In India, with a population of about 1.21 billion, 70 million of them have diabetes, and those numbers are expected to rise to 101 million by 2030 (KS Harikrishnan IPS, 2013).
What is causing such high number of diabetics, the widespread incidence of the disease in India, what can be done to prevent more cases, and how can the already affected be treated? The epidemiological approach can help answer these questions. It is important to look at it from this approach to understand the widespread nature of the disease and how it can be combated and prevented.
The Epidemiological approach has many facets, but as a whole, looks at health issues at a population level. Public health epidemiology is “the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems” (Pearce, 1999). It asks, what is going on in the population, and how can it be fixed or controlled? This population research can involve population comparisons between and within populations, and a mix of population level research and individual level hypothesis (Pearce, 1999). Epidemiologists look at context of populations, their history, culture, social structure and resources to create a full image of the population, the heath concerns, and the reasons behind those concerns, and how they can be remedied (Pearce, 1999). Epidemiologists must focus on a large number of factors, as the world they study is also rapidly changing (Pearce, 1999). Epidemiology involves looking at many different sciences, natural and social, to understand populations and health issues.
The reason the epidemiological approach is so appropriate to the study of diabetes in woman in India is because of how multifaceted it is. The Epidemiological approach is the best to look at diabetes in women in India because of how widespread and rapidly increasing it is, it requires a larger viewpoint and it is important to understand what the trends are, and what is contributing to this widespread increase. There are many biological factors that make south Asian populations more at risk for diabetes, there are also dietary factors, heath care access factors, socioeconomic factors, gender factors and many others that is causing India to be deemed the “diabetes capital of the world” (Mohan, 2007). It is extremely important to look at what makes this population so vulnerable, and diabetes so prevalent and why it is so rapidly growing, through an epidemiological approach. The benefits of that approach is the population level analysis, and the problem solving nature.
How has the prevalence of diabetes in India changed over the last half century? Between 1972 and 1975, the first study was conducted on the prevalence of diabetes in the Indian population, they found prevalence rates of 2.1% in urban populations and 1.5% in rural populations (Mohan, 2007). Studies done since then have only shown rapidly rising numbers. A study in a small township in 1988 showed 5% of the population presenting with diabetes and another study done the same year in Chennai showed 8.2% of prevalence in the urban population, and 2.4% in the rural population (Mohan, 2007). A study conducted five years later, in 1993, in the same areas of Chennai showed the prevalence had increased to 11.6% (Mohan, 2007). In 1999, a study was done in Thiruvanathapuram in the Kerala State showed a diabetes prevalence of 16.3% (Mohan, 2007). The National Urban Diabetes Survey, conducted in 2001, looked at diabetes prevalence rates in six metropolitan areas across India, 20 years old and above, across all socioeconomic levels (Mohan, 2007). The survey found a much higher prevalence in southern India, ranging from 12.4-16.6%, compared to eastern India prevalence of 11.7%, northern India prevalence of 11.6% and western India prevalence of 9.3% (Mohan, 2007). It must also be noted that along with the rapidly increasing prevalence, there is also a high prevalence of undiagnosed diabetes in many communities (Mohan, 2007).
What is the difference of prevalence in urban compared to rural populations? A study done by the “Diabetes India” organization found an overall diabetes prevalence of 4.3%, and 5.6% in urban population and 2.7% in rural populations (Ramachandran, 2005).
What is causing so many Indians to have diabetes? There have been many studies that show that the South East Asian population have a higher risk of developing diabetes for a number of different reasons. This is often called the “Asian Indian Phenotype” (Mohan, 2007). Indians develop diabetes about 10-15 years earlier than the white population (Ramachandran, 2005). How Indians carry their weight is also a big factor in their vulnerability to developing the disease. Although Indians may have a low Body Mass Index (BMI), they are more prone to abdominal obesity, which has a higher correlation with diabetes than overall obesity (Ramachandran, 2005). The Indian population also has a higher body fat content than other populations with similar BMIs and blood glucose levels, which can lead to a higher insulin resistance (Ramachandran, 2005). All of these population-specific weight characteristics and vulnerabilities mean that only minor changes in weight or physical activity can have drastic impacts on insulin resistance (Ramachandran, 2005). Women are especially vulnerable to diabetes due to increased weight, the number of male diabetics attributed to weight gain is 28%, but in females weight gain attributes to half of females 30 and older with diabetes (Ramachandran, 2005).
Another driving force towards increased Indian diabetics, is the rapid westernization and urbanization over the last 50 years, and the risk factors associated with it. Although this rapid westernization has led to longevity from improved nutrition, hygiene, control of communicable diseases and access to quality healthcare, all of this has made room for ‘new-age diseases’ such as obesity, diabetes and heart disease (Mohan, 2007). Nutrition and physical activity patterns have drastically changed over the last 50 years, business policies have encouraged overconsumption of unhealthy foods and urban design and increased transit has created a more sedentary lifestyle, all contributing to the rise in diabetes (Gutch, 2014).
With the increasing prevalence of diabetes in India, the challenges that will be faced in the future are only growing. By 2030, it is estimated that about 45% of the urban population in India will have diabetes (Ramachandran, 2005).
There are many factors that increase the risk of diabetes in woman in India. Indian women mostly live a sedentary lifestyle and observe more religious fasts than males and have limited access to recreational facilities to exercise, these social determinates lead to a higher risk for developing diabetes (Misra, 2010 & Gutch, 2014). There are also cultural determinates that increase the risk of diabetes in woman, there is a favor towards male children to carry to the family line, and an overall prioritizing of men, this leads to great under-reporting in woman and less treatment (Gutch, 2014). Mothers will also prioritize other family duties over their own health. One school teacher, when talking about her diabetic treatment said “I can say I was not aware of the disease and did not take due care because I was preoccupied with matters of the family. As a result, my case got aggravated” (KS Harikrishnan IPS, 2013). This story is echoed all over India. Women are also at an increased risk for developing Gestational Diabetes Mellitus (GDM) during pregnancy, which leads to a greatly increased risk of developing diabetes later in life (Seshiah, 2004). There is an overall prevalence of GDM of 17.8% in young, urban, pregnant Indian women, and 13.8% in the rural population with a similar profile, which is much higher than the global rates (Seshiah, 2008). Diabetes is an expensive illness to treat, and an unavailability of local, affordable healthcare and the family prioritizing against women all need to be addressed in the prevention and treatment of the disease (Gutch, 2014).
How can the issue of diabetes in India be fixed? The Indian diabetes problem can be combated by early identification of at-risk individuals, using simple and cost-effective screening tools like the Indian Diabetes Risk Score (IDRS) and lifestyle interventions (Mohan, 2007). Such measures could delay, or even prevent, the development of diabetes in the Indian population, reducing the increasing numbers and lowering the social and economic burden (Mohan, 2007). Universal screening of glucose intolerance in all pregnant women in India, and subsequent treatment if necessary, would help diminish the rising rates of diabetes and inform women to maintain a healthy lifestyle after pregnancy to reduce their chances of developing diabetes later in life (Seshiah, 2004).
The Epidemiological approach gives us a large-scale understanding of the widespread prevalence of diabetes in India, and allows us to identify at-risk people, and groups such as woman, for more close monitoring, screening, and education about the disease, its risk factors, how to manage it and prevent it.
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