Introduction:
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose due to
insufficient insulin action. It has become a major public health challenge in India, which
currently has one of the highest burdens of diabetes globally
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. Recent estimates indicate that about 77 million adults in India had diabetes in 2019, and this is
projected to exceed 130 million by 2045
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. This rising prevalence is largely driven by lifestyle and demographic changes, including
increasing obesity, urbanization, and population aging. Diabetes is linked to numerous health
complications and comorbidities that substantially increase morbidity and mortality. It
predisposes individuals to cardiovascular diseases, kidney failure, neuropathy, retinopathy, and
other conditions, imposing a heavy burden on patients and the healthcare system
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. Given its scale and impact, diabetes in India represents a pressing public health priority,
warranting comprehensive epidemiological assessment and effective management strategies.
Prevalence of Diabetes in India: The prevalence of diabetes in India has increased markedly in
recent years. Current population-based data show that roughly 8–9% of Indian adults have
diabetes
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. In absolute numbers, this translates to approximately 101 million people with diabetes as of
2021
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. This figure has risen from an estimated 77 million in 2019, reflecting rapid growth of the
epidemic
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. Projections are alarming – by 2030, over 10% of Indians are expected to be diabetic, and by
2045 the count may reach 134 million
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. Notably, a majority of diabetes cases remain undiagnosed; studies estimate around 57% of
individuals with diabetes in India are unaware of their condition
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. Such undiagnosed cases contribute to the silent progression of the disease. Large national
surveys also highlight a huge pool of prediabetes – about 15% prevalence – portending further
increases in diabetes incidence
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. Epidemiological patterns show higher diabetes prevalence in urban areas and among older age
groups and those with obesity. For example, a recent national NCD survey reported an overall
adult diabetes prevalence of 9.3%, with much higher rates in urban populations and in obese
individuals
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. Age is a major risk factor; adults over 50 have significantly greater diabetes prevalence than
younger adults
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. These trends underscore that diabetes has reached epidemic proportions in India. The rising
trajectory, combined with a large undiagnosed fraction, indicates an urgent need for strengthened
screening and prevention efforts. Robust recent data from nationwide studies are helping to map
the distribution of diabetes across regions and demographic groups, which is essential for
targeting public health interventions
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Common Comorbidities Associated with Diabetes: Patients with type 2 diabetes in India often
present with multiple coexistent comorbid conditions. Hypertension is the most prevalent
comorbidity, frequently co-occurring with diabetes due to shared risk factors and
pathophysiology. In clinical cohorts of Indian diabetics, hypertension and dyslipidemia are
reported as the two most common coexisting conditions
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. For instance, a large real-world study of young adults (18–45 years) with type 2 diabetes in
India found that 53.1% of patients had at least one other major comorbidity (hypertension and/or
dyslipidemia) alongside diabetes
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. Obesity is another prevalent associated condition; excess adiposity both predisposes individuals
to diabetes and complicates its management. Data indicate a high prevalence of overweight and
obesity among Indian diabetics – in the young adult cohort mentioned, nearly 70% had an
elevated body mass index (overweight or obese)
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. This reflects the strong link between the ongoing obesity epidemic and type 2 diabetes in India.
Cardiovascular comorbidities are also of great concern. People with diabetes have a markedly
elevated risk of cardiovascular disease (CVD), including coronary artery disease and stroke.
Studies in India have shown that a substantial proportion of diabetics have existing CVD. One
analysis reported coronary artery disease in about 21% of diabetic individuals, a prevalence
more than double that in people with normal glucose levels
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. Diabetic patients often have clustering of CVD risk factors such as hypertension, dyslipidemia,
and central obesity – a constellation sometimes termed “metabolic syndrome” when occurring
together. These comorbidities synergistically worsen outcomes. The presence of multiple
comorbid conditions in diabetic patients complicates management and contributes to higher rates
of complications and mortality. Overall, hypertension, dyslipidemia, and obesity are ubiquitous
companions of diabetes in India, and their prevalence underscores the need for integrated
management of all cardiometabolic risk factors in diabetic care
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. Effective control of blood pressure and lipids in diabetic patients is vital to reduce the risk of
cardiovascular events.
Complications of Diabetes: Chronic diabetes leads to a spectrum of microvascular and
macrovascular complications that pose serious health consequences. In India, the burden of
diabetic complications is substantial, even in relatively young patient populations
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. Among microvascular complications, diabetic retinopathy (DR) is a leading cause of vision
loss. The prevalence of DR increases with diabetes duration and poor control. Multi-center
hospital-based studies in India have found DR in roughly one-third of diabetic patients on
average – one report noted a 32% prevalence of diabetic retinopathy among patients with type 2
diabetes
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. This rate is quite high, though hospital samples may overestimate the general population
prevalence. Nevertheless, retinopathy is a significant problem; many patients are unaware of
retinal damage until vision impairment occurs
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. Diabetic nephropathy, manifesting as chronic kidney disease, is another major microvascular
complication. Indian cohorts show wide-ranging nephropathy prevalence, but substantial
proportions of diabetics have evidence of kidney involvement. A large study reported diabetic
nephropathy in about 26–27% of patients with type 2 diabetes
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. Even in community samples, around 15–20% of diabetics have microalbuminuria or reduced
renal function indicating nephropathy
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. Diabetic neuropathy is often the most prevalent microvascular complication. Nerve damage
(typically peripheral neuropathy) can be seen in roughly one-quarter to one-half of patients,
depending on assessment methods. For example, one national study observed neuropathy in
26.1% of diabetics
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, while a rural clinic study using clinical exams found peripheral neuropathy in 44.9% of patients
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. Neuropathy contributes to foot complications; diabetic foot ulcer and peripheral vascular
disease often occur in those with neuropathy and poor circulation. Indeed, peripheral vascular
disease has a reported prevalence around 15% in Indian diabetics
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and, coupled with neuropathy, leads to a significant risk of foot ulcers and amputations. On the
macrovascular front, diabetes markedly elevates the risk of cardiovascular complications.
Heart disease and stroke occur earlier and more frequently in those with diabetes. Indian data
confirm that diabetics have a high prevalence of coronary artery disease (as noted, ~20% in some
studies)
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. Cardiovascular disease is the leading cause of death in diabetic patients
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, accounting for a majority of diabetes-related fatalities. Furthermore, diabetics who suffer
cardiovascular events tend to have worse outcomes than non-diabetics
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. In summary, the long-term complications of diabetes – retinopathy, nephropathy, neuropathy
(microvascular), and ischemic heart disease, stroke, peripheral arterial disease (macrovascular) –
are highly prevalent in India. These complications greatly increase morbidity, causing blindness,
kidney failure, nerve damage, limb amputations, and cardiovascular deaths. Poor glycemic
control, along with coexisting hypertension and dyslipidemia, accelerates the development of
complications
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. Strengthening complication screening (e.g., regular eye and foot exams, kidney function tests)
is imperative so that these conditions can be detected early and managed to prevent progression
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Pharmacoepidemiological Insights: Effective management of diabetes in India faces
challenges related to medication adherence, treatment availability, and healthcare practices.
Medication adherence among diabetic patients is often suboptimal, which undermines glycemic
control. Studies consistently show that a large proportion of patients do not take their diabetes
medications as prescribed. A hospital-based survey in North India found that 56% of patients
had poor adherence to anti-diabetic medications, with only 44% being adequately adherent
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. Similarly, a tertiary care study in Uttarakhand reported that over half of patients were non-
adherent to their treatment regimens
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. The reasons for non-adherence are multifactorial – they include forgetfulness, lack of
awareness, side effects, cost or access issues, and the asymptomatic nature of early diabetes. The
consequences, however, are clear: poor adherence contributes to inadequate glycemic control
and higher complication risks. Nationwide data reveal a troubling care cascade for diabetes
management in India
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. According to the recent National NCD Monitoring Survey, among all individuals with diabetes,
only 45.8% were aware of their diagnosis, about 36.1% were on treatment, and a mere 15.7%
had their blood sugar under control
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. This means less than one in six people with diabetes achieve recommended glycemic targets,
reflecting gaps at every stage – from diagnosis to sustained control. Improving this situation
requires strengthening health systems for early detection, ensuring affordable access to
medications, and supporting long-term adherence to therapy
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. On a positive note, India has been ramping up efforts to address these gaps. The government’s
National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) has
expanded diabetes screening and care at the primary healthcare level
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. Under this initiative, routine screening of all individuals over 30 years for diabetes and
hypertension is being implemented at community health centers and Health and Wellness
Centres
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. Detected cases are linked to care, and essential diabetes medicines (like metformin,
sulfonylureas, insulin) and supplies (glucometers) are provided free or at subsidized cost through
public facilities
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. Such measures aim to improve treatment coverage and reduce financial barriers to adherence.
Pharmacoepidemiological data also indicate shifts in diabetes management strategies. There is
growing use of newer medication classes (e.g. SGLT-2 inhibitors, GLP-1 receptor agonists) in
India’s diabetes practice, in line with global trends, especially for patients with cardiovascular or
renal comorbidities
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. Nonetheless, metformin remains the first-line therapy for type 2 diabetes, and insulin is
essential for all type 1 and many type 2 diabetics. The key challenge in India is not the lack of
effective medications, but ensuring patients reliably take them and follow recommended lifestyle
modifications. Culturally appropriate patient education and counseling are therefore crucial
components of diabetes management. Improving medication adherence – through interventions
like patient reminders, support groups, and simplified regimens – could substantially improve
glycemic outcomes and quality of life for Indian patients
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. Overall, the pharmacoepidemiological picture suggests that while evidence-based treatment
options are available, much work is needed to translate this into consistent, long-term disease
control in the community.
Research Gaps and Future Directions: Despite the progress in understanding diabetes in India,
important gaps remain in the literature and surveillance of this disease. Historically, there was a
paucity of high-quality population data on diabetes prevalence, especially in rural areas and
certain regions, which impeded effective policy-making
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. In the past 4–5 years, large-scale surveys like ICMR–INDIAB and NNMS have begun to fill
these gaps by providing nationally representative data on diabetes prevalence, risk factors, and
care indicators. Still, continued surveillance is needed to monitor trends over time and evaluate
interventions. There is also a need for more research on diabetes in specific sub-populations,
such as among different ethnic groups, socio-economic strata, adolescents, and young adults.
Early-onset type 2 diabetes (often observed in Indians in their 30s or 40s) is an area that warrants
further study, as these patients have longer exposure to hyperglycemia and potentially worse
outcomes if not managed aggressively. Another research gap lies in understanding and
improving health system responses to diabetes. While we know awareness and control rates are
low, more implementation research is needed on effective ways to close these gaps – for
example, evaluating community-based screening programs, digital health interventions for
patient follow-up, or training modules to improve provider management of diabetes at the
primary care level. The impact of social determinants on diabetes care in India (such as
education, income, urban vs. rural residence) also merits deeper exploration to inform targeted
interventions. Moreover, data on diabetes-related comorbidities and complications in India
could be strengthened. Many available studies on complications are cross-sectional; longitudinal
cohort studies are relatively scarce. Future research could focus on prospective tracking of
diabetics to better ascertain incidence of complications and identify predictive risk factors in the
Indian context. This would help in developing risk scores or early warning systems for
complications like nephropathy or retinopathy in Indian patients. Importantly, there is a
recognized need for developing and testing preventive strategies to curb the diabetes epidemic.
Given the enormous number of individuals with prediabetes (over 136 million in 2021)
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, research should prioritize interventions that can halt progression to diabetes. Culturally tailored
lifestyle modification programs, community exercise or diet initiatives, and even
pharmacological prevention (e.g. metformin in high-risk individuals) could be trialed in the
Indian setting. As one expert commentary noted, discovering novel and more effective
interventions for the prediabetic stage and implementing them at scale will be key to a diabetes-
free future
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. Lastly, multidisciplinary research is needed to address health system barriers identified in the
literature – such as lack of a multisectoral approach, limited awareness, and poor access to care
in certain areas
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. Overcoming these barriers may require studies in health policy and systems, to design better
delivery models (for instance, integrating diabetes care with primary health services or
leveraging technology for remote monitoring). In summary, future research in India should focus
on longitudinal monitoring, prevention trials, and health system interventions to manage and
prevent diabetes more effectively. Bridging these gaps will inform evidence-based policies and
programs.
Conclusion: Diabetes in India is a growing public health crisis with significant implications for
individuals and healthcare systems. The literature from the past four years highlights a high and
rising prevalence of diabetes across the country, accompanied by common comorbidities like
hypertension, dyslipidemia, and obesity which further elevate health risks. If not adequately
controlled, diabetes leads to serious microvascular and macrovascular complications – already a
substantial burden in India as evidenced by high rates of retinopathy, kidney disease, neuropathy,
and cardiovascular events among diabetic patients. These findings underscore the need for urgent
and concerted action. On the positive side, greater attention is being directed to diabetes at
national and state levels. Screening programs and chronic disease clinics are being strengthened
as part of India’s primary healthcare upgrades
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, and there is increasing availability of essential medicines and insulin free of charge in
government facilities
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. However, the success of these initiatives depends on improving patient awareness, engagement,
and adherence to therapy. The literature indicates that a majority of Indians with diabetes are not
achieving adequate glycemic control
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, pointing to gaps in continuous care and self-management support. Going forward, an integrated
approach is required – one that involves public health prevention (to reduce new cases through
lifestyle changes), robust healthcare delivery (to actively manage existing cases and
comorbidities), and patient-centric education (to empower individuals in managing their
condition). Policymakers should consider the evidence of rising diabetes and its complications as
a call to strengthen health systems. This may include adopting multisectoral policies that
promote healthier diets and physical activity in the population, as well as expanding access to
screening and early treatment. From a clinical perspective, physicians are urged to routinely
screen diabetic patients for hypertension, cholesterol disorders, and early signs of complications,
managing these proactively to prevent end-organ damage. In conclusion, the recent evidence
paints a clear picture: diabetes has become endemic in India, but with early diagnosis,
comprehensive management of comorbidities, and sustained patient adherence to treatment, its
worst outcomes can be mitigated. Strengthening these aspects – alongside ongoing research to
fill knowledge gaps – will be crucial for India to curb the diabetes epidemic and reduce the
burden of its complications on millions of people. Effective health promotion and primary
prevention, implemented at both individual and population levels, are needed now to alter the
trajectory of diabetes and improve public health outcomes
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