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Type 2 diabetes in India: regional disparities
RAJEEV GUPTA,1 ANOOP MISRA2
Abstract
T
ype 2 diabetes mellitus epidemic in India is a result
of societal influences and changing lifestyles.
Diabetes has been known in India for centuries as
a disease of the affluent class. Epidemiological studies
in the 1960s and 1970s using random and post-load
blood glucose estimations reported diabetes prevalence
varying from 14% in urban populations and 12% in
rural populations. More standardised epidemiological
O ED S
studies since the 1990s reported prevalence rates that
PR IT EW
vary from 515% among urban populations, 46% in
semi-urban populations and 25% in rural populations
D
with large location-based disparities within urban and
N IM IN
TE
rural populations. There is a significantly increasing
IO ) L ED
trend in urban populations (exponential trend R2=0.744)
BI
while among rural populations the prevalence is
HI
CT TES M
increasing at a slower rate (R2=0.289). At the turn of
this century diabetes in adult urban Indian populations
DU E T
varies from a low of 5.4% in a northern state to a high
O AB GH
of 12.315.5% in Chennai, South India, and 12.316.8%
in Jaipur, Central India. This scenario is similar to other
South Asian countries and evolving populations in East
PR (DI RI
Asia, Middle-East, Americas, Australasia and Pacific
PY
Islands. Gene-environment interactions appear to be
responsible for this rapid increase. The insulin-resistant
CO
state that was meant to be protective mechanism for
regulation of calorie and fat metabolism at times of
famine has turned deleterious as affluence has
increased among these populations leading to diabetes
epidemic. Population based measures to prevent the
control of a diabetes epidemic include avoidance of
adiposity by enhanced physical activity and regulated
RE
calorie intake.
Br J Diabetes Vasc Dis 2007;7:1216
Key words: non-communicable diseases, diabetes,
epidemiology, glucose intolerance.
1
Department of Medicine, Monilek Hospital and Research Centre, Jaipur,
302004, India.
2
Department of Diabetes and Metabolic Diseases, Fortis-Rajan Dhall
Hospital, New Delhi, 110070, India.
Correspondence to: Dr Rajeev Gupta
Department of Medicine, Monilek Hospital and Research Centre, Jawahar
Nagar, Jaipur, 302004, India.
Tel: +91 141 2653021, 2653023; Fax: +91 141 2652181
E-mail: rajeevg@satyam.net.in
12
Preamble
Epidemiology of diabetes in India has a long history. Charaka
Samhita, the ancient Indian medical treatise, describes this con-
dition succinctly and suggests that being obese was a major risk
factor. It was commented that fat asymmetry impairs strength
and shortens lifespan; this may have been an indication of
increased incidence of diabetes among the asymmetrically
obese.1 Initial data on diabetes epidemiology in India were avail-
able as hospital and clinic-based case-series reported in early and
mid twentieth century. This was followed by epidemiological
studies that initially involved opportunistic screening and later
population based surveys. Ramaiah et al. reviewed all these stud-
ies in 1991.2 Hospital records in Kolkata in the 1930s, and
Mumbai and Delhi in the 1950s revealed that diabetes, as diag-
nosed by glycosuria, was not uncommon (0.71% of all
patients). Similar observations were reported by subsequent
opportunistic-screening studies from Kolkata, Mumbai, Lucknow
and Vellore in the 1950s. The initial systematic study of diabetes
prevalence in India emanated from medical institutes in Delhi,
Chandigarh, Hyderabad and Chennai, and organised sectors
such as the armed forces and railways, but these studies used dif-
ferent diagnostic criteria that varied from presence of glycosuria,
random or fasting blood glucose measurement and reported
results inconsistently.3 In recent years more epidemiologically
stringent studies have been performed.
Current diabetes scenario in India
The first systematic nationwide study in India was performed by
the Indian Council of Medical Research Task Force on diabetes.4
This study used a uniform methodology and sampling tech-
niques and was performed at six centres in the country.
Population sampling in urban areas was based on stratified ran-
dom design and in rural areas on cluster sampling. Population
aged > 14 years was screened using a post 50 g oral glucose load
and capillary blood glucose > 9.4 mmol/L (> 170 mg/dL) was
taken as diabetes. In all, 34,194 subjects were screened and
prevalence of diabetes was 2.1% in urban subjects and 1.5% in
rural populations. There has been a veritable explosion in dia-
betes epidemiology studies in India in the past 20 years (table
1).5-31 However, the studies suffer from major lacunae and there
is significant variability in various methodological issues such as
sample size, sample selection, case detection, responder-nonre-
sponder status, age-standardisation, diagnostic criteria, bio-
chemical estimations, regression-dilution effects and reporting
methods as well as multiple inherent limitations of cross-section-
al epidemiological studies.32 Therefore, most of these studies can-
not be taken as nationally representative. India has a population
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Table 1. Recent Diabetes Prevalence Studies in India

First author Year of Location Age-group Diagnostic Sample size (n) Prevalence rate (%)
publication criteria Male Female Total Male Female Total
(Age-adjusted)
Urban populations
Verma NP5 1988 Delhi 20+ K 3,643 3,235 6,878 3.8 2.3 3.1
Ahuja MMS6 1991 Delhi 20+ K+PG 2,572 - 2,572 4.1 - 4.1
Ramachandran A7 1992 Chennai 20+ K+F+PG 457 443 900 8.3 7.6 8.3 (8.3)
Ramachandran A8 1997 Chennai 20+ K+F+PG 1,081 1,102 2,183 10.4 12.7 11.6 (11.6)
Shah SK9 1998 Guwahati 20+ K+PG 595 421 1,016 8.7 7.8 8.2 (8.2)
Asha Bai PV10 1999 Chennai 20+ K+F+PG 743 455 1,198 8.7 5.7 7.6
Zargar AH11 2000 Srinagar 40+ K+F+PG 1,038 500 538 5.4 5.0 5.2
Kutty VR12 2000 Kerala 20+ K+PG 225 293 518 16.4 9.2 12.4
Joseph A13 2000 Trivandrum 20+ K+F 76 130 206 16.3 16.3 16.3
Asha Bai PV14 2001 Chennai 20+ K 13,366 12,700 26,066 2.9 3.1 2.9 (4.9)
Iyer SR15 2001 Mumbai 20+ K+F+PG - - 520 - - 7.5
Misra A16 2001 Delhi 18+ K+F 170 362 532 11.2 9.9 10.3
Mohan V17 2001 Chennai 20+ K+F+PG 518 657 1,175 - - 12.3
Ramachandran A18 2001 National 20+ K+F+PG 5,288 5,928 11,216 13.8 14.0 13.9 (12.1)

O ED S
Gupta A19 2003 Jaipur 20+ K+F 532 559 1,091 13.2 11.5 12.3 (8.6)

PR IT EW
Sadikot SM20 2004 National 20+ K+F+PG 10,865 10,651 21,516 4.7 4.8 4.8 (4.6)
Gupta R21 2004 Jaipur 20+ K+F 226 232 458 17.7 14.2 16.8 (12.1)

D
Mohan V22 2005 Chennai 20+ K+F+PG - - 2,350 18.0 13.4 15.5

N IM IN
Prabhakaran D23 2005 Delhi 2059 K+F+PG 2,122 - 2,122 15.0 - 15.0

TE
Reddy KS24 2006 National 2069 K+F 6,536 3,890 10,442 11.2 8.2 10.1 (8.3/9.0)
IO ) L ED
Semi-urban and mixed populations

BI
Ramachandran A25 1988 Karnataka 20+ K+F+PG 346 332 678 5.8 4.2 5.0 (5.0)

HI
Kutty VR12 2000 Kerala 20+ K+F+PG 2,388 2,600 4,988 7.2 6.2 6.7 (8.2)
CT TES M

Singh TP36 2001 Manipur 15+ K+F+PG 884 780 1,664 5.1 2.8 4.0
Rural populations
DU E T

Ahuja MMS6 1991 Bengal 20+ K+PG - - 2,375 - - 0.8

O AB GH

Ahuja MMS6 1991 Delhi 20+ K+PG - - 992 - - 1.5

Ahuja MMS6 1991 Kerala 20+ K+PG - - 1,488 - - 1.3
Ahuja MMS6 1991 Gujarat 20+ K+PG - - 1,294 - - 3.9
PR (DI RI

Ahuja MMS6 1991 Himachal 20+ K+PG - - 999 - - 0.4

Ramachandran A7 1992 Tamilnadu 20+ K+PG 520 518 1,038 2.6 1.6 2.4
PY

Wander GS27 1994 Punjab 20+ K+PG - - 809 - - 4.6

Patadin S28 1994 Tamilnadu 40+ K+PG - - 467 - - 4.9
CO

Zargar AH11 2000 Kashmir 40+ K+F+PG 1,996 2,049 4,045 3.5 4.5 4.0
Agrawal RP29 2004 Rajasthan 20+ K+F+PG - - 882 - - 1.8
Sadikot SM20 2004 National 20+ K+F+PG 9,669 10,085 19,754 1.8 1.9 1.9 (1.9)
Deo30 2006 Maharashtra 20+ K+F+PG 449 553 1,022 9.2 9.9 9.3
Chow31 2006 Andhra 30+ K+F - - 4,535 14.3 12.0 13.2

Key: K = known; F = fasting; PG = post glucose load

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of more than a billion and to extrapolate results from non-repre-
sentative studies to the whole country is not scientifically appro-
priate. However, despite these caveats it is worthwhile examin-
ing these studies.
Urban populations
Initial studies among urban subjects in Delhi reported on known
diabetes and compared this with the diabetes prevalence in
Southall, London.5 Diabetes was more prevalent among Indians
living in Delhi and Southall compared to British whites. Other
studies from urban, semi-urban and specific regions of India have
confirmed the high prevalence of diabetes among various popu-
lations although the prevalence rates are widely different.
In large cities in north and south India (Chennai,7,8,10,14,17,22
Trivandrum,12,13 Mumbai,15 Delhi,16,23 Jaipur19,21 and Gauhati9) as
well as a national study in large metropolises,18 and industrial
populations,24 diabetes prevalence among adults (> 20 years) has
ranged from 815%. A study from Kashmir in adults > 40 years
reported a low prevalence of 4.25%,11 but a national-wide study
of > 21,000 subjects from big and small cities in India, also
reported a lower prevalence of diabetes as compared to the
studies from large cities20 (table 1). Within urban populations
there is a large heterogeneity of diabetes prevalence depending
on the socioeconomic stratum studied and sampling response
rates. In the late 1990s Ramachandran et al. and Mohan et al.
reported a high prevalence of diabetes (1112%) in
Chennai7,8,17,22 while Asha Bai et al. reported a lower prevalence
of known diabetes (4.9%) as well as overall diabetes (7.6%)

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from different parts of the same city.10,14 Variable prevalence rates
in different urban populations in India is expected as there is a
large variation in cardiovascular risk factor prevalence33 as well as
cardiovascular mortality in different Indian urban regions.34
Semi-urban and rural populations
There are few epidemiological studies in semi-urban India12,25,26
and many in rural populations6,7,11,20,27-31 (table 1). In earlier years
there was a very low prevalence of diabetes in rural populations.
However, two recent studies, from Maharashtra30 and Andhra
Pradesh31 report very high prevalence rates similar to those in
urban Indian populations. Interestingly a significant correlation of
body mass index with diabetes has been observed in these stud-
ies. It has been hypothesised that although there is a significant
increase in diabetes as populations move from rural to semi-
urban to urban and cosmopolitan habitats, a reverse migration
of culture may already be taking place in Indian rural popula-
O ED S
tions.33 Earlier rural-urban disparities in diabetes could be due to
PR IT EW
a low prevalence of overweight and obesity in rural subjects
compared to urban subjects.
D
N IM IN
TE
Secular trends
IO ) L ED
Serial cross-sectional epidemiological studies on diabetes to
BI
demonstrate secular changes have been rare in India. From
HI
CT TES M
Chennai in south India a significant increase in type 2 diabetes
prevalence among adults has been reported.35 Using similar diag-
DU E T
nostic criteria (known diabetes and/or fasting and post-glucose
O AB GH
load hyperglycaemia) the age-adjusted diabetes prevalence
among adults in urban Chennai increased from 8.3% in
198889, to 11.6% (199495), 13.5% (2000) and 14.3% in
PR (DI RI
200304. Similar increase was observed in prevalence of
PY
impaired glucose tolerance from 8.3% to 9.1%, 16.8% and
10.2% respectively. Increase in diabetes prevalence has also been
CO
reported from rural Tamilnadu.36 Serial studies from Jaipur using
slightly different criteria (known diabetes and fasting hypergly-
caemia) have also reported increasing diabetes among urban
subjects.19,21
Analysis of secular trends reveals a very steep increase in
urban populations (exponential trend R2= 0.744) while among
rural populations the prevalence is increasing at a slower rate
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(R2= 0.289) (figure 1). Although the prevalence of diabetes is rel-
atively low in rural populations, there is evidence of a high bur-
den of impaired glucose tolerance.11,36
Regional disparities
There is substantial variation in diabetes prevalence worldwide,
with a prevalence of practically zero, in rural Third World coun-
tries and 3750% among the Asia-Pacific Islanders and
American Indians. Most of the worlds broad geographical loca-
tions include regions with both low and high prevalences of dia-
betes, e.g., Mapuche Indians versus Pima Indians in USA, and
rural Australian aborigines versus the urban aborigines.37,38 India
is no different (table 1): studies from north India reveal a lower
prevalence of diabetes,5,6,16,19,21,24 compared with the southern
parts of the country.7,8,10,13,14,17,18,22 The lowest prevalence among
14
Figure 1. Trends in prevalence of diabetes in Indian urban ( ) and
rural ( ) populations in India. There is a significantly
increasing trend in urban populations (exponential trend
R2=0.744) while among rural populations the prevalence is
increasing at a slower rate (R2=0.289)
18
16
14
Percent prevalence
12
Urban
10
8
6
4
Rural
2
0
1955 1965 1975 1985 1995 2005
Years
urban populations is in Kashmir11 and the highest in
Chennai7,8,10,14,17,18,22 and Trivandrum.12,13 However, as these studies
were performed using different criteria and methodology the
results may not be comparable but are indicative of a rising tide
of diabetes nationwide.
There are few multi-site studies in India that have used uni-
form criteria for diagnosis of diabetes that would help to clearly
identify regional disparities in its prevalence. The Indian Council
of Medical Research studies reported relatively low and variable
prevalence rates of diabetes6 among rural populations from
0.4% in Himachal Pradesh to 1.3% (Kerala), 1.5% (Delhi) and
3.9% in Gujarat.6 Reasons for this variation were not discussed.
The Diabetes Epidemiology Study Group in India (DESI)18 investi-
gators reported from several urban locations in India: age and
gender-standardised prevalence of diabetes ranged from 9.3%
in Mumbai to 11.6% (Delhi), 11.7% (Calcutta), 12.4%
(Bangalore), 13.5% (Chennai) and 16.6% in Hyderabad.
Multivariate logistic regression analysis revealed that significant
determinants of diabetes were age, body-mass index, waist-hip
ratio, low physical activity and family history of diabetes.18 Most
of the regional variations in diabetes prevalence could be
explained by lifestyle factors.
The Prevalence of Diabetes in India Study (PODIS)20 group
reported a low overall prevalence of diabetes in urban locations
but did not report on regional variations or location-specific
prevalence rates. The Indian Industrial Populations Study Group24
reported prevalence of diabetes in nine urban industrial loca-
tions. Age-adjusted prevalence of diabetes diagnosed using
criteria of known diabetes or fasting glucose > 7.0 mmol/L
(> 126 mg/dL) was 8.3% in men and 9.0% in women (table 1).
There was a very low prevalence of diabetes in eastern (Assam:
men 2.8%, women 1.7%) and central India (Nagpur: men
4.4%, women 3.8%); moderate prevalence in Pune (men 9.8%,
women 7.2%), and Coimbatore (men 7.5%, women 8.1%); and
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Key messages
Epidemiological studies show a significant and
escalating burden of type 2 diabetes in India
There are large regional disparities in prevalence of
diabetes in India with low prevalence in rural and high
prevalence in urban subjects. The disease is more
prevalent in southern regions as compared to northern
and eastern parts of the country
The principal reason for escalating diabetes and
regional disparities appears to be rapidly occurring
socioeconomic changes and affluence associated with
dietary excess and reduced physical activity
O ED S
PR IT EW
D
high prevalence in Delhi (men 12.5%, women 7.3%), Lucknow
N IM IN
TE
(men 12.6%, women 8.7%), Bangalore (men 12.1%, women
IO ) L ED
9.1%), Hyderabad (men 15.1%, women 11.9%), and
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Trivandrum (men 17.4%, women 15.3%). The investigators did
HI
CT TES M
not correlate diet or other lifestyle variables with disease preva-
lence, but concluded that the heterogeneity could be due to dis-
DU E T
similar levels of urbanisation and lifestyle factors such as differ-
O AB GH
ent diets and varying obesity levels.
It has been suggested that regional and national hetero-
geneity in diabetes prevalence is rooted in more recent (environ-
PR (DI RI
mental) events rather than genetic factors.39 Populations that
PY
have been continually exposed to under nutrition and now have
easy access to energy-rich foods and a lifestyle which does not
CO
demand such high energy expenditure, find themselves in obe-
sogenic environments. Indeed, among the world populations,
there is an escalating gradient in diabetes prevalence as one
moves from old world populations which have been developing
increasing improvements in agricultural and industrial technolo-
gies (over about 300 years) and have undergone more gradual
adaptation, whereas evolving urban populations have received
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these technologies ready developed over a much shorter period
(< 30 years) and have not experienced a protracted period of
change. This may account, in part, for the differences in diabetes
prevalence amongst White Europid population (23%) and
evolving urban populations in East Asia (510%), Middle East
(1012%), South Asia (1015%), Australia (2025%), North and
South America (3035%) and Pacific Islands (4050%).37,40
The way ahead
Prospective studies that have examined risk-factor determinants
of diabetes are still in progress in India. However, risk-association
studies demonstrate that lifestyle factors such as urbanisation,
socioeconomic status, stress, sedentary lifestyle, dietary calorie
excess, certain specific dietary factors and generalised and cen-
tral obesity are important diabetes risk factors. The important
VOLUME 7 ISSUE 1 . JANUARY/FEBRUARY 2007
REVIEW
conclusion from various studies appears to be that such risk fac-
tors tend to develop early in the lifecycle in Indian subjects and
consequently type 2 diabetes occurs at least 1015 years earlier
compared to people of non-Indian origin.41 The generalised and
central obesity levels at which diabetes occurs is also lower in
Indian subjects compared to the white populations42 and for
South Asians a waist size of > 90 cm in men and > 80 cm in
women is now accepted as a major risk factor for diabetes and
other cardiovascular risk factors of the metabolic syndrome.43
The influence of societal affluence levels on diabetes inci-
dence in India suggest that a global solution that shall have the
greatest impact on slowing or stopping the diabetes epidemic
lies with policy-makers and governments.44 There is a need to
change the economic and environmental structure in urban
areas of India so that physical activity and healthy dietary choic-
es are available.45
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