Review PANDEMIC TRENDS in PREVALENCE of DIABETES MELLITUS and ASSOCIATED CORONARY HEART DISEASE in INDIA – THEIR CAUSES and PREVENTION
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Review PANDEMIC TRENDS IN PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED CORONARY HEART DISEASE IN INDIA – THEIR CAUSES AND PREVENTION. O P Gupta*, Sanjeev Phatak ** ABSTRACT KEY WORDS: Pandemic, Epidemic; Risk factors The increasing trend of diabetes mellitus (DM) in for diabetes and coronary heat disease. India has become a major health problem. This is also true for the rising magnitude of associated INTRODUCTION coronary heart disease (CHD). In the last 25 years both have acquired pandemic forms, particularly in It is well known that the prevalence of type 2 the urban areas. The comparative studies conducted diabetes mellitus (DM) is rising globally but its in various regions of India till date have been impact is most marked in developing countries like reviewed and they support this trend. The studies on India. Some of the important risk factors associated the migrant population of Indians to various with diabetes are mostly similar in all countries but countries show significant increase in the prevalence their expression and intensities vary widely between of diabetes as compared to the native or other races, regions and countries. Asian Indians have a migrant populations in the same country. The racial predisposition and other unique risk factors to findings and importance of impaired glucose develop DM to a greater extent. In India there is tolerance has been emphasized. The possible causes increasing urbanization and industrialization which of the above increases have been described and has led to physical inactivity, sedentary lifestyle, India-specific factors have been mentioned. psychosocial stress and obesity leading to Particular emphasis has been laid on new and progressive increase in prevalence of DM. emerging risk factors for control of CHD in Indian diabetics. The role of modifiable and non- The current studies in India indicate that there is modifiable risk factors has been analyzed. To curb alarming rise in prevalence of diabetes which has the future rise of the magnitude of these pandemics gone beyond epidemic form to a pandemic one. To the preventive measures for both have been elaborate this situation we should understand the elaborately described. difference between epidemic and pandemic occurrence of a disease. Epidemic of a disease In the last quarter of a century there has been usually indicates an 'unusual' occurrence in a enormous rise in the prevalence of both DM and community or region of a disease which is clearly in CHD in India, more so in urban population. These excess of expected occurrence, while pandemic of a have already struck the pandemic proportions and disease denotes an epidemic usually affecting large are likely to rise dangerously in the next 25 years, population, occurring over a wide geographic area, if not curbed. As a consequence, India currently has section, or entire nation (1). With this definition, the highest number of DM (26.2 million) and CHD. DM in India has now acquired a pandemic form. (25 million) cases. The causes of these increases can be modifiable or non modifiable. Among the PREVALENCE OF DM modifiable factors important ones are change in life style, including modification of diet, weight The World Health Organization (WHO) (2,3) has regulation, optimum physical activity, yogic projected that the global prevalence of type 2 DM exercises, cessation of use of tobacco and alcohol will more than double from 135 million in 1995 to and pharmacological interventions. These form 300 million by the year 2025. Recently, very basic components of a preventive program, disturbing estimates have been reported by implementation of which has already brought International Diabetes Federation and WHO, that in encouraging results in some countries. Therefore, the year 2002, at least 177 million people are having adoption of preventive measures by individuals, DM worldwide, which indicates that previous families, entire society including governments can estimate of 225 million by 2010 is an underestimate certainly curb the rising prevalence of both diseases. (4). As shown in Table 1 the greatest increase will *Emeritus Professor of Medicine, B.J. Medical College, 170 Sunrise Park, Drive-in Road, Near ASIA School, Ahmedabad. 380054. **Consultant Diabetologist, Sterling Hospital, Off. Gurukul Road, Ahmedabad 380052. INT. J. DIAB. DEV. COUNTRIES (2003), VOL. 23 37 be in India from 19.4 million to 57.2 million, while became more uniform. Most of these studies from in China from 16 million to 37.6 million and USA 1938 to 1978 have been listed in Table 2 and studies from 13.9 million to 21.9 million during the same from 1979 to 2001 in table 3. period, unless effective preventive measures are Table 1: Top Ten Countries for their Estimated implemented to curb this enormous increase. Number of Adults with Daibetes (in Millions) (3) Currently India has got the largest number of Country Year 1995 Country Year 2025 diabetics and is being called as diabetic capital of the world. In table–1 this number has been 1. India 19.4 India 57.2 compared with the number of diabetics in other 2. 4China 16.0 China 37.6 countries having large number of diabetics. 3. U.S.A 13.9 U.S.A 21.9 4. Russian 8.9 Pakistan 14.5 Type 2 DM is the commonest form of diabetes Federation 5. Japan 6.3 Indonesia 12.4 globally as well as in India. It constitutes more than 6. Brazil 4.9 Russian 12.2 95% of the diabetic population in our country. The Federation prevalence of diabetes has shown increasing trend in 7. Indonesia 4.5 Mexico 11.7 the last three decades in India. Since 1938, 8. Pakistan 4.3 Brazil 11.6 prevalence studies of DM have been conducted in 9. Mexico 3.8 Egypt 8.8 our country. These studies have been carried out in 10. Ukraine 3.6 Japan 8.5 different places, in various age groups and by using All other different methods of examination. [Urine, blood or Countries 49.7 103.6 both]. Only in 1970's, the methodology was somewhat standardized and the prevalence studies Total 135.3 300.0 Table 2: Studies of Prevalence of DM in India from 1938 to 1978. YEAR AUTOHOR PLACE AGE (YEARS) TEST USED PREVALENCE RATE(%) 1938 Chakravarty Calcutta > 5 U 0.73 1959 Patel et al Mumbai All ages B 0.98 1963 Patel et al Mumbai All ages 2.36 1964 Ganguli et al Lucknow > 20 B 2.3 1964 Vaishnava et al Vellore All ages B 2.56 1965 Ramadwar D.K Nagpur > 20 B 2.4 1966 Berry et al Chandigarh > 15 U 1.53 1966 Sainani et al Mumbai All ages B 2.24 1966 Saroj kumari New Delhi - U 2.26 1966 Satyanarayan Hyderabad > 20 U 4.12 1966 Shanker et al Hubli All ages U 2.20 1966 Ahuja et al Delhi All ages U 9.4 1966 Vishwanathan Madras > 20 U 11.3 1966 Misra et al Jabalpur All ages B 1.70 1966 Pai et al Trivandrum > 20 U 8.7 1966 Gour K.N. Varanasi > 10 U 2.7 1966 Datta et al Pondichery All ages U 0.70 1968 Ajgoankar S.S Mumbai > 15 B 2.5 1970 Gupta et al > 15 B & U 1.67 1970 Moses Ahmedabad Adults B & U 3.8 1970 Tripathi et al Madras > 15 U 12.67 1971 Tripathi et al Cuttack > 10 B 1.2 (Ur) 1972 Ahuja et al Cuttack > 15 B 2.3 (Ur) 1972 Jaya Rao New Delhi > 20 B & U 2.4 1973 Mukherjee A.B. Hyderabad All ages GTT 0.7 1973 Parmoshware Calcutta > 5 B 0.81 1975 Gupta O.P. Bangalore > 15 U 2.16 1975 Mutallik Ahmedabad > 15 B & U 1.48 1975 Pai et al Poona > 15 B & U 1.81 1975 Tripathi B B Trivandrum > 15 B & U 1.40 1975 Chhetri et al Cuttack > 15 B & U 1.63 1978 Gupta et al Calcutta > 15 B & U 3.8 (Ur) Ahmedabad B & U 1.93 (R) B- blood glucose; U-urine glucose; GTT- Glucose tolerance test; Ur-Urban; R-rural INT. J. DIAB. DEV. COUNTRIES (2003), VOL. 23 38 The above studies were conducted in urban or in From the above table it will be seen that the rural and urban populations of one particular region, prevalence rate of diabetes in urban population of which did not reflect true prevalence for the entire four major regions of India has increased from 0.9 - country. In 1978 ICMR organized a multicentric 3.8% in 1978 to 9.5 – 13.5% in 2001. This indicates urban and rural diabetes prevalence study on a enormous increase in prevalence rate in urban areas computerized, centrally designed uniform proforma within 23 years in different regions of India. in six cities located in different regions of the However, the reports in 2001 from prevalence of country. In 2001, Ramachandran et al reported a diabetes in India study (PODIS–(7) unpublished similar study, also in six cities located in different data) indicate comparatively low prevalence of regions of the country. These two studies have been diabetes in different regions. The results of this compared in Table 4. study given below are at variance as compared to other studies up to this period Table 5. Table 3: Studies of Prevalence of DM in India from 1979 till 2001. Table 5: Showing the Prevalence of Diabetes in YEAR AUTHOR PLACE PREVALENCE India Study and Impaired Fasting Glucose (IFG) RATE(%) in Different Regions of India (7).* 1979 Johnson et al Madurai 0.5 (U) 1984 Murthy et al Tenali 4.7 (U) DM IFG 1986 Patel J.C. Bhadran 3.8 (R) Region Urban Rural Total Urban Rural Total 1988 Ramachandran et al Kudremukh 5.0 (U) 1989 Kodali et al Gangarathi 2.2 (R) West 5.91 2.48 4.28 6.12 2.87 4.62 1989 Rao et al Eluru 1.6 (R) South 5.67 2.08 4.11 6.90 2.81 4.94 1991 Ahuja et al New Delhi 6.7 (R) East 3.36 1.53 2.51 3.01 1.87 2.47 1992 Ramachandran et al Madras 8.2 (U) North 4.84 1.58 3.27 4.82 2.87 3.86 1997 Ramachandran et al Madras 2.4 (R) Central 3.20 152 2.39 2.89 1.19 2.07 1999 Ashabai et al Chennai 11.6 (U) All India 4.75 1.87 3.37 4.89 2.37 3.68 2000 Ramachandran et al National 17.4 (U) (DESI) 12.1 (U) *All values in percentages.