India stands at the crossroads of two epidemics, diabetes and tuberculosis (TB), the former fuelling vulnerabilities to the latter. The recently released National Family Health Survey-6 (NHFS-6) shows the share of Indian adults with high blood sugar has risen sharply, from about 14.5% to over 19% today, a nearly one-third increase since the last national survey. Once considered a disease of the affluent, diabetes now affects an astonishing one in nine Indian adults. Our country carries the world's second-highest burden of diabetes, with nearly 11% of the population living with the condition in several areas, while another 15% nearly teeter on the edge as pre-diabetics1. Alarmingly, 43% of Indians with diabetes remain undiagnosed.
Ironically, diabetes is a critical co-morbidity for TB, significantly increasing vulnerability, severity, risk of relapse, and even the emergence of drug resistance. People living with diabetes are up to three times more likely to develop TB. Conversely, TB can destabilise blood sugar control, making diabetes harder to manage. When these two diseases coexist, they invariably compound each other’s impact, creating a vicious cycle of poor health and adverse outcomes. The financial toll is also significant. A study from the Bhavnagar region in western India found that TB patients with diabetes faced nearly double the treatment-related costs compared to those with TB alone.
Research at AIIMS, New Delhi has clearly shown higher number of asymptomatic subclinical TB patients amongst known diabetics. Due to the absence of symptoms, patients don’t seek care in health facilities, TB disease may progress in the meantime and present with symptoms at a late stage, when control/treatment of the disease becomes difficult. The National Framework for Joint TB–Diabetes Collaborative Activities, released in 2017, established the policy foundation for coordinated detection and management of TB-diabetes comorbidity. Since then, the National Programme has mandated diabetes screening for all notified TB patients – in 2023, of the 2.4 million TB patients notified, 92% were screened for diabetes, and nearly 180,000 TB patients were diagnosed with the condition.
In December 2024, the programme launched the TB-Mukt Bharat Abhiyaan. This targeted campaign focused on screening vulnerable groups for TB with chest X-rays, including people living with diabetes, irrespective of whether they exhibited symptoms. This forward-thinking approach acknowledges that TB elimination necessitates addressing the co-morbidities that fuel its spread. Additionally, the programme’s ‘Differentiated TB Care’ approach mandates tailored treatment protocols that recognise diabetes as a major risk factor for poor outcomes and TB mortality.
{{/usCountry}}In December 2024, the programme launched the TB-Mukt Bharat Abhiyaan. This targeted campaign focused on screening vulnerable groups for TB with chest X-rays, including people living with diabetes, irrespective of whether they exhibited symptoms. This forward-thinking approach acknowledges that TB elimination necessitates addressing the co-morbidities that fuel its spread. Additionally, the programme’s ‘Differentiated TB Care’ approach mandates tailored treatment protocols that recognise diabetes as a major risk factor for poor outcomes and TB mortality.
{{/usCountry}}Additionally, the government has expanded vital nutrition support programmes and intensified public awareness campaigns emphasising the critical need for good nutrition, healthy and active lifestyles--strategies that are vital for preventing both diabetes and TB. We have witnessed how diabetes has transformed from a rare diagnosis to a household concern. Our changing diets, sedentary lifestyles, and urban stresses have made diabetes a pervasive lifestyle disease. Given its widespread prevalence in India, it is deeply concerning how many individuals are rendered vulnerable to TB.
In 2024 alone, an alarming 3.22 lakh TB cases of the ~26 lakh cases reported in India were attributable to diabetes. While recent government initiatives are commendable, we must decisively move forward. Most critically, TB screening, using a chest X-ray, for every person who is testing for diabetes should be mandated as a routine practice in every public and private clinic, hospital, and community health centre. And in case their X-rays suggest lesions in their lungs, patients must immediately be referred to labs or testing centres where they can receive a confirmatory molecular test. And perhaps most overlooked: TB Preventive Therapy, now standard for household contacts and people with HIV, is worth exploring in people with diabetes, given their three-fold higher risk of developing active disease.
This is not just good medicine; it is an essential public health measure to break the chain of transmission of TB. In an ideal scenario, a patient visiting a diabetes clinic is automatically screened for TB, and vice versa. This is entirely within our reach and is vital for comprehensive patient care. To enable such ambitions, we must harness the power of technology and innovation. Digital health tools can help us follow patients, ensure they adhere to treatment, and reduce cases lost to follow-up. Mobile health units can bring bi-directional screening and diagnostic services to the doorsteps of the most vulnerable, ensuring no one is left behind.
The NFHS-6 has shown us exactly where the next front of this battle lies. It is time we met it head on. India is on a steady path to address its challenges with novel strategies and innovations. With the government’s dedication to equitable public health, and the resilience of our people, we can turn the tide against the twin epidemics of diabetes and TB. Integrated screening and care should become the standard clinical practice. By investing in comprehensive approaches that work for people, we not only improve their lives but can also accelerate our country’s journey towards a TB-free future, while simultaneously addressing its growing diabetes epidemic.
(The views expressed are personal)
This article is authored by Dr Urvashi B Singh, professor-In charge, Tuberculosis Division, Department of Microbiology, AIIMS, New Delhi.