Review Article

Epidemiology of type 2 diabetes in India

Rajendra Pradeepa, Viswanathan Mohan

The burden of diabetes is high and increasing globally, and in developing economies like India, mainly Access this article online
fueled by the increasing prevalence of overweight/obesity and unhealthy lifestyles. The estimates in 2019 Website:
showed that 77 million individuals had diabetes in India, which is expected to rise to over 134 million www.ijo.in
by 2045. Approximately 57% of these individuals remain undiagnosed. Type 2 diabetes, which accounts DOI:
for majority of the cases, can lead to multiorgan complications, broadly divided into microvascular and 10.4103/ijo.IJO_1627_21
macrovascular complications. These complications are a significant cause for increased premature morbidity PMID:
*****
and mortality among individuals with diabetes, leading to reduced life expectancy and financial and other
costs of diabetes leading to profound economic burden on the Indian health care system. The risk for Quick Response Code:
diabetes is largely influence by ethnicity, age, obesity and physical inactivity, unhealthy diet, and behavioral
habits in addition to genetics and family history. Good control of blood sugar blood pressure and blood
lipid levels can prevent and/or delay the onset of diabetes complications. The prevention and management
of diabetes and associated complications is a huge challenge in India due to several issues and barriers,
including lack of multisectoral approach, surveillance data, awareness regarding diabetes, its risk factors
and complications, access to health care settings, access to affordable medicines, etc. Thus, effective health
promotion and primary prevention, at both, individual and population levels are the need of the hour to
curb the diabetes epidemic and reduce diabetes‑related complications in India.

Key words: Burden, complications, type 2 diabetes

Diabetes is one of the largest global health emergencies of this Diabetes is a progressive disorder that leads to serious
century, ranking among the 10 leading causes of mortality complications, which are associated with increased
together with cardiovascular disease (CVD), respiratory costs to the family, community, and healthcare system.
disease, and cancer. [1,2] According to the World Health Uncontrolled diabetes leads to increased risk of vascular
Organization (WHO), noncommunicable diseases (NCDs) disease and much of the burden of type 2 diabetes is caused
accounted for 74% of deaths globally in 2019, of which, diabetes by macrovascular (cardiovascular (CV), cerebrovascular,
resulted in 1.6 million deaths, thus becoming the ninth leading and peripheral artery disease) and microvascular (diabetic
cause of death globally.[2] By the year 2035, nearly 592 million retinopathy, nephropathy, and neuropathy) complications.[5,6]
people are predicted to die of diabetes.[3] Type 2 diabetes, which
constitutes 90% of all cases of diabetes, earlier considered to be Global Burden of Diabetes
a disease of the affluent “Western” countries, has now spread Type 2 diabetes susceptibility varies to a great extent around
globally, and has become a major cause of disability and death the globe, with Pacific Islanders, Asian Indians, and Native
affecting even younger age group.[1] Diabetes has reached Americans having a significantly higher risk of developing the
epidemic proportions in many developing economies, such disorder. The number of people with type 2 diabetes began to
as China and India.[1] According to WHO, the prevalence of rise globally in the 1990s, and since 2000, the world has seen
diabetes is growing most rapidly in low‑ and middle‑income a dramatic increase in the number of people with diabetes.[7]
countries.[4] The rapid socioeconomic change in conjunction According to the International Diabetes Federation (IDF), 8.8%
with urbanization and industrialization are the major factors of the adult population have diabetes, with men having slightly
for the global increase in the diabetes epidemic, with other higher rates (9.6%) than women (9.0%).[1] Current global
associated risk factors such as population growth, unhealthy statistics shows that 463 million and 374 million individuals
eating habits, and a sedentary lifestyle also playing an have diabetes and impaired glucose tolerance (IGT), a
important role.[5] prediabetic condition. These numbers are estimated to increase
to 700 million people with diabetes and 548 million people
with IGT by 2045, which represents a 51% increase compared
Madras Diabetes Research Foundation and Dr. Mohan’s Diabetes to 2019.[1]
Specialities Centre, IDF Centre of Excellence in Diabetes Care and ICMR
Centre for Advanced Research on Diabetes, Chennai, Tamil Nadu, India This is an open access journal, and articles are distributed under the terms of
Correspondence to: Dr. Viswanathan Mohan, President and Chief the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
of Diabetes Research, Madras Diabetes Research Foundation, ICMR
as long as appropriate credit is given and the new creations are licensed under
Centre for Advanced Research on Diabetes and, Chairman and Chief the identical terms.
of Diabetology, Dr. Mohan’s Diabetes Specialities Centre, IDF Centre of
Excellence in Diabetes Care, No 4, Conran Smith Road, Gopalapuram, For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Chennai ‑ 600 086, Tamil Nadu, India. E‑mail: drmohans@diabetes.ind.in
Received: 12-Jun-2021 Revision: 21-Jun-2021 Cite this article as: Pradeepa R, Mohan V. Epidemiology of type 2 diabetes
in India. Indian J Ophthalmol 2021;69:2932-8.
Accepted: 22-Jun-2021 Published: 29-Oct-2021

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

 Pradeepa and Mohan: Type 2 diabetes in India
November 2021 2933

Among the IDF regions, the Western Pacific has the highest undiagnosed diabetes in various IDF regions.[1] According
number of people with diabetes (163 million), followed by to reports, nearly 59.7% of people with diabetes in Africa
the South‑East Asian region (88 million), Europe (59 million), are unaware of their disease (the highest such proportion
Middle East and North Africa (55 million), and North America among all regions), while only 37.8% of people with diabetes
and Caribbean (47.6 million). Currently, the lowest numbers in North America and the Caribbean are unaware of their
are found in South and Central America (36.1 million) and disease (the lowest proportion among all the regions). When
Africa (19.4 million).[1] Thus, it is apparent that the affluent compared to other IDF regions, Africa and South and Central
regions of Europe and North America are not the only ones America have a lower number of individuals with undiagnosed
dealing with the diabetes epidemic. diabetes (11.6 and 13.3 million, respectively).[1] According to
According to the IDF in 2019, the top three countries with these estimates, there is an urgent need for improved diabetes
the highest number of individuals with diabetes are China screening. They also highlight the importance of identifying
(116.4 million), India (77.0 million), and the United States of undiagnosed diabetes and providing appropriate and timely
America (31.0 million). This trend is expected to continue in care as undiagnosed diabetes can have negative consequences
2030 and 2045, with China (140.5 and 147.2 million) and India such as an increased risk of diabetes related complications,
(101.0 and 134.2 million) continuing to have the highest burden increased healthcare use, and associated costs.[10]
of diabetes.[1] This is supported by the Global Burden of Disease
Study, which reported that population growth and ageing in the Burden of Diabetes in India
world’s largest countries, such as China and India, are driving Diabetes has steadily increased in India and around the
the absolute increase in the number of people with diabetes.[8] world over the last three decades, with India accounting for a
According to prevalence estimates by IDF, the diabetes sizable portion of the global burden. India’s disease patterns
burden is growing faster in low‑ and middle‑income countries have shown a switch due to an epidemiological transition:
(367.8 million) than in high‑income countries (95.2 million).[1] thus mortality from communicable, maternal, neonatal, and
The Global Burden of Disease study conducted in 195 countries nutritional diseases (CMNNDs) has decreased significantly,
and territories provided a detailed overview of the numbers, while NCDs and injuries have markedly increased their
rates, and rising trends in the diabetes burden between 1990 and contribution to overall disease burden and mortality.[11] In India
2025.[9] This study also reported that the low‑ and middle‑income in 1990, the total disability adjusted life years (DALYs) from
regions had higher burden of diabetes, while the high‑income CMNNDs were 61%, 30% from NCDs, and 9% from injuries.
regions had lower burden of diabetes. This study reported that However, due to major epidemiological transitions in India
the number of people with incident diabetes increased from 11.3 over the years, total DALYs from CMNNDs have decreased to
to 22.9 million between 1990 and 2017 (an increase by 102.9%) 33%, while those from NCDs and injuries have increased to 55
and the number of prevalent diabetes increased from 211.2 to and 12%, respectively, in 2016 [Fig. 2]. Across India, the disease
476.0 million (an increase by 129.7%), respectively. Furthermore, burden or DALY rate in 2016 was 4‑fold for diabetes, and when
modifiable metabolic, environmental, and behavioral factors looked at the leading individual causes of DALYs in India, most
were found to be the major risk factors for diabetes burden. NCDs have risen in rank since 1990, with diabetes showing a
dramatic increase, from 35th place in 1990 to 13th place in 2016.[11]
Another cause for concern is the high percentage of
individuals with undiagnosed diabetes, which is currently Prevalence of diabetes and trends over time
more than 50%. This is observed mainly in developing In India, the burden of diabetes has been increasing steadily
economies due to less developed health care systems. It is since 1990 and leaps and at a faster pace from the year 2000.
estimated that approximately 231.9 million (one in two) of Fig. 3 shows the increasing trend in diabetes prevalence in India
adults with diabetes are undiagnosed worldwide.[1] Fig. 1
depicts the proportion and number of individuals with

Figure 1: Proportion and number of individuals with undiagnosed Figure 2: Causes of total deaths in India, 1990 and 2016 (Communicable
diabetes – International Diabetes Federation (IDF) [ Ref No: 1] vs noncommunicable vs injuries) [Ref No: 11]
2934 Indian Journal of Ophthalmology Volume 69 Issue 11

Table 1: Burden of diabetes/prediabetes in India (Ref No. 1)

YEAR

2019 2045
Impaired glucose tolerance (estimates)
[20‑79 years]
Number of people (million) 25.2 35.7
Rank 4 3
Diabetes (estimates) [20‑79 years]
Prevalence (%) 8.9 ‑
Age adjusted prevalence (%) 10.4 ‑
Number of people (million) 77.0 134.2
Figure 3: Trends in diabetes prevalence during the past decade in Rank 2 2
India [Source: Ref 1, 12–16]
Diabetes (estimates) [>65 years]
Number of people (million) 12.1 27.5
during the past decade in India as per IDF.[1,12‑16] The prevalence
Rank 3 2
of diabetes in India has risen from 7.1% in 2009 to 8.9% in 2019.
Undiagnosed diabetes (estimates)
Table 1 provides the burden of diabetes in India at a glance.
Currently, 25.2 million adults are estimated to have IGT, which Prevalence (%) 57.0 ‑
is estimated to increase to 35.7 million in the year 2045. India Number of people (million) 43.9 ‑
ranks second after China in the global diabetes epidemic with Rank 2
77 million people with diabetes. Of these, 12.1 million are Healthcare expenditure on diabetes
aged >65 years, which is estimated to increase to 27.5 million Mean expenditure per person with diabetes (USD) 92.0 ‑
in the year 2045. It is also estimated that nearly 57% of adults
Deaths related to diabetes
with diabetes are undiagnosed in India, which is approximately
Total deaths (million) 1.0 ‑
43.9 million. The mean healthcare expenditure on diabetes per
*USD ‑ US dollars; Source IDF Diabetes Atlas 2019 (Ref No: 1)
person is 92 US dollars, and total deaths attributable directly
to diabetes account for 1 million. survey conducted in India on diabetes and prediabetes, the
The report on the state‑level disease burden in India stated data from 15 states/UT of the country [Table 2] showed that
that the percent change in diabetes prevalence among all ages in the prevalence of diabetes ranged from 3.5 to 8.7% in rural to
India from 1990 to 2016 was 64.3%, while the age‑standardized 5.8 to 15.5% in urban areas and the prevalence varied from
prevalence was 29.3%.[11] The India State‑Level Disease Burden 4.3% in Bihar to 13.6% in Chandigarh.[24,25] The prevalence of
Initiative Diabetes study collaborators[17] reported that the diabetes was higher in urban areas (11.2%) compared to rural
prevalence and number of people with diabetes in India areas (5.2%). The prevalence of prediabetes ranged from 5.8 to
increased from 5.5% and 26.0 million in 1990 to 7.7% and 65.0 14.7% in rural to 7.2 to 16.2% in urban areas. The prevalence
million in the year 2016. According to this report, Tamil Nadu of prediabetes exceeded that of diabetes in most states. This
had the highest prevalence in 2016, followed by Kerala, Delhi, indicates the presence of a large number of individuals who
Punjab, Goa, and Karnataka. may develop type 2 diabetes in the near future. There is also
evidence that Asian Indians progress more rapidly through
Diabetes is becoming more prevalent in India, based on
the prediabetes stage as compared to people of other ethnic
the data obtained from cross‑sectional surveys conducted in
groups.[25,26] The prevalence of diabetes was higher among
various parts of the country.[18] The first study was conducted in
states with higher per capita GDP and among individuals
Mumbai in 1963 among 18,243 individuals, and the prevalence
of diabetes was found to be 1.5% based on urine analysis.[19] belonging to the higher SES. This study demonstrates that there
There have been a few national studies on the prevalence of is clear evidence of an epidemiological transition, with a higher
diabetes. The national prevalence of diabetes was reported to be prevalence of diabetes in low socioeconomic status of urban
2.1% in the multicenter ICMR survey conducted between 1972 areas in more economically developed states.[25]
and 1975 in Ahmedabad, Calcutta, Cuttack, Delhi, Poona, and The National Family Health Survey, four survey [27]
Trivandrum, as well as neighboring rural areas.[20] In 2001, the conducted in 15 Indian states/union territories during the year
National Urban Diabetes Survey conducted in India’s six major 2014–2015, reported that Andaman and Nicobar Islands had the
cities reported an age‑standardized prevalence of 12.1%,[21] highest prevalence of diabetes (26 and 14.5% among men and
while the Prevalence of Diabetes in India Study, conducted in women, respectively), while Haryana had the lowest prevalence
40 urban and 37 small towns and rural areas across India in of diabetes (8.2%) for men and Bihar (6.1%) for women. The
2004, found that the prevalence of diabetes to be 5.9 and 2.7%,
prevalence was higher in urban than in rural areas. The recent
respectively.[22] The WHO‑ICMR NCD Risk Factor Surveillance
Secular Trends in Diabetes in India study which assessed the
Study, conducted between 2003 and 2005 in urban and rural
change in diabetes prevalence between 2006 and 2016 in urban
areas of six different states, reported a 4.5% prevalence of
and rural areas of Tamil Nadu reported that the prevalence
self‑reported diabetes.[23]
of diabetes increased from 18.6% in 2006 to 21.9 in 2016 in the
In the Indian Council of Medical Research–India DIABetes city, while in the smaller towns, it increased from 16.4 to 20.3,
study, the largest nationally representative epidemiological and in the periurban villages, from 9.2 to 13.4, respectively.[28]
 Pradeepa and Mohan: Type 2 diabetes in India
November 2021 2935

Table 2: Weighted prevalence of diabetes and prediabetes in 15 states/Union territory of India ‑ the ICMR INDIAB Study
[Ref Nos: 24,25]
States/UT Prevalence of diabetes (%) Prevalence of prediabetes (%)

Urban Rural Overall Urban Rural Overall

Andhra Pradesh 12.6 6.3 8.4 11.1 9.6 10.1
Arunachal Pradesh 5.8 4.9 5.10 14.2 12.3 12.8
Assam 12.4 4.4 5.5 13.6 11.6 11.9
Bihar 10.5 3.5 4.3 15.5 9.3 10.0
Chandigarh 14.2 8.3 13.6 14.5 14.7 14.6
Gujarat 9.5 5.1 7.1 8.4 11.5 10.2
Jharkhand 13.5 3.0 5.3 10.7 7.4 8.1
Karnataka 11.1 5.6 7.7 14.1 10.2 11.7
Maharashtra 10.9 6.5 8.4 15.2 11.1 12.8
Manipur 7.1 4.4 5.1 7.2 7.5 7.5
Meghalaya 8.9 3.5 4.5 7.4 10.6 10.0
Mizoram 7.9 3.6 5.8 6.2 5.8 6.0
Punjab 12.0 8.7 10.0 8.6 7.9 8.2
Tamil Nadu 13.7 7.8 10.4 9.8 7.1 8.3
Tripura 15.5 7.2 9.4 16.2 14.2 14.7

Data from the population‑based representative Center for In Kerala, participants of the Study of Life Style Diseases in
Cardio‑metabolic Risk Reduction in South Asia (CARRS) Study Central Kerala were followed up over a 10‑year period from
reports that 6 out of 10 adults in South Asian cities have either two semiurban wards of Venmony Panchayat of Alappuzha
diabetes or prediabetes.[29] In Chennai, 22.8%, and in Delhi, district. The incidence rate of type 2 diabetes and impaired
25.2% of the population was estimated to have diabetes. This fasting glucose (IFG) were 24.5 per 1000 person‑years and
study also reported a diabetes prevalence of 16.3% in Karachi, 45.01 per 1000 person‑years, respectively. During the follow‑up
Pakistan, which is lower than the two cities in India. In the period, nearly 60% of participants with baseline IFG converted
CARRS cohort, the lifetime diabetes risk for 20‑year‑old men to type 2 diabetes.[34]
was 55.5% compared to 64.6% for women and was high among
obese women (86.0%) and men (86.9%). With increasing age In another follow‑up study conducted in rural areas of
(at age 60 years), the lifetime risk of diabetes decreased to 37.7% Puducherry, the incidence rate of diabetes was reported to be
for women and 27.5% for men.[30] Recent studies contradict 21.5 per 1,000 person‑years. The incidence rate doubled among
previous findings that migrant Indians had higher prevalence males (28.7 per 1000 person‑years) compared with females
rates of type 2 diabetes than their counterparts in India. The (14.6 per 1000 person‑years).[35]
prevalence of type 2 diabetes was reported to be higher in Asian Morbidity and mortality
Indians living in Chennai (38%) compared to those residing
Diabetes is well known for its systemic impact on a wide range
in San Francisco and Chicago, US (24%).[31] These findings
of diabetes‑related complications, including macrovascular
highlight the fact that India’s current rapid economic and
and microvascular complications and death among the most
nutritional transitions increase the risk of type 2 diabetes, and
feared outcomes. In addition, recently diabetes is also being
that the “diabetogenic” environment in India is now as bad, if
linked to nontraditional complications such as mental health,
not worse, as in the United States.
cancer, disability, and liver disease.[36] Diabetic retinopathy
Incidence of diabetes is recognized as the most specific complication of diabetes
Apart to from the rising prevalence of diabetes in India, the and has been used to guide diabetes diagnostic thresholds.
incidence of diabetes are also rising steadily, with a fast transition The prevalence of diabetic retinopathy has been estimated
from euglycemia to prediabetes and diabetes. In India, very to be 17.6% among adults with diabetes in urban South
few longitudinal studies have been conducted to assess the India.[37] Spectrum of eye disorders in diabetes in India report,
incidence of diabetes and prediabetes. In the Chennai Urban pan‑India facility‑based study, concluded that diabetic
Population Study cohort, diabetes and prediabetes incidence retinopathy was prevalent in one‑third and sight‑threatening
rates were reported to be 20.2 and 13.1 per 1000 person‑years, diabetic retinopathy in one‑fifth of people with type 2
respectively,[32] while the follow‑up study conducted in the diabetes presenting at 14 eye‑care facilities.[38] The CURES
Chennai Urban Rural Epidemiology Study (CURES) cohort study conducted in urban Southern India reported lower
reported the incidence rates of diabetes, prediabetes, and any prevalences of retinopathy, nephropathy, neuropathy, and
dysglycemia to be 22.2, 29.5, and 51.7 per 1000 person‑years, peripheral vascular disease and higher prevalence of coronary
respectively.[33] The conversion rate to diabetes was reported to artery disease (CAD) compared to those reported for Western
be 19.4% among those with normal glucose tolerance and 58.9% populations.[37,39‑42] Data from rural areas indicate that the
among those with prediabetes. Diabetes incidence was reported burden of complications is comparable, if not higher, in rural
to be 78.9 per 1000 person‑years among those with prediabetes.[33] areas of South India than in urban areas.[43] The relatively high
2936 Indian Journal of Ophthalmology Volume 69 Issue 11

prevalence of diabetic complications in developing economies

like India could be due to delay in diagnosis of diabetes as
well as complications, coexisting illness, inadequate health
care systems, and high drug cost, particularly insulin leading
to poor control of diabetes.
Diabetes, along with its complications, is a leading cause of
mortality. The South East Asian region has the second highest
number of deaths attributable to diabetes in adults among
the IDF Regions, with 1.2 million deaths in 2019, with India
contributing the lion’s share with more than 1 million estimated
deaths accountable to diabetes and related complications.[1] The
Prospective Urban Rural Epidemiology study which compared
CV events, all‑cause mortality, and CV mortality rates among
143,567 adults with and without diabetes in 21 countries
including India with different income levels reported that CVD
rates, all‑cause mortality, and CV mortality were markedly
higher among those with diabetes in low‑income countries
compared with middle‑ and high‑income countries.[44] The
India State‑Level Disease Burden Initiative Diabetes study
reported that diabetes contributed to 3.1% of all deaths in India, Figure 4: Risk factors for type 2 diabetes
with an increase in death rates due to diabetes from 1990 to
2016 by 131%.[17] 2016, is another significant contributor to CVD and diabetes, as
There are as yet no large‑scale Indian studies on mortality well as cancer and some other diseases.[47] The Global Burden
in patients with type 2 diabetes, and most available studies of Disease Study 2016, reported obesity, low‑dietary intake of
are from clinical settings and therefore have shown different fruits, nuts and seeds, and whole grains, and tobacco use to
results. In a retrospective study from Srinagar[45] of 234,776 be the most important risk factors for DALYs and deaths due
inpatient admissions, 16,690 died, of whom 4.4% had diabetes. to diabetes.[48]
Of the top five causes of death, infections were reported by 41%,
chronic renal failure by 33.6%, CAD by 16.9%, cerebrovascular Strategies to Tackle the Epidemic of
disease by 13.2%, and chronic obstructive pulmonary disease Diabetes in India
by 6.9%. A follow‑up of the CURES cohort reported overall
The rising rates of prediabetes, diabetes, and associated
mortality rate to be nearly 4‑fold higher in people with
complications in urban as well as in rural areas and among
diabetes compared to those without diabetes (27.9 per 1000
the young in India are of great concern. Addressing health
person‑years vs. 8.0 per 1000 person‑years). The study also
issues related to diabetes in India, which is the second‑most
illustrated that ischemic heart disease and diabetes had the
populous country and has a large and diverse population,
highest population‑attributable risk for all‑cause mortality in
poses many challenges. The specific challenges in diabetes
the entire study cohort.[46]
prevention/management are (i) lack of strong national
Risk Factors partnerships for multisectoral actions, (ii) lack of availability of
robust surveillance and research data on diabetes, (iii) abysmally
The etiology of diabetes is believed to be multifactorial. Many low disease awareness among the public, (iv) lack of access
individual‑level nonmodifiable risk factors like genetic, age, to basic prevention/management of diabetes in the primary
ethnicity, and family history have been prospectively associated health care setting, which includes access to affordable
with type 2 diabetes, but the increases in prevalence in most medicines leading to premature deaths, (v) disproportionate
populations have probably been driven by a modifiable risk fund allocation for diabetes programs, (vi) difficulties in
factors including sedentary lifestyle and/or lack of exercise, engaging the industry and private sector, (vii) limited human
increasing prevalence of overweight/obesity, unhealthy resources, and (viii) inadequate community mobilization and
diets (increased intake of refined grains, fat, sugar, and weak coordination among civil societies and between the civil
sweetened beverages and decreased intake of fruits and societies and government agencies for diabetes.
vegetables) and habits (smoking and alcohol abuse), exposure
Tackling diabetes calls for a fundamental change, from
to environmental pollutants, altered intrauterine environment
addressing each risk factor separately to collectively addressing
and mental health (stress/depression), short sleep duration, and
a cluster of risk factors in an integrated manner, and from
the built environment [Fig. 4].
using a biomedical approach to a public health approach. Thus,
According to the India state‑level disease burden report,[47] when planning prevention/control programs, a multifaceted
in 1990, a tenth of the total disease burden in India was caused approach is essential for success. Diabetes prevention/control
by a cluster of risk factors that included unhealthy diet, strategies include (i) reduction in exposure to lifestyle risk
being overweight/obese, high blood pressure, blood sugar, factors through health promotion and primary prevention,
and cholesterol, all of which contributed to ischemic heart (ii) early detection and timely treatment, and (iii) surveillance
disease, stroke, and diabetes, which increased to a quarter of to monitor trends in diabetes and associated risk factors. High
the total disease burden in India in 2016. Tobacco use, which levels of commitment and multisectoral actions are needed to
was accountable for 6% of the total disease burden in India in reduce the growing burden of diabetes in India. Some of the
 Pradeepa and Mohan: Type 2 diabetes in India
November 2021 2937

policies that may help to slow down the epidemic of diabetes glucose and diabetes prevalence since 1980: Systematic analysis of
in India include (i) national food policies targeting availability health examination surveys and epidemiological studies with 370
and accessibility of healthy and nutritious foods, ensuring that country‑years and 2.7 million participants. Lancet 2011;378:31–40.
the food industry strictly complies with norms of food safety 9. Lin X, Xu Y, Pan X, Xu J, Ding Y, Sun X, et al. Global, regional,
and standards and supporting production and distribution of and national burden and trend of diabetes in 195 countries
healthy foods (whole grains, fruit, vegetables, legumes, and and territories: An analysis from 1990 to 2025. Sci Rep
2020;10:14790.
nuts), (ii) health policies to reduce harmful behaviors such as
smoking, alcohol misuse, use of trans fat, and consumption 10. Dall TM, Yang W, Halder P, Pang B, Massoudi M, Wintfeld N,
et al. The economic burden of elevated blood glucose levels in
of junk foods and increase physical activity by the creation
2012: Diagnosed and undiagnosed diabetes, gestational diabetes
of amenities such as public spaces (e.g., parks) for walking, mellitus, and prediabetes. Diabetes Care 2014;37:3172–9.
cycling, etc., (iii) prevention policies such as health information
11. Indian Council of Medical Research, Public Health Foundation
and communication to improve population awareness, and
of India, and Institute for Health Metrics and Evaluation. India:
(iv) policies to reduce the cost of essential drugs and ensuring Health of the Nation’s States ‑ The India State‑Level Disease
reasonable access to care. All these efforts need a healthy Burden Initiative. New Delhi: ICMR, PHFI and IHME; 2017.
collaboration between health, information, education, and Available from: https://www.healthdata.org/sites/default/files/
agriculture ministries to create awareness and to facilitate a files/policy_report/2017/India_Health_of_the_Nation%27s_States_
healthy lifestyle among the Indian population. Report_2017.pdf.
12. International Diabetes Federation. IDF Diabetes Atlas. 4th ed.
Conclusion Brussels, Belgium: International Diabetes Federation; 2009.
Diabetes has already become a leading threat to public health 13. International Diabetes Federation. IDF Diabetes Atlas. 5th ed.
Brussels, Belgium: International Diabetes Federation; 2011.
globally and the picture becomes grimmer for the low‑ and
middle‑income countries like India, where the burden has 14. International Diabetes Federation. IDF Diabetes Atlas. 6th ed.
risen significantly in recent decades and will continue to rise Brussels, Belgium: International Diabetes Federation; 2013.
in the coming decades. This could have a great influence on 15. International Diabetes Federation. IDF Diabetes Atlas. 7th ed.
morbidity and mortality associated with diabetes and, thus, Brussels, Belgium: International Diabetes Federation; 2015.
on the overall healthcare expenditure in India. To curb the 16. International Diabetes Federation. IDF Diabetes Atlas. 8th edn.
epidemic of diabetes and its associated complications, there is Brussels, Belgium: International Diabetes Federation; 2017.
a need for a multipronged strategy involving early diagnosis of 17. India State‑Level Disease Burden Initiative Diabetes Collaborators.
diabetes, screening for its complications, and offering optimal The increasing burden of diabetes and variations among the states
therapy at all levels of care for those who already have diabetes of India: The Global Burden of Disease Study 1990–2016. Lancet
Glob Health 2018;6:e1352–62.
and primary prevention of diabetes in those with prediabetes.
18. Anjana RM, Ali MK, Pradeepa R, Deepa M, Datta M, Unnikrishnan R,
Financial support and sponsorship et al. The need for obtaining accurate nationwide estimates of
Nil. diabetes prevalence in India‑Rationale for a national study on
diabetes. Indian J Med Res 2011;133:369–80.
Conflicts of interest 19. Patel JC, Dhirawani MK, Nanavathi BH, Shah BH, Aiyar AA.
There are no conflicts of interest. A sample survey to determine the incidence of diabetes in Bombay.
Indian Med Assoc 1963;41:448–52.
References 20. Ahuja MMS. Epidemiological studies on diabetes mellitus in India.
1. International Diabetes Federation. IDF Diabetes Atlas. 9th ed. In: Ahuja MMS, editor. Epidemiology of Diabetes in Developing
Brussels, Belgium: International Diabetes Federation; 2019. Countries. New Delhi: Interprint; 1979. p. 29–38.

2. World Health Organization. The top 10 causes of death. Available 21. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V,
from: http://www.who.int/en/news‑room/fact‑sheets/detail/ Das AK, et al. High prevalence of diabetes and impaired glucose
the‑top‑10‑causes‑of‑death. [Last accessed on 2021 Jun 04]. tolerance in India: National Urban Diabetes Survey. Diabetologia
2001;44:1094‑101.
3. Tao Z, Shi A, Zhao J. Epidemiological perspectives of diabetes. Cell
Biochem Biophys 2015;73:181‑5. 22. Sadikot SM, Nigam A, Das S, Bajaj S, Zargar AH, Prasannakumar KM,
et al. The burden of diabetes and impaired glucose tolerance in
4. World Health Organization. Diabetes. Available from: https:// India using the WHO 1999 criteria: Prevalence of diabetes in India
www.who.int/health‑topics/diabetes#tab=tab_1. [Last accessed study (PODIS). Diabetes Res Clin Pract 2004;66:301‑7.
on 2021 Jun 04].
23. Mohan V, Mathur P, Deepa R, Deepa M, Shukla DK, Menon GR,
5. Pradeepa R, Mohan V. Prevalence of type 2 diabetes and its et al. Urban rural differences in prevalence of self‑reported diabetes
complications in India and economic costs to the nation. Eur J Clin in India‑‑The WHO‑ICMR Indian NCD risk factor surveillance.
Nutr 2017;71:816‑24. Diabetes Res Clin Pract 2008;80:159‑68.
6. van Dieren S, Beulens JW, van der Schouw YT, Grobbee DE, Neal B. 24. Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R,
The global burden of diabetes and its complications: An emerging et al. Prevalence of diabetes and prediabetes (impaired fasting
pandemic. Eur J Cardiovasc Prev Rehabil 2010;17(Suppl 1):S3‑8. glucose and/or impaired glucose tolerance) in urban and
7. Mohan V, Pradeepa R. The Global Burden of Diabetes and Its rural India: Phase I results of the Indian Council of Medical
Vascular Complications (Chapter 1). In: Mechanisms of Vascular Research–INdia DIABetes (ICMR–INDIAB) study. Diabetologia
Defects in Diabetes Mellitus. Advances in Biochemistry in Health 2011;54:3022‑7.
and Disease. Kartha CC, Ramachandran S, Pillai RM (Eds). 25. Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK,
Springer International Publishing AG 2017. 2017; p. 3 - 23. et al. Prevalence of diabetes and prediabetes in 15 states of India:
8. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, results from the ICMR‑INDIAB population‑based cross‑sectional
et al. National, regional, and global trends in fasting plasma study. Lancet Diabetes Endocrinol 2017;5:585‑96.
2938 Indian Journal of Ophthalmology Volume 69 Issue 11

26. Sattar N, Gill JM. Type 2 diabetes in migrant south Asians: Murthy GVS, et al. Spectrum of eye disorders in diabetes (SPEED)
Mechanisms, mitigation, and management. Lancet Diabetes in India. Report # 2. Diabetic retinopathy and risk factors for sight
Endocrinol 2015;3:1004–16. threatening diabetic retinopathy in people with type 2 diabetes in
27. Kumar A, Kalra S, Unnikrishnan AG. Metabolic state of the nation: India. Indian J Ophthalmol 2020;68(Suppl 1):S21‑6.
Results of the national family health survey‑4. Indian J Endocrinol 39. Unnikrishnan RI, Rema M, Pradeepa R, Deepa M, Shanthirani CS,
Metab 2016;20:429‑31. Deepa R, et al. Prevalence and risk factors of diabetic nephropathy
28. Nanditha A, Snehalatha C, Satheesh K, Susairaj P, Simon M, in an urban South Indian population: The Chennai Urban Rural
Vijaya L, et al. Secular TRends in DiabEtes in India (STRiDE‑I): Epidemiology Study (CURES 45). Diabetes Care 2007;30:2019‑24.
Change in prevalence in 10 years among urban and rural 40. Pradeepa R, Rema M, Vignesh J, Deepa M, Deepa R, Mohan V.
populations in Tamil Nadu. Diabetes Care 2019;42:476‑85. Prevalence and risk factors for diabetic neuropathy in an urban
29. Deepa M, Grace M, Binukumar B, Pradeepa R, Roopa S, south Indian population: The Chennai Urban Rural Epidemiology
Khan HM, et al. High burden of prediabetes and diabetes in three Study (CURES‑55). Diabet Med 2008;25:407‑12.
large cities in South Asia: The Center for cArdio‑metabolic Risk 41. Pradeepa R, Chella S, Surendar J, Indulekha K, Anjana RM,
Reduction in South Asia (CARRS) Study. Diabetes Res Clin Pract Mohan V. Prevalence of peripheral vascular disease and its
2015;110:172‑82. association with carotid intima‑media thickness and arterial
30. Luhar S, Kondal D, Jones R, Anjana RM, Patel SA, Kinra S, stiffness in type 2 diabetes: The Chennai urban rural epidemiology
et al. Lifetime risk of diabetes in metropolitan cities in India. study (CURES 111). Diab Vasc Dis Res 2014;11:190‑200.
Diabetologia 2021;64:521‑9. 42. Mohan V, Deepa R, Rani SS, Premalatha G; Chennai Urban
31. Gujral UP, Narayan KM, Pradeepa RG, Deepa M, Ali MK, Population Study (CUPS No. 5). Prevalence of coronary artery
Anjana RM, et al. Comparing type 2 diabetes, prediabetes, and their disease and its relationship to lipids in a selected population in
associated risk factors in Asian Indians in India and in the U.S: The South India: The Chennai Urban Population Study (CUPS No. 5).
CARRS and MASALA studies. Daibetes Care 2015;38:1312–8. J Am Coll Cardiol 2001;38:682‑7.
32. Mohan V, Deepa M, Anjana RM, Lanthorn H, Deepa R. Incidence 43. Mohan V, Deepa M, Pradeepa R, Prathiba V, Datta M, Sethuraman R,
of diabetes and pre‑diabetes in a selected urban south Indian et al. Prevention of diabetes in rural India with a telemedicine
population (CUPS‑19). J Assoc Physicians India 2008;56:152‑7. intervention. J Diabetes Sci Technol 2012;6:1355‑64.
33. Anjana RM, Shanthi Rani CS, Deepa M, Pradeepa R, Sudha V, 44. Anjana RM, Mohan V, Rangarajan S, Gerstein HC, Venkatesan U,
Divya Nair H, et al. Incidence of diabetes and prediabetes and Sheridan P, et al. Contrasting associations between diabetes and
predictors of progression among Asian Indians: 10‑year follow‑up cardiovascular mortality rates in low‑, middle‑, and high‑income
of the Chennai Urban Rural Epidemiology Study (CURES). countries: Cohort study data from 143,567 individuals in 21
Diabetes Care 2015;38:1441‑8. countries in the PURE study. Diabetes Care 2020;43:3094‑101.
34. Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, 45. Zargar AH, Wani AI, Masoodi SR, Bashir MI, Laway BA, Gupta VK,
Vijayakumar A, et al. Incidence of type 2 diabetes mellitus and et al. Causes of mortality in diabetes mellitus: Data from a tertiary
prediabetes in Kerala, India: Results from a 10‑year prospective teaching hospital in India Postgrad Med J 2009;85:227‑32.
cohort. BMC Public Health 2019;19:140.
46. Anjana RM, Unnikrishnan R, Mugilan P, Jagdish PS, Parthasarathy B,
35. G h o r p a d e A G , M a j g i S M , S a r k a r S , K a r S S , R o y G , Deepa M, et al. Causes and predictors of mortality in Asian Indians
Ananthanarayanan PH, et al. Diabetes in rural Pondicherry, India: with and without diabetes‑10 year follow‑up of the Chennai
A population‑based study of the incidence and risk factors. WHO Urban Rural Epidemiology Study (CURES ‑ 150). PLoS One
South East Asia J Public Health 2013;2:149–55. 2018;13:e0197376.
36. Gregg EW, Sattar N, Ali MK. The changing face of diabetes 47. India state level disease burden report. Available from:
complications. Lancet Diabetes Endocrinol 2016;4:537–47. https://vikaspedia.in/health/health‑directory/
37. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. india‑state‑level‑disease‑burden‑report‑released. [Last accessed
Prevalence of diabetic retinopathy in Urban India: The Chennai on 2021 Jun 08].
Urban Rural Epidemiology Study (CURES) Eye Study ‑ 1. Invest 48. Tripathy JP. Burden and risk factors of diabetes and hyperglycemia
Ophthal Vis Sci 2005;46:2328‑33. in India: Findings from the Global Burden of Disease Study 2016.
38. Rajalakshmi R, Behera UC, Bhattacharjee H, Das T, Gilbert C, Diabetes Metab Syndr Obes 2018;11:381‑7.