep a Tota n pi ta ra-a d mi al A terior subcutPosterio neous Su a erf cial To l Int b o n Abdominal fat depots Fig. (2). Abdominal fat depots, pancreatic volume & liver span measured by MRI (1.5 Tesla) in non-obese patients with type 2 diabetes (n = 93, shown in black bars) & non-obese non-diabetic subjects (n = 40, shown in box filled with crossed lines). Reproduced with permission from [16]. of obesity as compared to the rural population [6, 7, 14]. DIABETES Further, the prevalence of obesity is observed to be higher in women than men [12]. In a multi-site study conducted in India has more than 69 million people with T2DM, and India on 4608 women over 35 years of age using WHO cut- these numbers are expected to rise to 140 million by 2040, offs for obesity, 33.2% of rural and 46.6% of the urban and an almost half of them remain undiagnosed [3].
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