|Year : 2022 | Volume
| Issue : 3 | Page : 227-234
Prevalence of diabetes in Odisha, India: A systematic review and meta analysis
Sanjeev Supakar1, Sachidananda Nayak2, Lipika Behera3, Jaya Kshatri4, Purna Chandra Pradhan1
1 Department of Community Medicine, SLN Medical College, Koraput, India
2 Department of Medicine, SLN Medical College, Koraput, India
3 Department of Biochemistry, MKCG Medical College, Bhubaneswar, Odisha, India
4 Scientist- C, Regional Medical Research Centre, Bhubaneswar, Odisha, India
|Date of Submission||13-May-2022|
|Date of Decision||19-Jun-2022|
|Date of Acceptance||08-Jul-2022|
|Date of Web Publication||26-Sep-2022|
Dr. Purna Chandra Pradhan
Department of Community Medicine, SLN Medical College, Koraput, Odisha
Source of Support: None, Conflict of Interest: None
Objective: The objective of this review was to summarize and compare the estimates of diabetes among adults in community and hospital-based settings in Odisha, India. Introduction: Diabetes Mellitus (DM) is a major non-communicable disease as well as a risk factor. In a vast and diverse country such as India, where health is a state subject, regional synthesized and up to date estimates of DM burden is necessary for informed policy making. No such estimates are currently available for the state of Odisha. Materials and Methods: Peer‑reviewed published original research articles related to prevalence DM in the state of Odisha published between 2011 and 2022 were retrieved from 4 medical databases and analysed. Study screening, selection, data extraction and critical appraisal was done by 2 independent review authors. Data synthesis and assessment of certainty of the evidence was done in meta-analysis of the results. Results: A total of 15 studies, that included 17339 participants, with overall good methodological quality were included in the review. The overall prevalence of DM among adults in the state of Odisha based on Community based surveys was 6.8% (95% CI: 2.3–13.4%). The prevalence in older adults aged 60 years or above is higher at 22.2% (95% CI: 8.6–39.9%). The prevalence in studies that relied on self-reported methods of screening was 4.8% (95% CI: 1.7–9.3%) as compared to those that diagnosed participants based on standard criteria (12.1%; 95% CI: 8.1–16.7%). Conclusions: We found a high prevalence of DM in the state of Odisha, which was higher than previously available national and regional estimates. This prevalence was much lower in community-based studies and in self-reported surveys pointing towards significant under diagnosis of hypertension in the state of Odisha and highlighting a need for a robust community-based screening program among adults in the state.
Keywords: Adults, diabetes, high blood sugar, Odisha, prevalence
|How to cite this article:|
Supakar S, Nayak S, Behera L, Kshatri J, Pradhan PC. Prevalence of diabetes in Odisha, India: A systematic review and meta analysis. J Diabetol 2022;13:227-34
| Introduction|| |
Diabetes Mellitus (DM) or increased blood sugar is a serious endocrine disorder that is a major cause of kidney failure, blindness, heart attacks, stroke, and lower limb amputation worldwide whose prevalence has been rising more rapidly in low- and middle-income countries., DM is a significant public health challenge with over half a billion people in the world are estimated to have DM, leading to a loss of around 80 million years due to resulting disability., The prevalence of DM among Indian adults is significant with estimates of about 70 million Indians living with the disease at present.,, A large proportion of these are not aware of this condition, thereby accentuating the challenge.
In addition to this, there is significant regional variation among states in a country of the size and diversity of India. With available preventive and management strategies, early identification is a key component that has to be part of any such intervention programs. Health being a state subject, it is important to have robust estimates of the epidemiology of DM at the state level for assisting policy makers in evidence informed decision making.
Odisha is an eastern state of India which has generally been a laggard in terms of health indicators in the country, thereby requiring special attention at the national and state level. While there are multiple surveys carried out in various settings, there is a lack of synthesized evidence of comparable data from the state of Odisha, not just on DM burden but many other health challenges. Additionally, there remains a gap of under reporting and under diagnosis regarding DM leading to clear distinction of prevalence estimates of self-reported and newly physician diagnosed estimates of burden of DM as well as a difference in hospital based and community-based studies.
Synthesized evidence on the burden of this common disorder is necessary for evidence informed policy making towards preventive and curative programs in the state. We carried out a preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Evidence Synthesis and no current or underway systematic reviews on the topic and context were identified.
With this background this systematic review and meta-analysis was carried out to identify, summarize and compare the estimates the prevalence of DM among adults in community and hospital-based settings in the state of Odisha, India.
What is the prevalence of diabetes among adults in community and hospital based settings in Odisha, India?
| Materials and Methods|| |
This systematic review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of prevalence and incidence. This review was conducted in accordance with an a priori protocol with no deviations. The protocol was registered on institutional internal library KOHA server of ICMR and the Prospero registration was not done. We used the following selection criteria for the studies:
All studies that reported the condition of interest among adults aged 18 years or older and carried out in the state of Odisha, in part or exclusively, were included in our review.
We included studies that reported prevalence of DM, either as self-reported or measured by physician/health-worker, either as part of primary or secondary objectives of the study or even reported as a covariate.
As the focus of the review is to summarize the prevalence of DM, we have excluded studies that included reports of the same during pregnancy such as Gestational DM. We have also excluded studies for which full text was not available/accessible even after contacting authors or for which age classification of participants was not available/reported. For studies presenting duplicate data on DM from same sample, we have included only one of them. We have included studies reporting data from the last decade (i.e. Jan 1st 2011 to Jan 1st 2022) in order to be fairly contemporary in use of the data sources.
Types of studies
Descriptive or analytical observational studies including baseline reports of longitudinal cohort studies and analytical cross-sectional studies were considered for inclusion. Experimental study and qualitative designs were excluded. We also excluded conference abstracts or presentations, protocols, books/book chapters, preprints, reviews—narrative or systematic, letters/news articles/opinions/commentaries.
A comprehensive systematic search was performed on January 1, 2022, in the following electronic databases: Medline (via PubMed), Embase (via Ovid), PsycINFO (via Ovid), and CINAHL (via EBSCOHost). In order to keep the search strategy sensitive enough, the databases were searched for those studies that had a mention of the name of the state of Odisha and its variations as well as the name of all the districts and major cities in the state within their abstracts and titles. The detailed search strategy template used is provided in Appendix-1 for MEDLINE. The search strategy, including all identified keywords and index terms, was adapted for each included database and/or information source. The reference list of all included sources of evidence was screened for additional studies.
Following the search, all identified citations were collated and uploaded into Mendeley reference management software and duplicates were removed. Following a pilot test, titles and abstracts were screened by two reviewers independently for assessment against the inclusion criteria, using Rayyan platform. Potentially relevant studies were retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (JBI, Adelaide, Australia). The full text of included articles were assessed in detail against the inclusion criteria by two reviewers. Reasons for exclusion of papers at full text that do not meet the inclusion criteria were recorded and reported. The discrepancies were discussed and resolved by consensus. In case of a disagreement, a third author made the decision. The excluded studies and 15 included studies are listed in Appendices.
Assessment of methodological quality
Eligible studies were critically appraised by two independent reviewers for methodological quality using standardized critical appraisal instruments from JBI for observational studies. This includes assessment of appropriateness of sample frame, sampling, sample size, study setting, data analysis, methods for reliable measurement of DM, statistical analysis and response rates. Any disagreements that arose were resolved through discussion. All studies, regardless of the results of their methodological quality, underwent data extraction and synthesis (where possible).
Data was extracted from studies included in the review by two independent reviewers using a modified version of the standardized data extraction tool for prevalence and incidence available in JBI SUMARI. The data extracted included specific details about the condition, populations, study methods and proportions of interest on DM. The tool used is given in appendix.
Narrative synthesis of relevant findings from the included studies and the subgroups of interest was done. Studies, where possible, were pooled in statistical meta-analysis using JBI SUMARI. Effect sizes were expressed as a proportion with 95% confidence intervals around the summary estimate. Statistical analyses were performed using a random effects model using the double arscine transformation approach. Subgroup analyses was conducted where there was sufficient data to investigate. Heterogeneity was assessed statistically using the standard chi-squared and I squared tests. The JBI SUMARI software was used for all statistical analysis.
| Results|| |
We included a total of 15 articles in this review that were identified from screening of 2285 articles from database searches and 12 from citation searching. The details of exclusions and reasons are shown in the PRISMA flow chart below [Figure 1].
The methodological quality of the included studies as a whole was high based on the results of the critical appraisal. The studies reported moderate reliability in reporting methods used for screening and/or identification of DM. Adequate sample size is considered over 225 for community-based studies and 100 for special situations and hospital based studies. The details of the critical appraisal findings of the included studies are provided in [Table 1].
Characteristics of included studies
The study synthesised results from 17339 participants in total collected during the past decade. While 4 studies were exclusively among older adults, the remaining included all adults aged either 18 or 20 years and above. All studies included both males and females (No studies reported transgenders or other genders). Most of the studies were conducted in community-based settings (n = 8) followed by tertiary care hospitals and primary healthcare facilities. Only 6 studies relied on self-reported information on occurrence of DM while the rest were based on laboratory diagnosis by trained health care workers using the acceptable standard definition of either fasting blood sugar or glycosylated haemoglobin. The descriptive characteristics of the included studies are summarized in [Table 2] below.
The pooled prevalence of DM from community-based studies in Odisha among adults is 6.8% (95% CI: 2.3–13.4%) based on 4 studies. Similarly, the prevalence in older adults aged 60 years or above is higher at 22.2% (95% CI: 8.6–39.9%) as shown in [Figure 2] below. The prevalence of DM when studies relied on self-reported methods of screening was 4.8% (95% CI: 1.7–9.3%). In contrast, the prevalence was much higher in studies that diagnosed participants based on standard criteria at 12.1% (95% CI: 8.1–16.7%). The difference is highlighted in [Figure 3] below. Prevalence among patients attending out-patient departments is also higher at 11.5% (95% CI: 7.2–16.5%). DM is a major chronic condition present in over 36% of people with at least one long term chronic condition. All meta-analysis reported a high degree of heterogeneity in the study results.
|Figure 3: Prevalence of Diabetes using Self-reported vs. newly diagnosed methods in Odisha (2011–21)|
Click here to view
| Discussion|| |
This review summarises the evidence on burden of diabetes in the state of Orissa in the past decade. The review included 15 studies representing information from over 17000 adult participants from different settings.
The prevalence of DM among adults in the state of Odisha based on Community based surveys was around 7% in all adults and over 22% in older adults. While there has been an increasing trend in the burden of DM across India, the state of Odisha has generally reported a low prevalence of DM between 1–2% as summarized by Unnikrishnan et al.  Our review has found a significantly higher prevalence than previous reports from the region and is closer the global burden of disease estimates that predict a very steep rise in prevalence of DM in Odisha. Our findings corroborate national estimates for India by Jayawardena et.al. (12%) as well as the latest National family Health Survey (NFHS-5) report that found a significantly higher prevalence of elevated (>140 mg/dl) blood sugar or taking medicine to control blood sugar level to be 17% and 14% in men and women respectively in Odisha.,, This is even higher than the national estimates of prevalence of the same indicators at 15% and 13% in men and women respectively. Although elevated blood sugar can be considered only a proxy marker for DM diagnosis, this data indicates that the possible burden of DM is higher than previous estimates in Odisha.
The estimates of DM prevalence were higher in older adults at around 22%. This is reflecting the fact that age is a major risk factor of DM, as with many other chronic conditions. Our findings are however higher than the national estimates provided among older adults by the Longitudinal Aging Study of India (LASI) that reports a prevalence of around 15% in the same age group. Although we were not able to assess this, among elderly age 60 and above, the prevalence of DM has been reported to be three times higher in those living in urban areas (26%) than those living in rural areas (9%), most possibly linked to under diagnosis. This rural urban schism is a global phenomenon which is more marked in low income settings such as India and Odisha. Subgroup and sensitivity analyses did not explain the significant heterogeneity in the meta-analysis.
This under diagnosis of DM is also highlighted in our finding that out-patient based prevalence estimates from hospitals are almost twice greater than the community-based estimates in Odisha. Although the measurement of blood sugar by health workers at the community level is now well accepted and in practice, there still remains a large gap between estimates of ‘self-reported’ and laboratory confirmed diagnoses of DM. Studies that relied on self-reported measures of DM have reported almost 2.5 times lower prevalence than lab confirmed estimates. This shows a significant gap in the community level knowledge of one’s own DM status, which is a critical first step in remedial measures.
Our meta-analysis reported a high degree of heterogeneity, and this is a potential limitation of the study. The review has included studies with good methodological quality. However, variations in settings and other potential bias in individual studies may impact the findings. We were unable to estimate publication bias due to insufficient studies from similar categories.
| Conclusions|| |
Our study highlights the need for sub national estimates of prevalence of a common and important disorder, Diabetes, in a large and diverse nation such as India. We found a higher than previously reported prevalence of DM in the state of Odisha. This prevalence was much lower in community-based studies and in self-reported surveys pointing towards significant under diagnosis of DM in the state of Odisha.
Recommendations for practice or policy
The findings imply a need for a robust community-based screening program among adults in the state and linking with facilities for timely diagnosis and management of DM. The modalities of the community-based screening being followed under the National program for prevention and control of cardiovascular diseases, cancer and stroke may need improvements in the diagnostic pathways to better identify patients with DM in the community.
Recommendations for research
While there is adequate evidence on the burden of DM in the state, research may now be aimed at designing and testing specific interventions that may improve the under-diagnosis rates. Further, reliance on self-reported measures of DM is a potential source of bias and may be avoided in future community-based research studies.
Financial support and sponsorship
No external funding was received for this review.
Conflicts of interest
The authors declare no potential conflict of interest or any personal, financial, professional, or intellectual bias for any of the authors listed on the manuscript.
All authors contributed equally to the designing of the study, data extraction and manuscript preparation. Searches were run and meta-analysis was carried out by JSK and PP.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]