Why India’s diabetes epidemic is a policy failure

India is sleepwalking toward a diabetes disaster. An estimated 101 million Indians are living with diabetes and an additional 136 million are pre-diabetic, said an Indian Council of Medical Research-India Diabetes study published in The Lancet Diabetes & Endocrinology in July 2023.

The International Diabetes Federation’s Diabetes Atlas, puts the figure even higher, at 89.8 million diagnosed adults, with projections suggesting that number will grow to a massive 156.7 million in 2050.

India is referred to as the diabetes capital of the world. But what makes the country’s crisis so uniquely devastating is how this is the product of a form of structural violence perpetuated by economic policy failures, the collapse of the food system and the chronic neglect of the well-being of working-class Indians.

The cruelty of this situation is compounded when accounting for the low wage rates in India. There has been a virtual stagnation of real wages since 2014, according to data from the Labour Bureau related to rural India, analysed by economists Jean Dreze and Arindam Das.

In the decade leading to that period, the increase in real wages was strong at 5% to 6% a year. But in the succeeding decade, the rate of increase has been close to zero.

Meanwhile, the India Employment Report 2024 of the International Labour Organisation noted that the average real monthly wages of regular workers fell from Rs 12,100 in 2012 to Rs 10,925 in 2022. An economy growing at 6% to 7% a year that fails to provide meaningful wage growth to its workers is unequal but also is structurally violent.

For those at the bottom of the income pyramid – and to some extent for the diminishing middle-class – putting nutritious food on the table is walking a financial tightrope. Vegetables, pulses, eggs, fruit and dairy products, which nutritionists say help prevent diabetes, are now luxuries.

What is affordable are refined carbohydrates: polished rice, white flour and sugar – the exact ingredients of a diabetogenic diet.

On top of that, there have been disturbing findings about the quality of food itself. A study published in November 2023 in Scientific Reports by researchers from the Indian Council of Agricultural Research, found that five decades of breeding programmes of the Green Revolution have systematically reduced the nutritional content of the staple grains of India.

Zinc concentration in rice has dropped by approximately 33% since the 1960s and iron by 27%. In wheat, zinc declined by 30% and iron by 19%. The study warns that if current trends continue, rice and wheat stand to lose up to 45% of their food value by 2040.

In other words, India’s population is eating less and also eating food that delivers less nourishment per mouthful.

The repercussions can be seen in hospital wards and clinics. The International Diabetes Federation estimates that Indians suffering from diabetes spent $109.5 (approximately Rs 10,000) on treatment in 2024, even as diabetes-caused deaths crossed 334,000 that year alone.

Over 50% of all the burden of disease today in India is attributed by experts to unhealthy diets. An estimated 56.4% of India’s total burden of disease is diet-related, as has been observed in the Indian Council of Medical Research-National Institute of Nutrition Dietary Guidelines for Indians, 2024.

These are the hallmarks of a health catastrophe.

Workers, whose real wages have been stagnant for a decade, cannot afford healthy diets, as prescribed by medical science. The only food they can afford is nutritionally impoverished, a legacy of agricultural policies that have favoured quantity over quality. Workplace stress, fuelled by long hours and job insecurity, and also the erosion of labour protections, increases the risk of metabolic stress.

The policy response to this crisis has been inadequate. India’s National Programme for Prevention and Control of Non-Communicable Diseases can only do so much given the under-resourced, fragmented public health infrastructure. There is no universal screening for diabetes, and nearly 57% of diabetics in India are undiagnosed, said the Indian Council of Medical Research-India Diabetes study.

The rise in type 2 diabetes among Indians is a clear indictment of policy failures, and hardly an urban lifestyle disease.

It is the result of an economic model that has failed to share prosperity, an agricultural system that has exchanged nutrition for tonnage and a food economy where inflation has exceeded wages year after year.

Anand Prakash is an assistant professor at SVKM Narsee Monjee Institute of Management Studies’ School of Economics in Bengaluru.