Diabetes and its risk factors in a remote rural area of South India: A community based cross sectional survey

Introduction

India is one of the epicentres of the diabetes pandemic [1]. Diabetes (DM) is a risk factor for many non- communicable diseases (NCDs) [1]. With more than 65 million people having the disease, DM is growing alarmingly in India. These numbers are projected to increase to 101.2 million by the year 2030 [2, 3]. Currently, India is considered the ‘Diabetes Capital’ of the world [4]. Main contributors for major NCDs including diabetes are—physical inactivity, unhealthy diet, smoking and alcohol consumption [5]. Even though evidence from large prevalence studies is available in India, there is a need for community-based studies on various aspects of the disease [4, 6-8]. Not only is DM under-diagnosed, there is also a huge gap in managing the already diagnosed individuals [4, 6-8]. This gap is even more pronounced among the rural and neglected population [9]. So, to fill this gap there is a need to conduct and construct a population-based registry in the community, especially in the rural areas, this could in-turn be used as a tool for further follow up and management. With this background, we aimed to construct a population-based registry on self-reported diabetes patients in a remote rural area.

Methodology

Pondicherry Institute of Medical Sciences has established its Rural Health Training Centre (RHTC) in a remote rural area of Chunampet, situated in Chengalpattu district of Tamil Nadu, South India. The RHTC was established as per the Medical Council of India (MCI) norms for medical colleges and has been functioning since the year 2002. This centre serves around the clock through its outpatient and emergency medical services. The centre also caters to 20 near-by villages through its community health services. The services were offered at their door steps with the help of medical interns, post-graduates, medical social workers (MSWs) and Medical Officers (MOs). In the 20 villages served by the RHTC, a large-scale socio-demographic and morbidity survey was conducted in March 2018 to October 2018. For this survey a pretested ‘data collection questionnaire’ was used which contained socio-demographic, mortality and morbidity details associated with diabetes. A detailed data collection guide was prepared and the medical interns, MSWs and Auxiliary Nurse Midwifes (ANMs) were trained in data collection using this guide. The data collection was (directly) supervised by the faculty in-charge, post graduate and MOs of the RHTC. Persons with age 20 and above belonging to any of the 20 villages and having resided for more than six months were included in the study. Those found eligible as per the mentioned criteria were included in the study. Self-reported diabetes was defined as those respondents who were already diagnosed with diabetes and were either on treatment or had discontinued treatment or were not on treatment [10].The software used for data entry was EpiData software version 3.1 [11]. The quality of data collection was ensured by checking a subset of data collected in the field. Also, EpiData V 3.1 has quality checks to prevent data entry errors. Data was analysed with the help of Statistical Product and Service Solutions (SPSS) version 22 and STATA version 14 [12, 13]. We used SPSS for reporting frequency distribution and chi square test, while STATA was used for Prevalence Ratio (PR) and adjusted Prevalence Ratio (aPR). PR and aPR were calculated using Poisson regression. An ethical clearance for the survey was obtained from the Institute ethics board (Ref No - RC 100/18).

Results

In total 10,739 persons were included in the study, among them 346 were reported to have diabetes. Prevalence of self-reported diabetes was 3.2% (95% CI: 2.9-3.6). Hypertensive patients were 12 times (aPR 12.1; 95% CI: 9.6-15.2) more likely to have DM. With increase in age, increase in prevalence of HT was 3% (aPR1.03; 95% CI: 1.02-1.04). Married people were 5 times (aPR 5.2; 95% CI: 2.1-12.9) and widowed were 4 times (aPR 3.9; 95% CI: 1.5-10.2) more likely to have DM. Alcoholics were 37% (aPR 1.37; 95% CI: 1.0-1.9) more likely to have DM, while non-vegetarians were 35% (aPR 0.65; 95% CI: 0.5-0.9) less likely to have DM.

Discussion

One of the main findings in our study was 3.2% self-reported DM. Our results are similar to those of Indian Council of Medical Research - INdia DIABetes Study (ICMR - INDIAB study) wherein self-reported and newly-diagnosed diabetes in rural Tamil Nadu were found to be 4.1% and 3.8%, respectively; the ratio of self-reported diabetes to newly-diagnosed diabetes in rural area was 1:0.9 and overall diabetes was 7.8 % [14]. This shows that nearly half of diabetics in rural India are still undiagnosed, there is thus a need for improved diagnosis of diabetes through active search in the community. While regional differences exist, in India the prevalence of diabetes in rural areas has quadrupled in the past 25 years. Few studies have found to have higher prevalence in a rural area of neighbouring Andhra Pradesh, however the sample population comprised only of individuals above 30 years of age. However, in our study we included persons above 20 years of age since identification at an earlier stage can help in modifying the risk factors thus preventing future complications [15, 16]. Chronic diseases have been the leading cause of death, globally. About 20% of Indians are estimated to suffer from a chronic condition. Type 2 DM is an international pandemic with high morbidity and mortality, having a great economic impact [15, 17]. Nearly 80 % of the global burden lies in low- and middle-income countries (LMICs) and India falls in this category [18]. Diabetes is a serious threat to rural regions, where it often goes unidentified; this problem is no longer confined only to urban areas of India [15, 19]. DM affects over 70 % of rural population of India, characterized by poverty, lack of awareness, illiteracy, inadequate health care services and poor access to health care services.

Our findings of increase in prevalence of DM with age, hypertension, among married, widowed and with alcohol intake was also noticed in other studies [1, 20, 21]. Higher prevalence among married and widowed compared to unmarried may be due to differential age. Unmarried are at lower risk and are younger. Prevalence was also high among those who consumed alcohol. Probability of diabetics being hypertensive was also high in our study. An interesting finding in our study was that non-vegetarians were 40% less likely to have diabetes than vegetarians, this contradicts findings from other studies [22-24]. This may be due to relatively smaller sample size of vegetarians. Also, since most non-vegetarians in this part of the country consume fish, which may be protective [25-27]. Vegetarians however might be consuming calorie dense foods, rich in sugars and fats. This aspect needs to be studied in details further in this population, using a detailed case control design [22-24]. Our study shows that there was no significant relationship of DM with gender, caste, socio-economic status, literacy level and smoking. In addition, there are a number of potential risk factors, including physical activity, family history, central obesity, abdominal obesity, poly-unsaturated fat consumption, and tobacco consumption, which are all associated with diabetes indicators, pre-diabetes, and/or diabetes in the research site and warrant future investigation [24].

A limitation of our study is that it is based on the self-reporting and can be considered as a self-reported prevalence but not a true prevalence study, as we have not actively screened the population for diabetes. Strengths of our study are, this is a population-based study covering a large sample size from a remote rural area, spreading across 20 villages. Our study has the certain policy implications. Presently, NCDs in rural area are managed through NCD clinics under the National Program for Cancer Diabetes and Cardio vascular disease (NPCDCS) programme. Individuals with NCDs (mainly diabetes and Hypertension) belonging to a particular Primary Health Centre area are managed through this NCD clinic. Our study adds strength to this concept by having a population-based registry; updating this on serial surveys may help ensure proper management of DM in rural India.

Conclusion

Diabetes was found to be significantly associated with hypertension, increase in age, being married or widowed, alcohol and vegetarian diet in the remote rural area of South India under study. Diabetes diagnosis and management need to be improved in rural areas of India.

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