Socioeconomic Inequality in Awareness, Treatment and Control of Diabetes Among Adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

doi:10.21203/rs.3.rs-2147462/v1

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Socioeconomic Inequality in Awareness, Treatment and Control of Diabetes Among Adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

https://doi.org/10.21203/rs.3.rs-2147462/v1

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published 20 Feb, 2023

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Diabetes is a growing epidemic and a major threat to most of the households in India. There is little evidence on awareness, treatment, and control (ATC) among adults in India is limited. We estimate the prevalence and ATC of diabetes among adults across various sociodemographic groups and states of India. We used 2,078,315 individuals aged 15 years and over from the recent fifth round of National Family Health Survey (NFHS-5), 2019-21, that was carried out across all states of India. Diabetes individuals were identified as those who had random blood glucose above 140 mg/dL or taking diabetes medication or doctor diagnosed diabetes. Individuals who were measured as diabetic and (i) reported diagnosis were labelled as aware, (ii) reported taking medication for controlling blood glucose levels as treated and (iii) had measured blood glucose levels < 140 mg/dL as controlled. The estimates of diabetes prevalence, and ATC were age-sex adjusted, and disaggregated by household wealth quintile, education, age, sex, urban-rural, caste, religion, marital status, household size and state. Concentration indices was used to quantify socioeconomic inequalities and multivariable logistic regression was used to estimate adjusted differences in these outcomes. We estimated diabetes prevalence at 16.1% (15.9–16.1%). Among those with diabetes, 27.5% (27.1–27.9%) were aware, 21.5% (21.1–21.7%) were treated and 7% (6.8–7.1%) were under control. Across states of India, adjusted rates of ATC varied from 14.4% (12.1–16.8%) to 54.4% (40.3–68.4%), from 9.3% (7.5–11.1%) to 41.2% (39.9–42.6%), and from 2.7% (1.6–3.7%) to 11.9% (9.7–14.0%), respectively. Age–sex adjusted rates were lower (p < 0.001) in poorer, less educated, and social backward groups, as well as for male and residents of rural areas. Among individuals with diabetes, the richest fifth were 12.4 percentage points (pp) (11.3–13.4; p < 0.001), 10.5 pp (9.7–11.4; p < 0.001), and 2.3 pp (1.6-3.0; p < 0.001) more likely to be aware, getting treated, and having control, respectively, than the poorest fifth. The concentration index of ATC was 0.089 (0.085–0.092), 0.083 (0.079–0.085) and 0.017 (0.015–0.018) respectively. Overall, the ATC of diabetes is low in India. The ATC was much lower among adults belonging to poorer class and were less educated. Targeted intervention and management can reduce the diabetes burden in India.

Earth and environmental sciences/Environmental social sciences/Socioeconomic scenarios

Health sciences/Medical research/Epidemiology

Health sciences/Diseases/Endocrine system and metabolic diseases/Diabetes/Diabetes complications

Health sciences/Diseases/Endocrine system and metabolic diseases/Diabetes/Type 2 diabetes mellitus

Diabetes, a non-reversible chronic condition is now a disease of common. It is the major cause for mortality and morbidity, leading to increased treatment costs across the globe^1–3. In 2021 alone, over 6.7 million deaths were attributed to diabetes, globally⁴. The International Diabetes Federation (IDF) estimates that 537 million people worldwide are living with diabetes in 2021 and projected to increase to 643 million by 2030 if no effective preventive measures are adopted ⁴. Over 541 million people are at an elevated risk of getting diabetes. During 1990–2016, there was more than two-fold increase in Disability Adjusted Life Years (DALYs) related to diabetes⁵. The prevalence of diabetes has increased rapidly in almost all countries but people from low-and middle-income countries (LMCs) alone accounts 75% of the diabetics worldwide^4,6,7.

The prevalence, growth and distribution of diabetes varies largely across countries. Diabetes is associated with almost every chronic disease. It complicates medical treatment and aggravates chronic conditions. Over time, diabetes can cause serious heart conditions and damage to eyes, kidneys and nerves, increasing the risk of limb amputation, loss of vision and early death⁸. Global estimate of health expenditure on diabetes, in 2021, estimated at USD 966 billion, projected to increase to USD 1028 billion by 2030⁴. The United Nations (UN) Sustainable Development Goal (SDG) target 3.4 is to reduce premature mortality owing to non-communicable diseases (NCDs) by one-third, which cannot be achieved without prevention and control of diabetes^9,10. The World Health Organization (WHO) launched the Global Diabetes Compact in 2021, a global initiative aimed at sustained improvements in diabetes prevention and care with special focus for people living in LMCs^11,12.

Early detection of diabetes mellitus can reduce this disease burden and key to better quality of life. Given the non-reversal nature of the disease, awareness, treatment and control (ATC) are key to reduce the disease burden. The ATC has strong socioeconomic gradient. As per Hart’s inverse care law, individuals with highest need are least likely to receive healthcare^13,14. Low SES in general are less aware, less treated and in less control of diabetes. A growing number of studies globally analysed the country specific prevention, awareness, treatment and control of diabetes and found low ATC among individuals belonging to low socio-economic conditions^15–17. During 2011–2012, 80.6% of South African adults with diabetes had unmet need for care¹⁸. In Bangladesh, in a study among adults 35 years and over, it was found that among individuals with diabetes, 41.2% were aware, 36.9% were treated and 14.2% controlled diabetes¹⁹. In a cross-sectional survey conducted in Northeast China in 2012, among individuals in age bracket of 18 to 79 years found the ATC rates of diabetes at 64.1%, 52.9% and 44.2% respectively²⁰. ATC rates of diabetes for a study conducted in a semi-urban area of Nepal among adults aged 25 years and over in 2016–2017 was found to be at 65%, 94% and 21% respectively²¹. A most recent report shows a consistent rise in the prevalence of diabetes across Latin America with 50% awareness²².

India is home to the world's second highest number of diabetic patients with projected increase to 124.9 million by 2045⁴. According to IDF, one out of every seven diabetic adults worldwide reside in India and one in every third household has diabetic patients⁴. In case of India, there have been very few nationally representative studies for diabetes^23–32. A population-based study of 1.3 million adults carried out during 2012–2014 estimated 7.5% diabetes prevalence in India³³. Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) which is a population-based cross-sectional study conducted in 15 states of India interpreted that the prevalence of diabetes varied widely between states and was found to be higher in low SES groups in urban areas of developed states^29,34,35. The prevalence of diabetes in adults aged 20 years and above in India increased from 5.5% in 1990 to 7.7% in 2016²⁴. According to a much recent report by the National NCD Monitoring Survey (NNMS), diabetes prevalence in India was estimated at 9.3% in 2018²³. Similar estimates were found by IDF, where diabetes prevalence was estimated at 9.6% in 2021 with a projected increase to 10.4% by 2030⁴.

In this study, we estimate the prevalence, awareness, treatment, and control of diabetes at the national and state levels using a nationally representative study, National Family Health Survey (NFHS-5) conducted in 2019–2021³⁶. We also examine socioeconomic inequalities that arise in evaluating diabetic care.

Data Source

We used data from the fifth round of National Family Health Survey (NFHS-5), a nationally representative, household-based survey, conducted during 2019-21 in India. It surveyed across 707 districts in 28 states, and 8 union territories of India. A total of 2,843,917 individuals from 636,699 household were successfully interviewed. Among the 2,843,917 individuals, 2,078,315 were adults above 15 years age. The NFHS-5 used a stratified two-stage sampling method. In the first stage, within each district, the sampling process was carried out differently in rural than in urban areas. In rural areas, villages were used as primary sampling units (PSUs), which were selected using probability proportional to size (PPS), whereas, census enumeration blocks (CEBs), selected with PPS systematic sampling, were used as PSUs in urban areas. In the second stage, in every selected rural and urban cluster, twenty-two households were randomly selected with systematic random sampling after complete mapping and household listing of the selected PSU. Detailed methodology about NFHS-5 can be found in NFHS India Report³⁶.

Measures

All adults 15 years and above were requested to undergo a finger-stick blood glucose measurement using Accu-Chek Performa glucometer with glucose test strips for random blood glucose testing by trained health investigators. An individual was classified as having high blood glucose if they had random blood glucose level of 141-160 mg/dL and very high blood glucose if they had a random blood glucose level of more than 160 mg/dL. For our purpose, we have combined the high blood glucose and very high blood glucose categories, and redefined it as having high blood glucose levels. Diagnosis of diabetes was defined as having responded with “yes” to the question “Told high blood glucose on two or more occasions by doctor or health professionals?”. Medication for diabetes was defined as having responded with “yes” to the question “Currently taking any prescribed medicine to lower blood glucose?”. In our analysis, an individual was ascertained as having diabetes if they had high blood glucose (above 140 mg/dL) or if they were diagnosed with diabetes or if they consumed medication for lowering blood glucose. We classified individuals with diabetes as (a) “Aware” if they reported having been diagnosed with diabetes; (b) “Treated” if they reported consuming medication for lowering blood glucose; and (c) “Controlled” if they were taking medication for lowering blood glucose and their random blood glucose levels were under the threshold for diabetes used in this study (<140 mg/dL). The blood glucose thresholds used to ascertain diabetes was determined as per the NFHS-5 India Report³⁶.

We used various socio-demographic attributes as independent variables in this analysis. The household wealth index was used as the primary indicator of socioeconomic status, which had been constructed based on principal component analysis (PCA). It used a set of variables including housing characteristics, household amenities and household ownership of durable goods. The wealth quintiles are calculated by assigning a score to each usual (de jure) household member, ranking each person in the household population according to their score and dividing the distribution into five equal categories, each with 20% of the population³⁶. Additionally, this study includes socio-demographic variables ascertaining an individual’s age (15-29, 30-44, 45-59, 60-74 and 75+ years), sex (male/female), household size (1-3, 4-6 and 7 & above members), educational attainment (no education, primary, secondary and higher), caste (Schedule Castes (SC), Schedule Tribes (ST), Other Backward Classes (OBC) and Others), religion (Hindu, Muslim, Christian and others), place of residence (urban/rural), marital status (unmarried, currently married and others), alcohol (yes/no) and tobacco (yes/no) consumption status and state fixed effect. Our analytical sample covers 2,078,315 adults above 15 years age.

Statistical Analysis

We used the full sample of individuals aged 15 years and over to estimate diabetes prevalence. A subsample of these participants who were identified as having diabetes, was used to estimate rates of ATC. We estimated prevalence and these rates nationally, by state, by household wealth quintile group and by other socio-demographic characteristics. We adjusted the estimates for age and sex using the age-sex composition of the full sample as used in literature³⁷. Descriptive statistics along with bivariate analysis was used to observe the distribution and association of the variables. F-statistic values along with a 95% confidence interval were presented in the results.

We used a concentration index (covariance between an outcome and rank in distribution of household wealth) and the concentration curve to quantify the wealth disparity among the individuals, using the full distribution of household wealth score^38,39. The concentration indices were adjusted for age and sex. Multivariable logistic regression was used to estimate adjusted marginal effects of the various independent variables and state indicators on the probabilities of having diabetes and on the probabilities of ATC among those with diabetes. Each marginal effect was averaged over the sample used in the respective regressions.

Utilizing Stata (version 16.0), svyset package, sampling weights were applied throughout the analyses to account for stratification and cluster sampling to ensure that the findings were nationally representative. Confidence intervals were provided for each estimate at 95% level. All the individuals with a complete response to blood glucose testing, diabetes diagnosis and treatment recorded, wealth quintile, and all reported covariates were included in the study sample. State estimates of ATC were presented using maps generated in R version 4.1.1 using ggplot2 package⁴⁰.

The selection of the analyses sample was performed as shown in Figure 1. Out of 2,078,315 adults, blood glucose was measured for 1,812,440 (87.20%) participants. For the rest of the participants some did not give consent, or were interviewed by proxy, or they had some physical limitations barring them from blood glucose measurement. Furthermore, 3,445 (0.2%) individuals did not report all information on diabetes diagnosis, treatment, and sociodemographic characteristics, leaving an analysis sample of 1,808,995 participants with full response which was used to estimate diabetes prevalence. Within this sample, 265,864 (16.1%) were identified as having diabetes and were used to estimate rates of diabetes ATC.

Table 1: Participant Characteristics and adjusted Diabetes Prevalence among adults in India, 2019-21

	Participants		Diabetes Prevalence		F-stat (p-value)
Characteristic	n	%	%	95 % CI
Overall	1808995	100.0	16.1	[15.9,16.1]
Wealth Quintile
Poorest	374555	18.4	13.1	[12.9,13.3]	391.14(<0.001)
Poorer	397856	20.0	14.3	[14.1,14.5]
Middle	377699	20.7	15.8	[15.6,16.0]
Richer	348695	20.9	17.6	[17.3,17.8]
Richest	310190	20.0	18.8	[18.5,19.1]
Education
No Education	471754	25.1	13.2	[13.0,13.2]	718.4 (<0.001)
Primary	249542	14.0	16.5	[16.2,16.6]
Secondary	858014	46.9	17.9	[17.7,18.1]
Higher	229685	14.1	18.2	[17.8,18.5]
Age, years
15-29	638081	35.1	5.1	[5.0,5.2]	12032.8 (<0.001)
30-44	504550	27.6	13.2	[13.0,13.4]
45-59	387121	21.3	25.2	[24.9,25.4]
60-74	227003	13.0	32.7	[32.3,33.0]
75+	52240	2.9	33.3	[32.7,33.9]
Sex
Male	844591	46.4	16.8	[16.6,16.9]	361.5 (<0.001)
Female	964404	53.6	15.4	[15.2,15.4]	361.5 (<0.001)
Location
Rural	1368285	68.4	14.9	[14.7,15.0]	648.6 (<0.001)
Urban	440710	31.6	18.5	[18.2,18.7]	648.6 (<0.001)
Caste
SC	347548	21.7	15.2	[14.9,15.4]	318.0 (<0.001)
ST	342194	9.5	12.7	[12.4,12.9]
OBC	674072	42.0	16.2	[16.0,16.3]
Others	445181	26.8	17.6	[17.3,17.8]
Religion
Hindu	13375813	82.4	15.7	[15.6,15.8]	123.1 (<0.001)
Muslim	209977	12.2	17.7	[17.3,18.0]
Christian	132674	2.6	20.2	[19.6,20.8]
Others	90531	2.8	14.2	[13.7,14.6]
Marital Status
Unmarried	410822	22.0	14.9	[14.5,15.2]	24.5 (<0.001)
Currently Married	1249302	69.6	16.2	[16.0,16.3]
Others	148871	8.4	16.1	[15.8,16.3]
Alcohol Usage
Not Drinking	1589858	90.5	16.2	[16.0,16.3]	109.1 (<0.001)
Drinking	219137	9.5	14.9	[14.6,15.1]	109.1 (<0.001)
Tobacco Status
Not Using	1341921	77.1	16.8	[16.6,16.9]	724.3 (<0.001)
Using	467074	22.9	14.2	[14.0,14.3]	724.3 (<0.001)
Household Size
Less Than 3	397921	22.5	17.4	[17.2,17.6]	162.8 (<0.001)
4-6 Members	1165031	63.5	15.7	[15.5,15.8]
More than 7 members	246043	14.1	15.0	[14.7,15.1]

Table 1 shows characteristics of the full analysis sample and estimates of age-sex adjusted diabetes prevalence. Women made up the majority of the responders (53.6%). Half of the sample completed secondary education. The sample was made up primarily of married (69.4%) and rural (68.4%) people. With an average household size of 4-6 people, more than half of the sample belonged to underprivileged classes.

We estimated the prevalence of diabetes among people aged 15 and older to be 16.1% (15.9-16.1%). Prevalence increases with age and was higher for males (16.8% (16.6-16.9%)) than for females (15.4% (15.2-15.4%)). Adjusted for age and sex, the estimated diabetes prevalence increased significantly in moving from the poorest quintile (13.1% (12.9-13.3%)) to the richest quintile (18.8% (18.5-19.1%)). According to estimates, prevalence increased from 13.2% (13.0-13.2%) for those without a formal education to 18.2% (17.8-18.5%) for those with the highest levels of education. Compared to people living in rural regions, people in urban areas had a greater prevalence of diabetes (18.5% (18.2-18.7%)) in rural and (14.9% (14.7-15.0%)) in urban areas). Additionally, it was higher among those who belonged to the "others" caste, those with small families (of 1-3 members), and those who were married.

In Figure 2, we show the proportion of households with at least one diabetic across states in India. There exist stark observable differences across the households with the least affected being state of Rajasthan with 25.3% (24.5-26.2%) and the most affected being Kerela with 53.6% (52.6-54.6%). On an average in India 32.9% (31.2-34.6%) of the households had at least one diabetic which is nearly one third of all households in India. Out of all the states of India, 20 states had households with at least one diabetic prevalence more than the national average. Economically prosperous states like Goa, and southern states like Andhra Pradesh, Tamil Nadu and Kerela had more than 40% households with diabetic individuals.

Table 2 shows adjusted percentage of respondents aged 15 years and over having diabetes who (a) were “aware” of this health condition; (b) were under “treatment” for it; and (c) had their blood glucose level under “control”. In total, 27.5 % (27.1-27.9%) were considered to be aware, 21.5 % (21.1-21.7%) to be seeking treatment, and just 7 % (6.8-7.1%) to be in control. The difference in awareness between the lowest and highest quintiles was 23 percentage points (pp). The rich-poor divide was the same for treatment and control, at 21 pp and 6 pp, respectively. Females were more likely than males to be aware of, receiving treatment for, and maintaining control over diabetes. ATC rates were also lower for STs, rural residents, unmarried people, and those with large families (more than 7 members). In comparison to being aware or receiving treatment, participants in younger age groups had more control.

The age-sex adjusted concentration indices for diabetes and for ATC among diabetics for people aged 15 and above are shown in Table 3. Diabetes prevalence concentration indices and ATC concentration indices were all positive, supporting pro-rich inequality. The concentration curves for diabetes and ATC for those with diabetes are shown in Figs. 3.1 and 3.2. We can deduce from Fig. 3.2 that the likelihood that an individual will be aware, treated, or attain control decreases with increasing poverty.

Table 2: Adjusted percent aware, treated and controlled among those with diabetes among adults in India, 2019-21

n=265864
Characteristic	Awareness		F (p value)	Treatment		F (p value)	Control		F (p value)
	%	95 % CI		%	95 % CI		%	95 % CI
Overall	27.5	[27.1,27.9]		21.5	[21.1,21.7]		7.0	[6.8,7.1]
Wealth Quintile
Poorest	14.1	[13.5,14.7]	660.8 (<0.001)	9.9	[9.4,10.3]	897.8 (<0.001)	4.7	[4.3,4.9]	97.0 (<0.001)
Poorer	20.3	[19.6,20.9]		14.1	[13.6,14.5]		5.8	[5.4,6.0]
Middle	26.3	[25.6,26.9]		19.8	[19.2,20.2]		6.7	[6.3,6.9]
Richer	31.6	[30.9,32.3]		25.3	[24.6,25.8]		7.5	[7.2,7.5]
Richest	37.3	[36.5,38.0]		30.8	[30.1,31.4]		9.1	[8.6,9.4]
Education
No Education	19.5	[19.0,19.9]	602.2 (<0.001)	14.4	[14.0,14.7]	644.9 (<0.001)	5.4	[5.1,5.6]	77.1 (<0.001)
Primary	26.9	[26.2,27.5]		21.1	[20.5,21.6]		6.8	[6.4,7.0]
Secondary	32.5	[31.9,32.9]		26.5	[26.0,26.9]		8.0	[7.7,8.3]
Higher	37.7	[36.5,38.8]		29.4	[28.4,30.3]		8.7	[8.1,9.2]
Age, years
15-29	15.7	[14.9,16.4]	647.7 (<0.001)	10.6	[10.0,11.1]	941.8 (<0.001)	8.9	[8.3,9.4]	115.0 (<0.001)
30-44	19.8	[19.1,20.3]		12.8	[12.4,13.2]		4.9	[4.6,5.1]
45-59	29.5	[29.0,30.0]		23.6	[23.0,24.0]		6.4	[6.0,6.6]
60-74	35.3	[34.7,35.9]		29.5	[28.9,30.0]		8.4	[8.0,8.6]
75-89	33.5	[32.4,34.6]		27.6	[27.4,29.6]		8.9	[8.5,9.8]
Sex
Male	25.8	[25.3,26.2]		20.4	[20.0,20.7]		6.6	[6.3,6.7]
Female	29.3	[28.7,29.7]	223.8 (<0.001)	22.5	[22.1,22.8]	87.2 (<0.001)	7.4	[7.2,7.6]	36.5 (<0.001)
Location			223.8 (<0.001)			87.2 (<0.001)			36.5 (<0.001)
Rural	23.9	[23.4,24.3]		17.7	[17.4,18.0]		8.3	[7.9,8.5]
Urban	33.7	[32.9,34.4]	508.8 (<0.001)	27.8	[27.2,28.3]	966.5 (<0.001)	6.3	[6.1,6.4]	112.7 (<0.001)
Caste			508.8 (<0.001)			966.5 (<0.001)			112.7 (<0.001)
SC	25.4	[24.6,26.1]		18.9	[18.3,19.4]		6.6	[6.2,6.8]
ST	16.3	[15.3,17.1]	231.9 (<0.001)	12.7	[11.9,13.3]	239.4 (<0.001)	5.5	[5.0,5.9]	21.2 (<0.001)
OBC	29.3	[28.7,29.9]		22.5	[22.0,22.8]		7.1	[6.8,7.3]
Others	28.9	[28.3,29.5]		23.6	[23.0,24.1]		7.5	[7.1,7.8]
Religion
Hindu	26.8	[26.3,27.2]		20.7	[20.3,21.0]		6.9	[6.6,7.0]
Muslim	28.3	[27.2,29.3]	72.7 (<0.001)	23.1	[22.1,23.9]	89.7 (<0.001)	7.1	[6.6,7.5]	15.9 (<0.001)
Christian	40.9	[39.0,42.8]		33.6	[31.9,35.1]		10.2	[9.2,11.1]
Others	28.4	[26.9,29.8]		22.1	[20.9,23.3]		6.3	[5.5,7.0]
Marital Status
Unmarried	26.5	[25.0,27.9]		21.1	[19.7,22.4]		7.3	[6.5,8.0]
Currently Married	27.9	[27.4,28.3]	12.1(<0.001)	21.8	[21.4,22.0]	8.9 (<0.001)	7.0	[6.8,7.1]	0.6 (0.5250)
Others	26.2	[25.4,26.8]		20.3	[19.7,20.9]		6.8	[6.4,7.2]
Alcohol Usage
Not Drinking	27.9	[27.5,28.3]		21.9	[21.5,22.1]		7.1	[6.9,7.2]
Drinking	24.4	[23.5,25.2]	70.5 (<0.001)	18.1	[17.4,18.8]	102.9 (<0.001)	6.3	[5.8,6.6]	11.9 (0.0005)
Tobacco Status			70.5 (<0.001)			102.9 (<0.001)			11.9 (0.0005)
Not Using	30.6	[30.1,31.0]		24.2	[23.8,24.5]		7.5	[7.3,7.7]
Using	19.8	[19.3,20.2]	1279.3 (<0.001)	14.6	[14.2,15.0]	1393.8 (<0.001)	5.6	[5.3,5.8]	131.4 (<0.001)
Household Size			1279.3 (<0.001)			1393.8 (<0.001)			131.4 (<0.001)
Less Than 3	29.3	[28.6,29.9]		23.4	[22.8,23.8]		7.3	[7.0,7.6]
4-6 Members	27.0	[26.5,27.4]	37.9 (<0.001)	21.0	[20.6,21.3]	82.2 (<0.001)	6.9	[6.7,7.1]	6.2 (0.002)
More than 7 members	25.3	[24.5,26.1]	37.9 (<0.001)	18.3	[17.6,18.9]	82.2 (<0.001)	6.5	[6.1,6.9]	6.2 (0.002)

Table 3: Adjusted concentration indices for diabetes and for ATC among those with diabetes in India, 2019-21


Variables	Wagstaff Concentration Index (95% CI)	n
Diabetes Prevalence	0.023 [0.022,0.024]	1808995
Awareness	0.089[0.085,0.092]	265864
Treatment	0.083 [0.079,0.085]	265864
Control	0.017 [0.015,0.1827]	265864

The state-level variance in age-sex adjusted diabetes prevalence and rates of ATC among individuals with diabetes is shown in Figure 4. In 15 of the 36 states, the prevalence of diabetes was higher than the 16.1% national average and ranged from 10.0 % (9.6-10.4%) in Rajasthan to 23.2 % (22.6-23.7%) in Lakshadweep. Diabetes awareness levels ranged from 14.4% (12.1-16.8%) in Meghalaya to 54.4% (40.3-68.4%) in Telangana. Treatment rates varied from 9.3% (7.5-11.1%) in Nagaland to 41.2% (39.9-42.6%) in Lakshadweep. The projected percentage of diabetes cases with controlled blood sugar was below the national average of 7% in 21 out of 36 states. The percentage with controlled blood glucose level varied from 2.7% (1.6-3.7%) in Nagaland to 11.9% (9.7-14.0%) in Tamil Nadu.

Figure 5 displays the adjusted concentration indices for diabetes and for ATC among persons who have the disease by state, ranked from lowest to highest. With the exception of one state, this index's point estimate is positive, pointing that a proportionately greater prevalence of diabetes among those with higher incomes. The majority of the 95 % confidence bands do not contain 0, which is consistent with inequality. Similar results were found for ATC, with the exception of a small number of states, showing that those who were better off were more likely to be aware of having diabetes, seek treatment for it, and have it under control in those states.

For each of the outcomes, multivariable logistic regressions average marginal effects are shown in Figure 6. After adjusting for sociodemographic traits and states, it was determined that people in the richest fifth had a 5.7 pp (5.3- 6.1) greater prevalence of diabetes than those in the lowest fifth. Greater prevalence was seen in elderly persons, people who lived in urban areas, those with tiny nuclear families, and married people. Socioeconomic differences in ATC remained unchanged even after controlling for features and state. According to estimates, the ATC's poorest and richest fifths differ by 12.4 pp (11.3-13.4), 10.5 pp (9.7-11.4) and 2.3 pp (1.6-3.0) respectively. After controlling for other factors, the outcomes remained better for women, nuclear families, and urban dwellers. While keeping all other variables constant, awareness and treatment were higher among older persons when compared to control among the same older individuals.

We estimated the prevalence of diabetes among age 15 years and older at 16.1% (15.9-16.1%), based on the nationally representative sample of NFHS-5. Among the individuals with diabetes, it was observed that there exist significant differences in prevalence, awareness, treatment and control of diabetes in the population. In all, 27.5 % (27.1-27.9%) adults in India were aware of, 21.5 % (21.1-21.7%) sought treatment, and just 7 % (6.8-7.1%) had controlled over diabetes^27,31,33,41. As per the NNMS study, the prevalence of diabetes was at 9.3% among adults²³ and as per another study using NFHS-4, the prevalence was found at 3% only for the age group 15-49 years³¹. The novelty of our study lies in the fact that we used a full sample of individuals interviewed above 15 years of age in NFHS-5, 2019-21. This large sample of individuals gives us robust estimates for prevalence and ATC of diabetes, and our estimate is much higher that is found in the other small-scale studies^{24,27,28,31,33,41,42}, which might be attributed to the fact that increasing diabetes prevalence and varying methods used in estimation.

We found significant disparities in diabetes prevalence, awareness, treatment, and control across geographic and socioeconomic groups. High-income states like Maharashtra, Telengana and Andhra Pradesh as well as states in advanced demographic transition stages like Kerala, had the highest prevalence rates. We found some of the poorer states had relatively lower prevalence of diabetes. Extent of undiagnosed, untreated and uncontrolled diabetes is likely to be higher in poorer states of India. The SES inequality in ATC of diabetes is high. Only 14.1% in the poorest fifth were aware of their condition, compared to 37.3% of those in the richest. The concentration of ATC is pro-rich. Therefore, the likelihood of diagnosis was lower for the poor. This pattern is consistent with greater socioeconomic inequality becoming more prevalent as a result of increased awareness of the issue. Only 9.9% of those with diabetes in the poorest fifth received treatment, compared to nearly 30.8% in the richest fifth.

Not only did people who were poorer and less educated have lower rates of ATC of diabetes, but so did those who were young (not the control group), male, living in rural areas, single, and had larger families. In this study, we predicted a higher prevalence of diabetes, as well as higher rates of ATC. Age is an incremental factor for awareness and treatment, but not control. Therefore, there is an urgent need to implement interventions that prevent diabetes along with its early detection and newly devised treatments to delay progression to serious complications Our findings that men and socioeconomically disadvantaged populations have lower incidence of ATC are in line with earlier studies³¹.

India's adult population has low awareness of diabetes, which highlights the need for better health monitoring and education. Diabetes treatment and control rates are low and suboptimal³⁴, especially among the poor and in rural regions, which may be due to barriers to healthcare access and price. There are low-cost glycemic medications available, but the poorest individuals cannot afford them. Health is a state subject in India, which explains the apparent state-level variances in ATC. The primary stakeholder in funding, operating facilities, providing manpower, and supplying pharmaceuticals is the state government, even if the central government can provide rules and offer support for some health-related services. Increased funding for diabetes management from the central government and state governments is urgently needed. Some studies have previously pointed out the need for preparedness in the primary and secondary health care centres in India, for tracking non-communicable diseases⁴². The state of healthcare remains in utter despair, where the rural counterpart is severely handicapped and marred with challenges compared to their urban counterparts^34,42. The National Programme For Prevention And Control Of Cancer, Diabetes, Cardiovascular Diseases And Stroke (NPCDCS), is a programme set up by Government of India (GoI) to control NCDs including diabetes, which has been fruitful so far but with shortcomings too⁴³. The programme has been able to meet some of its targets of early detection and screening of NCDs like diabetes, which is key to resolving complications at an initial stage⁴⁴. As pointed out by the recent ICMR-INDIAB study, across India there is suboptimality in the achievement of targets related to tackling diabetic conditions and a very low proportion of individuals are able to achieve all three of ATCs³⁴. Monitoring at the population level can be achieved using the care cascade method of representing the number of people that pass through each stage of diagnosis, and treatment to control³¹. ATC across the states can be increased by educating the masses and by placing checks for early detection and monitoring.

The primary limitation of the study is that the diagnosis of diabetes was made based on a single finger stick random blood glucose measurement and may differ from the gold standard set by a HbA1c. Secondly, the fact that there were a very small proportion of non-respondents or people whose blood glucose sample could not be collected, however, means that this potential bias in the estimations cannot set off our estimates.

Despite these limitations, this paper provides comprehensive estimates on prevalence, awareness, treatment and control of diabetes in India. These findings may be helpful in monitoring and designing national guidelines for diabetes control and management in India.

Ethics approval and consent to participate

The study used a secondary dataset which is freely available in the public domain. The survey agencies had obtained the prior consent from the respondents. The local ethics committee of the International Institute for Population Sciences ruled that no formal ethics approval was required to carry out research using this data source.

Consent for publication

Not applicable.

Availability of data and materials

The data is freely available from https://dhsprogram.com/data/dataset/India_Standard-DHS_2020.cfm?flag=0 .

Competing interests

The authors declare that they have no competing interests.

Funding

The authors received no funding from any sources or any grants.

Authors’ contribution

SKM conceptualized the study. SM performed the data analysis. SM and SA were involved in writing the draft. SKM and AKU provided overall supervision for the study.

Acknowledgments

Not applicable.

Wong, E. et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 1, 106–114 (2013).
Mutyambizi, C., Pavlova, M., Chola, L., Hongoro, C. & Groot, W. Cost of diabetes mellitus in Africa: A systematic review of existing literature. Global Health 14, 1–13 (2018).
Dal Canto, E. et al. Diabetes as a cardiovascular risk factor: An overview of global trends of macro and micro vascular complications. Eur J Prev Cardiol 26, 25–32 (2019).
Federation, I. D. IDF Diabetes Atlas 10th Edition. Preprint at (2021).
Lin, X. et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep 10, (2020).
Khan, M. A. B. et al. Epidemiology of Type 2 Diabetes – Global Burden of Disease and Forecasted Trends. J Epidemiol Glob Health 10, 107 (2020).
Misra, A. et al. Diabetes in developing countries. J Diabetes 11, 522–539 (2019).
Deshpande, A. D., Harris-Hayes, M. & Schootman, M. Epidemiology of diabetes and diabetes-related complications. Phys Ther 88, 1254–1264 (2008).
Health - United Nations Sustainable Development. https://www.un.org/sustainabledevelopment/health/.
collaborators, N. C. 2030. NCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4. Lancet 396, 918–934 (2020).
Hunt, D., Hemmingsen, B., … A. M.-T. L. D. & & 2021, undefined. The WHO Global Diabetes Compact: a new initiative to support people living with diabetes. thelancet.com.
The WHO Global Diabetes Compact. https://www.who.int/initiatives/the-who-global-diabetes-compact.
Moody, A., Cowley, G., Fat, L. N. & Mindell, J. S. Social inequalities in prevalence of diagnosed and undiagnosed diabetes and impaired glucose regulation in participants in the Health Surveys for England series. BMJ Open 6, e010155 (2016).
Tudor Hart, J. THE INVERSE CARE LAW. The Lancet 297, 405–412 (1971).
Liu, X. et al. Prevalence, awareness, treatment, control of type 2 diabetes mellitus and risk factors in Chinese rural population: The RuralDiab study. Sci Rep 6, (2016).
Khodakarami, R., Abdi, Z., Ahmadnezhad, E., Sheidaei, A. & Asadi-Lari, M. Prevalence, awareness, treatment and control of diabetes among Iranian population: results of four national cross-sectional STEPwise approach to surveillance surveys. BMC Public Health 22, 1–12 (2022).
Lee, J. et al. Prevalence, awareness, treatment, and control of diabetes mellitus by depressive symptom severity: a cross-sectional analysis of NHANES 2011-2016. BMJ Open Diabetes Res Care 9, (2021).
Stokes, A. et al. Prevalence and unmet need for diabetes care across the care continuum in a national sample of South African adults: Evidence from the SANHANES-1, 2011-2012. PLoS One 12, e0184264 (2017).
Rahman, M. S. et al. Awareness, treatment, and control of diabetes in Bangladesh: A nationwide population-based study. PLoS One 10, (2015).
Wang, Q. et al. Prevalence, awareness, treatment and control of diabetes mellitus among middle-aged and elderly people in a rural Chinese population: A cross-sectional study. PLoS One 13, (2018).
Gyawali, B. et al. Awareness, prevalence, treatment, and control of type 2 diabetes in a semi-urban area of Nepal: Findings from a cross-sectional study conducted as a part of COBIN-D trial. PLoS One 13, (2018).
Avilés-Santa, M. L., Monroig-Rivera, A., Soto-Soto, A. & Lindberg, N. M. Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent. Curr Diab Rep 20, (2020).
Mathur, P., Leburu, S. & Kulothungan, V. Prevalence, Awareness, Treatment and Control of Diabetes in India From the Countrywide National NCD Monitoring Survey. Front Public Health 10, 205 (2022).
Tandon, N. et al. The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990-2016. Lancet Glob Health 6, e1352–e1362 (2018).
Claypool, K. T., Chung, M. K., Deonarine, A., Gregg, E. W. & Patel, C. J. Characteristics of undiagnosed diabetes in men and women under the age of 50 years in the Indian subcontinent: The National Family Health Survey (NFHS-4)/Demographic Health Survey 2015-2016. BMJ Open Diabetes Res Care 8, (2020).
Mohan, V., Shah, S., Joshi, S. & al., et. Current status of management, control, complications and psychosocial aspects of patients with diabetes in India: results from the DiabCare India 2011 Study. Indian J Endocrinol Metab 18, 370–378 (2014).
Unnikrishnan, R., Anjana, R., Deepa, M. & al., et. Glycemic control among individuals with self-reported diabetes in India—the ICMR-INDIAB Study. Diabetes Technol Ther 16, 596–603 (2014).
Singh, A., Mani, K., Krishnan, A., Aggarwal, P. & Gupta, S. Prevalence, awareness, treatment and control of diabetes among elderly persons in an urban slum of Delhi. Indian Journal of Community Medicine 37, 236–239 (2012).
Anjana, R. M. et al. Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR–INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 5, 585–596 (2017).
Ranasinghe, P., Jayawardena, R., Gamage, N., Sivanandam, N. & Misra, A. Prevalence and trends of the diabetes epidemic in urban and rural India: A pooled systematic review and meta-analysis of 1.7 million adults. Ann Epidemiol 58, 128–148 (2021).
Prenissl, J. et al. Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years. BMC Med 17, (2019).
Borgharkar, S. S., Das, S. S., Surendra, D. & Borgharkar, S. Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: the TIGHT study. BMJ Open Diabetes Res Care 7, e000654 (2019).
Geldsetzer, P. et al. Diabetes and hypertension in India a nationally representative study of 1.3 million adults. JAMA Intern Med 178, 363–372 (2018).
Anjana, R. M. et al. Achievement of guideline recommended diabetes treatment targets and health habits in people with self-reported diabetes in India (ICMR-INDIAB-13): a national cross-sectional study. Lancet Diabetes Endocrinol 10, 430–441 (2022).
Anjana, R. M. et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase i results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 54, 3022–3027 (2011).
International Institute for Population Sciences (IIPS) & ICF. National Family Health Survey (NFHS-5), 2019-21. http://rchiips.org/nfhs/NFHS-5Reports/NFHS-5_INDIA_REPORT.pdf (2021).
Mohanty, S. K. et al. Awareness, treatment, and control of hypertension in adults aged 45 years and over and their spouses in India: A nationally representative cross-sectional study. PLoS Med 18, e1003740 (2021).
O’Donnell, O., O’Neill, S., van Ourti, T. & Walsh, B. conindex: Estimation of concentration indices. Stata J 16, 112 (2016).
O’Donnell, O., Doorslaer, E., Wagstaff, A. & Lindelow, M. Analyzing health equity using household survey data : a guide to techniques and their implementation. Preprint at (2007).
Wickham, H. ggpolt2: Elegant Graphics for Data Analysis. Use R! series (Springer-Verlag New York, 2016).
Anjana, R., Deepa, M., Pradeepa, R. & al., et. Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR-INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 5, 585–596 (2017).
Krishnan, A. et al. Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a National Noncommunicable Disease Monitoring Survey (NNMS). BMC Health Serv Res 21, (2021).
NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER, DIABETES, CARDIOVASCULAR DISEASES & STROKE (NPCDCS) OPERATIONAL GUIDELINES (REVISED: 2013-17) Directorate General of Health Services Ministry of Health & Family welfare Government Of India 2013.
Indian Council of Medical Research, Public Health Foundation of India & Institute for Health Metrics and Evaluation. India: Health of the Nation’s States-The India State -level Disease Burden Inititative. https://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States_Report_2017.pdf (2017).

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Socioeconomic Inequality in Awareness, Treatment and Control of Diabetes Among Adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

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