‘Sedentary Lifestyle Responsible For Surge': Dr RM Anjana On India's Diabetes Crisis

A recent study by the Indian Council of Medical Research (ICMR) revealed alarming numbers for India's diabetes situation, with 101 million diabetics and 136 million people at risk of pre-diabetes. According to the ICMR study, published in The Lancet Diabetes and Endocrinology journal, the number of diabetic cases in India has surged by 44% over the past four years, from 70 million in 2019 to 101 million.

Based on its findings, the study interpreted that the prevalence of diabetes and other non-communicable diseases (NCD) in India is considerably higher than previously estimated. "While the diabetes epidemic is stabilising in the more developed states of the country, it is still increasing in most other states. Thus, there are serious implications for the nation, warranting urgent state-specific policies and interventions to arrest the rapidly rising epidemic of metabolic NCDs in India," the study said. At 26.4%, Goa showed the highest prevalence of type 1 and type 2 diabetes cases, followed by Puducherry with 26.3%, and Kerala ranked third with 25.5% of cases.

To understand why we are more vulnerable than before to diabetes, Govindraj Ethiraj, founder, The Core, spoke to Dr RM Anjana, lead author of this report, and Managing Director of Dr Mohan's Diabetes Specialty Center. She is also the Vice President of the Madras Diabetes Research Foundation, which is an ICMR center for advanced research on diabetes. 

Commenting on the factors driving the increasing cases of diabetes and pre-diabetes, Dr Anjana said, "If you just look at dietary patterns over the last 10-20 years, physical activity levels and obesity levels, all of these things have undergone drastic change. People are becoming more and more sedentary. Now with COVID coming in and with work from home, people barely move from one room to another. So naturally you will see that when these things come together, it all leads to obesity, hypertension, then diabetes. So it is all kind of linked."

Here are the edited excerpts from the interview: 

Why diabetes needs to be tackled urgently and how is the ICMR-led study important in this context?

I think it has a huge importance because right now we are talking about India's metabolic health report, and we're talking not just about diabetes, but also pre-diabetes, hypertension, obesity, and dyslipidemia or cholesterol levels. We are talking about all of this together. And what we are showing is that there are huge increases in the number of all of these factors that I just mentioned, from earlier reports. Now this is done in the ICMR India Diabetes Study, or INDIAB study for short, which has been going on since about 2008. Like you rightly said, it is funded by ICMR, but also by the Department of Health Research, Government of India. 

So state by state, and India being such a vast and diverse country, we have looked at a very representative population in terms of socioeconomic status, population size, demography, etc. And we have looked at each of these stats, how do all of these metabolic risk factors work, how do they work, and where are we right now?

So overall, across the country, we are seeing increases. We are seeing increases in urban areas. We are seeing increases in rural areas. Now, the urban prevalence, as you would expect, is higher in all of these aspects-diabetes and hypertension and obesity and everything is much higher in the urban areas compared to the rural areas. But one of the significant points that the study is looking at is the prevalence of pre-diabetes. Now, how does one progress? One does not  progress suddenly to diabetes from normal life. It appears like that to the individual person. But in the body, you go from stage of normalcy to the stage of prediabetes and then you progress onto diabetes.

A large proportion of these people with pre-diabetes will convert into diabetes. About 60% in 2-5 years is the kind of conversion. When you see these, if you look at the country overall, right now, the diabetes levels are high, mostly in the South. There are some parts of North Delhi, Haryana, all of those regions. But you have some central areas that are still lower in prevalence that you would see in some areas of the Northeast. 

But the important point here is that wherever you see lower prevalence of diabetes, we are showing a very high prevalence of pre-diabetes. What does that mean in the near future? All of these states which you are falsely thinking are low prevalence now, are all going to start converting and all of these people with pre-diabetes. So in the next five years, we are going to see these alarming numbers increasing. You may see plateaus in states that have already reached there, but these huge numbers are going to keep exploding in all of those. So this is how it looks for diabetes at the moment.

As per the study, 11.4% of the population, or roughly 101 million have diabetes, and 15%, or 136 million have prediabetes. What is driving this and including that interesting demographic insight that you brought in about South and North having higher levels and Central India and Northeast heading in that direction.

So that's exactly what I said. The common thing about all of these is that since they are all metabolic non-communicable diseases (NCD), they have common risk factors. So diet and physical activity alone, kind of explain about 50% of all of this stuff put together.

Now if you just look at dietary patterns over the last 10-20 years, look at physical activity levels., look at obesity levels. All of these things have undergone drastic changes. Now you add COVID into the mix and there is like a multiplier factor here. So dietary habits are largely unhealthy with too much carb, very less fruit and vegetable intake, and high in salt, sugar, fat, etcetera. So this is common everywhere– not just in urban areas, but in rural areas too.

You take physical activity, it looks quite dismal as well because people are becoming more and more sedentary. And now with COVID coming in, with work from home, people barely move from one room to another, forget going to the office and coming back. All that has become like a weekly phenomenon now. So barely, what is your activity level? You move from bedroom to kitchen to bathroom and you sit again. So with this, there is a compounding of your physical inactivity. People are not exercising anyway and all this is compounding. 

Now this has moved to children also. So when you see this is a further risk factor, add in stress. Stress levels are increasing everywhere, all ages, everybody who is not stressed. So naturally you will see that when these things come together, it all leads to obesity, hypertension, then diabetes, it is all kind of linked. 

 

The study also exposes in some ways or provides insights into how things are inter-regionally in the country. Can you tell us more about what you have seen or are seeing? 

When you look at diabetes, there are clear regional differences where it is quite high. So let's talk about it by GDP or you can talk about the Human Development Index (HDI) that we have mentioned in the paper. For those states that have high GDP, high HDI, you have high diabetes. That is how it works. States which are lower on these factors are also lower in terms of diabetes. But this will change because there is this demographic transition that is happening across regions. 

Having said that, obesity is all pervasive. So across all states, we have these colour coded maps that we have in the paper, you will see just red everywhere, in terms of all over the country. Once obesity increases, diabetes increases. Similarly, hypertension is high overall and more so in rural areas, maybe because of smoking, very high in the Northeast. So there's a lot of smoking there. So that could be also contributing. 

 

You touched on complications and I know during COVID the people who were in some ways likely to be more affected if they had COVID. So COVID is perhaps one aspect when this is more historical.What is the complication that arises, as in, why should people worry about what you found? 

This is a very good question because diabetes affects everything from your head to your toe. So the primary ones are, of course, your eyes. And diabetes is a very avoidable cause of blindness, something that should not happen these days with good control of blood sugar. It can also cause kidney failure. To put that very simplistically. And again, this is an avoidable cause completely. If you are not careful, it can cause gangrene of your foot, leading to amputations. It can cause nerve damage in any part of your body, anywhere. That can lead to further heart attacks, you can get vascular problems, you can get strokes. So diabetes is a silent killer in many ways because on the outside you look fine, but if your sugars are uncontrolled one by one by one, the internal organs are getting affected without your knowledge.

What happens at the pre-diabetes stage? You could be living with it from the way data seems to suggest, and not knowing about it, which I am assuming is the problem with most of India in any case.

It is. I think you got that right. So that appears to be the main problem. So the good thing about pre-diabetes is that it gives you a window of opportunity for action. So, a lot of the pre-diabetes comes with obesity. It comes with everything I just spoke about. 

Now the lifestyle changes, you focus on that in this kind of population. If you want to do an intervention that is going to work, do it in this population. So pre-diabetic population, because this population can progress, as I said, but they can also regress and they can go back to normal. I think that is the golden window that we have. And that is where effort should be made to see that more and more people fall from that pre-diabetes, instead of becoming diabetic, they should move into the normal category. 

 

How would that happen? Is that medical intervention, or could it be possible without that? 

Lifestyle intervention, just diet and exercise alone. And if you add some stress element-yoga and pranayama and all that. Just that. It is not really rocket science. So weight control is very important. Every kilo that you gain increases your risk on someone who has a genetic pre-disposition for all of this. So weight control through healthy living, which includes dietary restriction of carbohydrates, increase in fruits and vegetables, increasing physical activity, decreasing your sedentary time, taking care of stress, smoking, alcohol, all of this together. And they are not rocket science. It is not something that people do not know. It's just that people do not practice it, that's all. 

 

What would trigger the testing? Because unless, obviously, you have tested, you do not know. And if you do not  know, then life goes on. 

That is the very important one, right? So people have to screen. These things run in families. So if you have parents, even a parent with diabetes, then anyone above the age of 20, it's better to test. If you have a family member, a blood related family member, again, it's better to test. If you yourself are overweight or obese, it's better to test. So there is this thing called the Indian Diabetes Risk score. It's a simple scoring system in which you can just enter your age, your family history, etc, and it tells you your risk of developing diabetes. So if you are low risk, which means you have a score of less than 30, you can wait. Nothing is going to happen in the next 4-5 years. If you are between 30 and 60, it's better to keep an eye on all of this and get tested, say, within the next six months to a year. If you have a score of above 60, it is possibly mandatory for you to get a test done immediately. 

 

How do I find out what my score is? 

There are four questions, and it's available online. It's called the Indian Diabetes Risk Score. So it takes into account your age, your occupation, your family history, and how active you are. These are the four questions. And your waist measurement, your pants size. You just enter that and it gives you a score. 

 

What should be or can be the public policy response to address both ends of the spectrum, which is your pre-diabetic as well as your diabetic population.

I think this has to be done at many levels, but primarily mass education. People need to know that there is a problem and there is a solution to the problem. It's not fatalistic, it is a problem. But you can do something about it. So making this a priority, I think, is number one. 

So obviously, the only people who can reach that level are the government. Governmental efforts are already there, actually. The Ayushman Bharat scheme by the Government of India has introduced 150,000 (hundred and fifty thousand) wellness clinics in the country. So that is one very effective scheme. More schemes like that where massive education to people about what are the risk factors and how they can be controlled is one.

Second, I think individuals knowing their risk and trying to take up the responsibility for looking after and preventing themselves are important. What can be done in terms of dietary changes, etc. Now, when you talk about physical activity and you tell somebody to walk, they have to be in safe places where they can walk. So places like parks and things like that have to be available. 

Food, when you say eat healthy, again, there's a question of availability and affordability. Fruits and vegetables are expensive, so trying to bring down that and making it available for everybody, as opposed to giving large volumes of rice or wheat, is possibly another policy decision. Putting tax on foods that are unhealthy and are going to make you sick, like sugar and fat and things like that, make it more unreachable. 

A general thing. When you go to a supermarket, what is the availability of healthy foods? And there are lots of claims about what is healthy, but are they actually healthy? So putting those things in place, I think, would go a long way. A lot of people want to be healthy. You have to make it accessible to everybody, and that is when they are going to choose the healthy options. 

 

What are the one or two things that you would recommend that one should avoid, which have high sugar content and are easily available maybe on supermarket shelves or elsewhere? 

All the good things in life, I suppose. So everything that's sweet and delicious is kind of high in fat. So bakery products, high sugar substances, including cakes and stuff like that, but also stuff that is very high in carbohydrate. 

So there are plenty of people who do not eat bakery or sweets or cakes or but are eating a lot of rice or a lot of wheat. So this high carbohydrate mentality needs to be replaced with something that is high in fiber and protein. The population is deficient in protein as a whole. So trying to increase the protein intake and fiber intake--they go together-and then automatically everything else comes down. So that would be a simple take home. 

 

What made you specialize in diabetology and what's been the journey like so far? Is it frustrating sometimes because the numbers seem to be rising all the time. You're fighting in some ways. I mean, it's not a losing battle, but it's not a winning battle either. 

I think to make it win, it cannot be one or two people. It has to be effort at so many levels by people coming together. And I think that is the strength of this paper, where you start and people like you, the media, where awareness is the first step to success. 

So awareness is the first step. I think that's where we are at. And I don't like to say that we are losing this battle. I think we are on the way and it takes time, but we will all get there. Nobody wants to be unhealthy. It's just that we are not there yet. And once we can, I think we will ultimately reach there.

 

Why did you choose this particular discipline? 

Mine is a very funny story because I chose this when I was three. Both my parents are doctors and my mother has been my inspiration, my father has been my hero. So my father is a diabetologist. We're a family of diabetologists. I am third or fourth generation now and my mother was an ophthalmologist.

Right from the time I was a baby, I've seen healing around me. So when I was three, I used to be with my mother and I used to say I'll treat diabetic retinopathy. I had no clue what it was but I think my parents were my inspiration. And seeing them, doing what they did, making a difference, I think that's what made me do what I'm doing today. 

 

Till your next report,  what are the two or three things that you're focusing on? 

So for us now, we are going to each of the individual governments and we are submitting this report so that they know what needs to be done in their state. Also the Indian Council of Medical Research also has taken a good stand for making more implementable projects and things like that. So they have reached out to people all over the country, including us, asking for solutions to problems. So we're working on many things. We are working on remission of diabetes. We are working on trying to find other ways and means. We are also trying to get healthier foods. So in food technology, we work- healthy snacks, healthy foods, availability of all of this. So there's a lot to be done. And I think the more people are involved, the better for everyone.