In recent years, diabetes mellitus has rapidly emerged as a global health problem and identified as a major non-communicable disease (NCD) responsible for about two-thirds of the global burden of deaths and disabilities. Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs) as well, where the rate of increase in its prevalence over the past two decades has surpassed that of high-income countries (Smolen et al., 2016). India’s share in this global count of diabetes is significant owing to its being in the third Stage of Epidemiological Transition with rising trends in emergence of Non-Communicable Diseases. Nearly 12% of global health expenditure is spent on diabetes (WHO, 2016). According to the World Health Organisation (WHO) estimates, the global prevalence of diabetes among the adult population almost doubled between 1980 and 2012 (from 4.7% in 1980 to 8.5% in 2012). Such a growth is largely owing to its rapid increase in low- and middle-income countries compared with high-income countries (WHO, 2016).
Findings from a study in Denmark shows the relationship between Socio-economic Position (SEP) and Type 2 diabetes. The prevalence of type 2 diabetes is higher among people with a lower socioeconomic position than people with a higher SEP (Espelt et al., 2008; Sacerdote et al., 2012), and the burden of complications increases with declining SEP (Espelt et al., 2013). Both type 2 diabetes and income, education and cohabitating status had a significant effect on all-cause mortality. Mortality rates were higher among people with low SEP than among those with high SEP both among people with and people without type 2 diabetes. SEP was measured in terms of educational level, income level, and cohabitation status (Dalsgaard et al., 2015).
The most frequently cited reason behind the spread of this disease has been the changing life style with increasing affluence. However, the rising trends of NCDs in developing countries is seen among the poor and the rich alike that intrigues one as to how does the interplay of affluence and awareness shapes the occurrence of this disease. The pattern of this disease as revealed by the International Diabetes Federation (IDF) in 2013 observes nearly 80% of the adult population suffering from diabetes lives in low- or middle-income countries, and almost every tenth adult in India is affected by diabetes (IDF, 2013). The Indian Council of Medical Research–India Diabetes (ICMR-INDIAB) study conducted in 15 states of India at varying time points between 2008 and 2015 reports the overall prevalence of diabetes among adults ≥ 20 years as 7.3% (Anjana et al., 2017). In India, 77 million were living with diabetes, approximately 9% are adult population (IDF,13). Moreover, India is having the 2nd largest diabetes population, wherein 1 in 6 adults are having diabetes (Atlas, 1955).
Alternative finding relating to diabetes in high-income countries associates its greater prevalence among populations with lower SEP (Clark & Utz, 2014; Espelt et al., 2008), with some studies observing that this relationship is not solely driven by overweight and obesity (E. E. Agardh et al., 2004; Steele et al., 2017). Hence there is a need to understand the relationship between SEP and diabetes. However, the health system strategies focus on the prevention and management of diabetes and direct interventions toward the highest-risk populations (Clark & Utz, 2014). In contrast, in low-income countries, diabetes is associated with affluence and awareness, although this finding has been inconsistent and limited by lack of individual-level data (E. Agardh et al., 2011; Williams et al., 2018). Prevailing understanding on diabetes, particularly in India is limited to hospital based studies and site-based enquiries. However, its observed rising trend need a macro-inspection to understand the complexities of its correlates beyond the levels and burden of the disease.
There is evidence to suggest a socio-economic pattern of this disease but with shift from communicable to non-communicable diseases in India, its predominance is obvious and a population level inspection on the same may well be meaningful. In such an inspection, exploring the complex aspect of association between awareness and affluence may offer some fresh clues for intervention. Here awareness component may be proxied with levels of education given that it can make individuals aware of the possible preventive and protective measures against the disease. At the same time the affluence component can be proxied by the economic status gradient that has its own bearing on the life style. This is an attempt at examining the nexus between awareness and affluence shaping the disease, where in a potential exposition is made as regard the conditional aspect of the twin dimensional gradient of awareness and affluence.