Non-communicable Diseases (NCDs) account for nearly 70% of all deaths globally. Non-communicable diseases include heart disease, stroke, cancer, diabetes, and chronic lung disease. Diabetes is a global public health issue and now emerging as an epidemic of NCDs. There are two types of diabetes – type-1 and type-2. Type-1 diabetes is a hereditary disease and is more prevalent in children and adolescents. More prevalent type-2 diabetes is a lifestyle disease caused by obesity, smoking, physical inactivity, alcohol intake, air pollution, and heredity. With the ongoing covid-19 pandemic, diabetes is becoming more prevalent in India, accounting for one in every six diabetics worldwide. India is also termed as ‘Diabetes capital of the World’.
Sedentary lifestyle clubbed with obesity are the most prevalent causes of type-2 diabetes. Few researches done in the Western countries indicate that consumption of too much sugar in form of sugar-sweetened beverages (SSB) is directly linked to diabetes. Thus, named sugar ‘white poison’. While studies on sugar consumption in India, indicate a low intake of sugar (18.4 kg/capita/year in 2020). This article will try to explore scientific studies and available data to study diabetes and sugar consumption in the Indian context.
Diabetes: An Indian Overview
In India, Non-Communicable Diseases (NCDs) are estimated to account for 63% of all deaths among which 3% overall mortality is attributable to diabetes. In a report “India: Health of the Nation’s States” by Ministry of Health and Family Welfare (MOHFW), it is found that there is an increase in proportion of deaths due to NCDs (among all deaths) from 37% in 1990 to 61% in 2016 and decrease in proportion of deaths due to Communicable Diseases (CDs) (among all deaths) from 53% in 1990 to 27% in 2016. This shows an epidemiological transition with a shift in disease burden to NCDs.
As per the 10th edition of Diabetes Atlas 2021 of the International Diabetes Federation (IDF), the estimated number of patients of diabetes between the age group of 20-79 years is 74.2 million in the year 2021 and it is estimated to be increased to 124.8 million in the year 2045.
Chart-1: People (age group 20-79 years) with Diabetes in India (in 1000’s)
Source: IDF (2021)
Indian Council of Medical Research (ICMR) conducted a study “The ICMR INDIAB Study – A Compendium of Type 2 Diabetes in India: Lessons Learnt for the Nation” and published in 2017. The prevalence of diabetes is more in the urban area as compared to rural areas in the country. The incidence of diabetes is higher in the metro cities and lower in the smaller cities and still lower in the villages.
Sugar Consumption in India:
India is the largest consumer of sugar in the world. However, the per capita consumption of sugar in India (18.4 kg/year) is still low by the global standard (21.8 kg/year). In the last decade, data indicates a decline in sugar consumption in India in the wake of adopting a healthy lifestyle and limiting sugar in daily diet.
Chart -2: Per Capita per year Sugar Consumption in India (1992-2021)
Diabetes & Sugar: Facts & Myths
In India, diabetes is often termed as “Sugar” in the general population. Thus, creating a popular misconception against sugar that "If you eat too much sugar, you will become diabetic." While science explains it in a totally different. A person with type 1 diabetes got the condition because their immune system damaged insulin-producing beta cells. Type-1 diabetes is a hereditary disease and is more prevalent in children and adolescents. Which clearly indicates that there is no direct link between type-1 diabetes and sugar consumption.
The most common NCD, type-2 diabetes is caused mostly by obesity, smoking, physical inactivity, alcohol intake, and heredity. Singla et al. (2019) investigated these aspects in depth. As per the study, obesity and overweight can lead to serious medical problems such as diabetes and heart failure. Tobacco use is one of the modifiable risk factors for various chronic illnesses, including cardiovascular disease, asthma, and diabetes. Diabetes and diabetes-related comorbidities are indisputably and independently linked to physical inactivity. People with family ancestry have a higher risk of sickness than patients without family ancestry.
Indian Council of Medical Research (ICMR) conducted a study “The ICMR INDIAB Study – A Compendium of Type 2 Diabetes in India: Lessons Learnt for the Nation” and published in 2017. The prevalence of diabetes is more in the urban areas as compared to rural areas in the country. The incidence of diabetes is higher in the metro cities and lower in the smaller cities and still lower in the villages.
The studies clearly say that consumption of ‘too much sugar’ is linked to diabetes. There has been extensive research focused on soda or other caloric beverages and their role in health outcomes. While these studies provide data on the role those caloric beverages may have in health, these beverages are not a proxy for all the ways that sugar is consumed in the diet, and these studies should not be extrapolated to represent the role of sugar in health.
Available data also indicate that sugar consumption in countries like the U.S., Central and Latin America, and European countries is much higher than the consumption in India. According to a study conducted by the ICMR-National Institute of Nutrition (NIN) in 2015-16 on sugar consumption, the average daily consumption of added sugar in major cities was 19.50 grams, which was significantly lower than the recommended limit (30 grams/day).
Above sugar consumption data chart- 2 clearly indicates that since 2008, sugar consumption in India has been stagnant and reducing. On the other hand, diabetes in those years has increased significantly. Thus, there is a need for an India specific research study to determine the major causes of diabetes.
Research has found a strong link between air pollution and type-2 diabetes. G. O'Donovan & C. Cadena-Gsitan (2018) have identified air pollution as one of the most unknown variables contributing to the worldwide growth in type 2 diabetes incidence. According to research, nanoparticle exposure can also induce type 2 diabetes mellitus. In this context, a survey of 1.7 million US veterans who were followed for 8.5 years provided a rigorous examination of the association between pollution levels and the chance of getting diabetes.
Diabetes and its consequences are an increasing concern in India, according to the studies referred to above. Diabetes is a complex lifestyle disease. And it is clear from the above discussion that sugar consumption is not the cause of increasing diabetes cases in India. While moderating sugar consumption is advised by several health experts, there is a need to invest in health research pertaining to the subject. While sugar consumption has remained static for the past decade or so; in fact it has decreased after the pandemic, on the other hand, there is a fast increase in diabetes patients. This clearly shows that there is no linkage between diabetes and sugar consumption. Rather to combat diabetes, it is critical to raise general knowledge and build a stable environment in which an active healthy lifestyle and dietary habits with a clean environment play a major role. No single ingredient will be responsible for Diabetes or any other NCDs.
Czapp (2021, October) Where next for Indian sugar consumption? ChiniMandi.com. https://www.chinimandi.com/where-next-for-indian-sugar-consumption, accessed on 28-04-2022.
IDF (2021) IDF Diabetes Atlas 10th Edition, International Diabetes Federation (IDF), Brussel, Belgium. www.diabetesatlas.org
Lal, B.S. (2016) Diabetes: Causes, Symptoms and Treatment, Public Health Environment and Social Issues in India. Pp. - 55-67. https://www.researchgate.net/publication/311562631, accessed on 17-04-2022.
NIN (2011) Dietary Guidelines for Indians - A Manual, National Institute of Nutrition (NIN), ICMR, Hyderabad, India.
O’Donovan, G. and C. Cadena-Gsitan (2018) Air pollution and diabetes: it’s time to get active, The Lancet Planetary Health, 2(7). DOI:https://doi.org/10.1016/S2542-5196(18)30148-7
Singla, S., Kesheri, M., Kanchan, S. and S. Aswath (2019) Current Status and Data Analysis of Diabetes in India, International Journal of Innovative Technology and Exploring Engineering (IJITEE), 8(9), Pp. - 1920-1934.
Zimlich, R. (2021) What to Know About Diabetes Prevalence in India, Healthline Newsletter. https://www.healthline.com/health/diabetes/diabetes-in-india, accessed on 17-04-2022.