Translating Research To Policy: How Heart Problems Are Killing Poorer Indians And What To Do About It 

Yes, we all know that heart disease is the leading cause of death globally, and in India, for both men and women. But did you know that diabetes is the prime risk factor for heart disease? To put it differently, cardiovascular disease (CVD)—a class of heart disease where fat build-up narrows blood vessels—is the key cause of death in people with diabetes.

A new study now shows that the risk of CVD and death are disproportionately high among people with diabetes in low-income countries (LIC). While devastation from CVD among diabetics have come down in wealthier countries, their poorer neighbours are still caught in the vicious loop of inadequate healthcare and lack of access, especially among the poorest of the poor.

Science vs public policy

The study takes on new salience when framed at the intersection of science and public policy. In the last decade or so, public policy arena in healthcare has faced a stringent critique from the scientific establishment: that the insights of science often go unaddressed in policy deliberations; and that the search for solutions should not go by political ideologies but by a globally acceptable approach based on evidence-based scientific facts. The new research is one of the first to address this concern in the sub-field of diabetes and CVD.

Recent reports from high-income countries suggest that death from CVD among people with diabetes might be coming down. The possible reasons are: use of statins and anti-platelet agents, a decrease in smoking rates, better glucose and blood pressure (BP) control, apart from access to high-quality healthcare. There are, however, little data from middle-income and low-income countries, which bear the worst brunt. What, then, is the premise on which policy prescriptions should be formulated for disadvantaged countries and people?

“There is a more equitable distribution of healthcare in high-income countries, due to the availability of social security systems, insurance and other facilities,” points out Dr V. Mohan, a key collaborator of the study. “In contrast, in absence of universal health insurance systems and social support mechanisms in the LICs, including India, the highest death rates are seen among people in these countries and in the lowest tertile of personal wealth,” adds Dr Mohan, the Chairman of Dr. Mohan’s Diabetes Specialities Centre and President of Madras Diabetes Research Foundation.

A unique project

The study on cardiovascular mortality rates in diabetes in low-, middle-, and high-income countries. Published online in Diabetes Care on October 15, 2020, it encapsulates data from the well-known PURE (Prospective Urban Rural Epidemiology) Study co-ordinated by the Population Health Research Institute (PHRI), Hamilton Health Sciences and McMaster University, Canada. Conducted on 143,567 people, between age 35 and 70 years, from 21 countries across five continents and over a broad range of income groups. The results were collated with a mean follow-up of nine years.

It is a unique study: first, because, research on diabetes and CVD have so long been confined to the wealthier world; second, it is the study on poorer countries, where no data exist so far; third, very few studies exist that are globally applicable in scale, range, standard and method; fourth, it underscores the urgent need to improve access to quality diagnostic and therapeutic healthcare among disadvantaged people and countries; fifth, it reflects a model of translational research, communicating knowledge and strategies for prevention from scientists to policymakers.

As Dr Salim Yusuf, the Principal Investigator of the PURE Study and senior author of the research under review, points out: “The findings of this study are very significant as they provide new data from different regions of the world, belonging to different socio economic levels.” The study points to the issues that need to be addressed urgently by increased provision of quality care through a universal health care package and improved access to quality health care systems, he explains. Here is, a blue-print of evidence-based science that policymakers can use if death rates of CVD are to be decreased among people with diabetes, in the poorer parts of the world and strata of society.

A word for policymakers

Diabetes afflicts 460 million people globally, causes more than 5 million deaths. The economic burden associated with diabetes is substantial, both in terms of medical care as well as diminished productivity from illness and death. The direct costs of diabetes is primarily attributed illness and death from blood vessel complications, the most prominent being CVD. The relative risk for CVD morbidity and mortality in adults with diabetes ranges from 1 to 3 in men and from 2 to 5 in women, compared to those those without diabetes.

As both the prevalence and economic burden of diabetes continue to mount, a primary goal of treatment should be to improve the CVD risk of diabetic patients. However, a big challenge is the complex nature of the relationship linking diabetes to CVD risk factors: obesity, hypertension and abnormal amount of blood lipids are common in people with diabetes, particularly those with type 2 diabetes. Due to the numerous mechanisms linking diabetes to CVD, it is crucial to focus treatment to what will have the greatest clinical impact on improving CVD outcomes.

Health and wealth reinforce each other. And policymakers need to choose appropriate and effective investment in health systems to improve both health and wealth. As Dr R.M. Anjana, the first author of the study, explains, the difference in death rates from CVD in people with diabetes between nations on different rungs of the wealth index clearly relates to differences in access to healthcare systems. “We report on the low use of anti-diabetic, anti-hypertensive and lipid-lowering drugs among those with CVD and diabetes in LICs compared to MICs and HICs,” adds R.M. Anjana, the Managing Director of Dr.Mohan’s Diabetes Specialities Centre and Vice President of Madras Diabetes Research Foundation: “There is an urgent need to ensure access and adherence to medications. The mortality rates in LIC and MIC have to improve to the levels currently seen in HICs.”

The key takeaways

• The study shows that the overall CVD rates remain higher in those with diabetes across all regions. However, among those with diabetes, all-cause and cardiovascular mortality were strikingly higher in LICs, compared to MICs and HICs.
• The results underscore the urgent need to improve access to quality diagnostic and therapeutic healthcare in those with diabetes in LICs, especially the poorer strata of these countries, so that the excess mortality rates can be reduced.
• When the analysis was performed by categorising countries based on wealth index, mortality was higher in those with lowest wealth index compared to the upper two tertiles of wealth (within the LICs). Such a clear pattern with the wealth index was not observed in the MIC and HIC.
• The increased CV mortality in those with diabetes in LIC remained unchanged even after accounting for behavioural risk factors (such as, physical activity level and smoking) and treatments (those on blood pressure lowering drugs, cholesterol lowering drugs, glucose lowering agents and aspirin), whereas in MICs and HICs, there is some reduction of the risk, suggesting that treatment levels remain suboptimal in LIC.