Dr. Sunil Gupta.
Consultant in Diabetes,
Nagpur.

The prevalence of Type 2 diabetes (non insulin dependent diabetes, NIDDM)is increasing all over the world. According to the recent WHO report, the prevalence of diabetes in adults worldwide will rise from 4.0% in 1995 to 5.4% and the number will rise from 135 million in 1995 to 300 million in the year 2025. By the year 2025, more than 75% of people with diabetes will reside in developing countries, as compared with 62% in 1995. The countries with the largest numbers of people with diabetes are and will be in the year 2025, India, China and the U.S.

In India the prevalence of diabetes has increased from 5.2% in 1983 to 8.2% in 1989 and 11.6% in 1995. With the rising trend in the prevalence of diabetes, it is estimated that by the year 2000 A.D. the number of diabetic persons in India will be 33 million and the prevalence will be 14.7% in subjects aged 20 years or more. The World Health Organization (WHO) has recently acknowledged that India has the maximum number of diabetic patients in any given country in the year 1995 (19 million) and that this would increase to 57 million by the year 2025. India has thus become the "Diabetic Capital of the World".

Onset of type 2 diabetes occurs at a younger age in Indians compared to several other races. This implies that they suffer from the consequences of the disease at the prime of their life. Due to the long duration of diabetes of the disease at the prime of their life. Due to the long duration of diabetes they are also vulnerable to the vascular changes resulting in severe complication of diabetes. It is well known that diabetes produces changes in blood vessels and hence can affect almost every part of the body.

Diabetes mellitus is a leading cause of adult blindness in developed countries. It carries a 2-3 times higher risk of heart attack and an even higher risk for stroke. Diabetic patients are at 5 times higher risk of developing nephropathy (Diabetes Kidney disease) and an estimated 25% of all new cases of end stage renal disease, are due to diabetes. Diabetic patients are five times more prone to develop gangrene of the lower extremity. Consequent to the rising prevalence of diabetes, the number suffering from the vascular complications of diabetes is also increasing. Retinopathy (Diabetes eye damage) is a vascular complication specific for diabetes.

Prevalence of retinopathy at the time of diagnosis of diabetes show that vascular pathology could precede the clinical diagnosis of diabetes.This could be due to the fact that hyperglycemia may remain undetected for several years. It was estimated that hyperglycemia ( high blood glucose ) might have been present diabetic subjects for a period of at least 4.1 years prior to clinical diagnosis.

The important risk factors for the high prevalence of diabetes include:

a) High familial aggregation (heredity).
b) Obesity especially central obesity
c) Insulin resistance (high insulin insulin levels in the body due to it's inadequate action to form energy from glucose).
d) Life style changes due to urbanization

Familial Aggregation (Heredity)

Several studies in India and abroad have shown that Indians have a genetic predisposition to diabetes which gets easily unmasked when the environment conditions are adverse. The fact that nearly 75% of the type 2 diabetic patients have first degree family history of diabetes indicate a strong familial aggregation in the Indian diabetic patients. Central obesity (Big Belly) is common in Indians despite low rates of obesity. Distribution of body fat Central adiposity (big belly) indicates deposition of large quantities of abdominal fat, which consists of visceral fat and subcutaneous fat.

Visceral fat increases the risk of diabetes and hyperlipidaemia. Effect of Urbanization Urbanization has brought several changes in life styles in most urban areas in India. These changes include consumption of excess calories, reduction in complex carbohydrates with increasing fats, Such diets have been partly responsible for several diseases including diabetes, cardiovascular disease, cancer and gastrointestinal problems. Moreover, availability of energy saving methods of transport and labour have resulted in severely reduced physical activity.

Tight control of hyperglycemia and hypertension could reduce the risk of vascular complication to a great extent. Early diagnosis of diabetes and control of hyperglycemia and hypertension will help in secondary prevention in diabetes.

For primary prevention of diabetes steps need to be taken to modify the environmental factors influencing diabetogenesis such as obesity, diet and physical activity. Long-term studies have shown the beneficial effects of life style modifications on reducing the risk of diabetes.

India needs to implement preventive measures to reduce the burden of diabetes as it poses a medical challenge which is not matched by the budget allocation for diabetes care in India. It is estimated that the annual cost of diabetes care would be approximately 90,200 million rupees. The average expenditure per patient per year would be a minimum of Rs. 4,500. There is an urgent need to implement preventive measures to reduce the cost of the disease which involves direct and indirect cost to the patient and the society also.