Worldwide, at least 537 million persons are living with diabetes – a number slated to touch 783 million by 2045.1 At least 75 per cent of those living with diabetes hail from low- and middle-income nations

As people’s working lives become more hectic, sedentary habits and wrong dietary practices are rising worldwide. As a result, more people are developing diabetes – a chronic metabolic disease classified as a lifestyle disorder. Diabetes impacts how our body produces or utilises the hormone, insulin. As insulin converts food into energy, any abnormality in the amount of insulin produced or used eventually ends in higher blood sugar levels.  
If detected late and managed improperly, it can cause chronic, life-threatening conditions such as cardiovascular diseases, kidney failure, stroke, blindness and other complications. Diabetes can also lead to ‘insulin resistance’, which primarily affects the liver, muscle and fat tissues. Since the disorder often remains undetected until serious health complications arise, it is also called the ‘silent killer’.  
Over 50% of diabetes cases remain undiagnosed 
The two most common forms are type 2 and type 1 diabetes. In type 2 diabetes (also termed ‘diabetes mellitus’), the body either does not produce adequate insulin or resists insulin, affecting the way it processes glucose or blood sugar. In type 1 diabetes, which usually appears in children and adolescents, the pancreas produces little or no insulin. Insulin helps blood sugar enter the cells in your body for use as energy. Without insulin, blood sugar can’t get into cells and builds up in the bloodstream causing high sugar levels..  
Previously perceived as largely afflicting affluent cohorts and countries, diabetes has spread globally. Today, it is a major cause of disability and death, even affecting the younger generation. Worldwide, at least 537 million persons are living with diabetes – a number slated to touch 783 million by 2045.1 At least 75 per cent of those living with diabetes hail from low- and middle-income nations.   
At 74.2 million, India hosts the second-largest percentage of people living with diabetes. By 2045, this is anticipated to touch 124.9 million. What’s worse, 53.1 per cent of these patients remain undiagnosed. After China and the US, India has the third-largest number of annual deaths due to diabetes at 600,000.   
Studies suggest the disease burden differs in genders because of varied factors. In North India, women are more prone to developing diabetes, whereas males are more susceptible in South India. Significantly, another study noted that states having higher per capita GDP and a better socioeconomic status had more cases of diabetes.  
As per the DIABetes study, India’s largest nationally-representative epidemiological survey with data from 15 States and Union Territories, disease prevalence varied from 3.5 per cent to 8.7 per cent in rural regions and 5.8 per cent to 15.5 per cent in urban areas. In Bihar, while it was 4.3 per cent only, in Chandigarh it was as high as 13.6 per cent. The statistics highlight the higher prevalence of 11.2 per cent in urban areas versus 5.2 per cent in rural zones.   
Indians have poor glycaemic control 
In low- and middle-income nations, subpar public healthcare systems remain a big barrier to providing quality care for people with diabetes. Conversely, many private diabetes care clinics, both big and small, help patients with diabetes manage their condition, but accessibility and affordability remain a concern as these are far too few to cope with the growing need for continuous care and with diabetes related expenses being out-of-pocket, compliance continues to suffer.  
76.6 per cent of the population in India had poor glycaemic control (HbA1c >7 per cent), as per a real-world study that surveyed 55,633 diabetes mellitus patients and out of which one third had microvascular complications. Additionally, an ICMR-INDIAB study noted that barely 31 per cent of those with self-reported diabetes had HbA1c, less than 7 per cent. More than 60 per cent of the patients had failed to check their HbA1c in the past year.  
The main hurdles in achieving glycaemic targets were low disease awareness, clinical inertia and poor adherence to drug protocols. Poor adherence is attributed to low awareness, the cost of treatment and the lack of healthcare accessibility. Additionally, the quality of diabetes care is impacted by the attitude, awareness levels and perceptions of diabetes care among physicians.  
To surmount these barriers, the right of people to universal healthcare must be emphasised. Recently, the Supreme Court reaffirmed the right of every citizen to good health. Consequently, the right to proper diabetes care is a natural corollary, which should be provided with proper awareness, easy accessibility and adequate affordability. 
The 3As for universal diabetes care 
Based on the 3As of awareness, accessibility and affordability, the government must create a patient-centric, universal, sustainable and self-sufficient diabetes care model. Such an egalitarian approach would ensure every citizen is provided quality diabetes care, irrespective of his or her social standing, age, gender, economic status, educational background, etc.  
Accessibility: In diabetes care, accessibility is impeded due to the high patient-to-practitioner ratio and geographic barriers, especially in smaller cities and towns where people need to travel for hours simply to consult specialists or undergo check-ups. Disease management is also suboptimal in low- and middle-income settings because of limited access to medications, the growing cohorts of patients and comorbidities, which end in the overuse of current resources. Moreover, delays in diagnosis create a bigger burden for those with complications.  
In such situations, digital health solutions such as virtual and real time access to experts such as doctors and nutritionists, self monitoring blood glucose tracking apps and decision support through AI can resolve some of the above issues, reshaping the future of diabetes care in India.  
Affordability: Considering the high expenses of check-ups, diagnosis, monitoring and management, cost-effective measures are crucial for diabetes care. In low- and middle-income nations, diabetes care is expensive as many without health insurance must make payments themselves. For instance, the average cost of outpatient care for diabetes in India is around Rs. 15,000-18,000 per year for an average middle/low income household, which places a huge financial burden on the patient’s family. Multiple studies indicate that low compliance with medication protocols is behind almost 50% of treatment failures, leading to complications.  
Again, digital technology can facilitate easy access to quality healthcare facilities, reducing the cost of diabetes care and improving patient outcomes.   
Awareness: A nationwide National NCD Monitoring Survey on diabetes revealed that only 45.8 per cent of people with diabetes had awareness of their disorder. Even among those diagnosed with diabetes, only 40.6 per cent were aware the condition could damage vital organs. Here again, through mobile health interventions, one can improve diabetes risk behaviours and boost awareness of the condition, its complications and related issues.  
Given the burgeoning number of people with diabetes, digital technology must be leveraged to boost the 24×7 management of the condition through a comprehensive care programme that democratises diabetes care in both urban and rural India.  
The risk of diabetes can be lowered through continuous care and timely intervention by doctors or experts along with a sustained healthy lifestyle. This includes regular physical activity, healthy food choices, shunning smoking and tobacco and overconsumption of alcohol, timely intake of medications as well as controlling blood pressure and cholesterol. A comprehensive and virtual diabetes care program designed to provide holistic and continuous care at an affordable cost to people living with diabetes will help ensure the democratization of diabetes care in India. That is the only way to transform India from the ‘Diabetes Capital of the World’ into the ‘Diabetes Care Capital of the World’. 
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