INDIAbetes says: Don’t Give China The Title Yet!

I demand a recount of the rural prevalence estimates in India!

So You Think China Has More Diabetics Than India?

A recent study published in the New England Journal of Medicine last month estimates that China has 92 million people with diabetes, and an additional 150 million with pre-diabetes, putting them at an elevated risk of developing Type 2 diabetes. This would make China the new "diabetes capitol of the world", capturing the title from India as it almost doubles the most recent estimates of the prevalence of Type 2 diabetes in India.

What is possibly more alarming is what this implies for the landscape of the epidemic of Type 2 diabetes in the developing world. Whereas Type 2 diabetes has typically been conceptualized as a disease of affluence, with rapidly increasing rates being largely attributed to the urban middle class in the developing world, this may no longer be the case.

March's NEJM China study suggests that while the urban population is still leading with an estimated  11.4% of residents having Type 2 diabetes, the rural areas are not far behind at an estimated 8.2% of rural residents in China having the disease. It seems that we can no longer assume that major risk factors such as sedentary lifestyles and diets heavy in calorie dense foods are unique urban phenomena, and the public health response must immediately reflect this change.

Despite recognizing that there appears to be a growing problem in China, I'd have to agree with what Dr. K.M. Venkat Narayan says in his blog post for the British Medical Journal last month, in response to the China study published in March's NEJM.

Does China have more diabetics than India? Dr. Narayan isn't sure it does.

India lacks the nationally representative rural diabetes data that fueled the estimates made for China's rural diabetes prevalence. No such survey has been completed. However, there exists data for urban areas that is comparable to the China study. These studies have estimated India's urban diabetes prevalence to be somewhere between 16 and 18%, which is greater than the recently estimated 11.4% in urban China. It is not unreasonable, therefore, to suggest that India's rural prevalence of Type 2 diabetes may also be greater than China's, given that they are both comparable emerging economies and experiencing similar dietary and lifestyle changes conducive of Type 2 diabetes and obesity.

Who will resolve the question of whether China has surpassed India to become the diabetes capitol of the world? Check the comments section of Dr. Narayan's blog post: Dr. V. Mohan will.

But don't expect Dr. Mohan to fight for the title. As he says in his comment, if China has indeed overtaken India as the diabetes capitol of the world, it is good news for India. However, we should not rush to conclusions based on one study, especially considering the lack of comparable data for rural India.

In collaboration with the Indian Council of Medical Research, the Madras Diabetes Research Foundation (the research institution associated with Dr. Mohan's Diabetes Specialties Centre in Chennai, India) will provide us with an estimate of statewide (including rural) Type 2 diabetes prevalence in India through the ICMR-INDIAB study, for all the 28 states and two of the Union Territories of India. To date, this is the largest epidemiological study undertaken by MDRF. According to Dr. Mohan, Phase I of the INDIAB study is nearing completion and data on four states (Tamil Nadu, Maharashtra, Jharkhand, and Chandigarh) may soon elucidate the landscape of Type 2 diabetes in rural India.

What does this mean for INDIAbetes?

It means we need to film more interviews with researchers in the US and in India, to keep up to date with the latest research! It also means we are in a fortunate position to have access to interviews with the leading researchers on this subject.

You may recognize Dr. V. Mohan, Chairman and Chief Diabetologist at DMDSC and President and Director of MDRF, from his starring interview in the 10 minute version of INDIAbetes. Dr. K.M. Venkat Narayan is a distinguished professor of Global Health and Epidemiology at Emory's Rollins School of Public Health, as well as a professor of medicine at the Emory School of Medicine, in Atlanta, GA. Dr. Narayan was my thesis adviser while I was a student at RSPH and, through his work with the Global Diabetes Research Centre, is responsible for connecting me with Dr. Mohan and the Madras Diabetes Research Foundation. The INDIAbetes team is extremely grateful for their past support and looks forward to continuing to work with Dr. Mohan and Dr. Narayan.

-Catherine R. Armbruster, MPH
Director, the INDIAbetes Project