The prevalence of diabetes is increasing in epidemic proportions to the extent that it has become a global health emergency. According to the IDF, one in 10 adults now has diabetes. In 2021, an estimated 537 million adults (20-79 years) had diabetes. Unheeded, this number is projected to rise to 643 million by 2030 and 783 million by 2045. The low- and middle-income countries particularly have a high burden of disease where diabetes is more prevalent in the younger population, which is the most productive age group. What is more worrisome is the fact that almost 1 in 2 (240 million) persons with diabetes remain undiagnosed.

At 74.2 million, India ranks second to China (~141 million) in the number of people, aged 20-79 years, living with diabetes. By 2045, this may increase to ~125 million.

In the ICMR National Non-communicable Disease Monitoring Survey (NNMS) 9.3% had diabetes, while nearly 25% were prediabetic (impaired glucose tolerance). And, almost half of the surveyed population was unaware of their diabetic status.¹ Diabetes is often an incidental diagnosis.

Management of diabetes is wrought with huge challenges and barriers, which not only hamper optimal glycemic control but also contribute to missed diagnosis. Obstacles to diabetes diagnosis and/or care include non- or poor compliance with pharmacotherapy (due to polypharmacy) or lifestyle modifications, ignorance about the disease, poor access to drugs and healthcare services, inadequate resources/infrastructure, financial constraints, sociocultural factors, gap in the knowledge about the disease among physicians. Another crucial contributory factor is clinical or therapeutic inertia causing delayed treatment intensification even when indicated. This is particularly applicable to insulin and is marked by the reluctance to start insulin plus lack of dose titration.² Frequently, patients too are not receptive to addition of a new drug or starting insulin. The year 2021 marked 100 years of the discovery of insulin, yet it is beyond reach for many. 

Diabetes care requires a multidisciplinary approach and can be expanded from ABC to ABCDEFGHI i.e. A1c, Blood pressure/microalbumin, Cholesterol/Aspirin, Diabetes education, Eye examinations, Foot examinations, Glucose monitoring, Health maintenance (flu and pneumonia vaccines) and Indications for specialty care.³ The coexistent cardiometabolic risk factors may also be often poorly controlled as the huge rush of patients in the OPDs precludes their optimal management.

The need of the hour is to control the escalating prevalence of diabetes, which may soon go out of hand if not held in check, and to also reduce inequities in treatment and care. One of the targets for SDG Goal 3 “Good Health And Well-Being” is “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being”.

Towards this end, the WHO has ratified the first global coverage targets for diabetes relating to diagnosis, disease control and availability of drugs, which are⁴:

 “By 2030:  

• 80% of people living with diabetes are diagnosed
• 80% have good control of glycemia
• 80% of people with diagnosed diabetes have good control of blood pressure
• 60% of people with diabetes of 40 years or older receive statins
• 100% of people with type 1 diabetes have access to affordable insulin and blood glucose self-monitoring”.  

The new targets focus on 80% of people with diabetes instead of the entire diabetic population to control the disease, which may indeed be a formidable task and an unrealistic one at that. The goals are now less stringent and achievable and their realization might be easier. It is hoped that the new targets will also help reduce the risk of complications and the associated morbidity and mortality. This will by no means be an easy battle, which requires intense collaboration between the various stakeholders and very few countries would be on course to achieve this by 2025. According to a Health Ministry press release on the occasion of the World Diabetes Day in 2019, India is also endeavoring to stop the rise in prevalence of diabetes by 2025. 

References

1. Mathur P, et al. Prevalence, awareness, treatment and control of diabetes in India from the countrywide National NCD Monitoring Survey. Front Public Health. 2022 Mar 14;10:748157.
2. Russell-Jones D, et al. Identification of barriers to insulin therapy and approaches to overcoming them. Diabetes Obes Metab. 2018 Mar;20(3):488-496
3. Abbate SL. Expanded ABCs of Diabetes. Clin Diabetes. 2003;21(3):128-33.
4. Wilkinson E. World Health Assembly ratifies first global diabetes targets. Lancet Diabetes Endocrinol. 2022 Aug;10(8):560.