Diabetes & CVD

1. Diabetes & CVD Lifesciences, Healthcare & MedTech Consulting Practice October 2014 Mumbai I New Delhi I Chennai I Bangalore CONFIDENTIAL & PROPRIETARY Any use of this material without specific permission of UNIVERSAL CONSULTING INDIA PVT LTD is strictly prohibited

2. Non-communicable diseases account for c. 60% of deaths in India Percentage of Mortality (% of total deaths, all ages, both sexes) %  Overall non-communicable diseases are the leading causes of death in the country, constituting 60% of all deaths  Urban areas have a lower number of deaths from communicable, maternal, perinatal and nutritional conditions but a higher proportion from non-communicable diseases compared to rural areas 100% Injuries 80% Communicable, maternal, perinatal and nutritional conditions 60% 40% Non-communicable diseases 20%  Treatment cost is almost double for NCDs as compared to other conditions and illnesses 0%  Burden of NCDs and resultants mortality is expected to increase unless significant efforts are made to prevent and control NCDs and their risk factors Percentage of Mortality – NCDs (% of total deaths, all ages, both sexes) % Regional studies have reported that even in rural India the leading cause of death is NCDs followed by injuries and external cause of deaths  100% Diabetes Cancer 80% Other NCDs 60% Chronic respiratory disease ( namely COPD, asthma, other respiratory diseases)  NCDs account for more than two fifth of the DALYs and among this group cardiovascular diseases, Diabetes, cancers together account for over 40% of the NCD related DALYs 40% 20% CVD 0%  Projection estimates from the WHO have shown that by the year 2030, CVDs will emerge as the main cause of death (36%) in India Source: WHO, Planning Commission Report | | 2 Copyright © Universal Consulting India Pvt Ltd

3. The four leading chronic diseases in India, as measured by their prevalence, are cardiovascular diseases, Diabetes, COPD and cancer Cancer Prevalence Mn Diabetes Prevalence Mn CVD Prevalence Mn CAGR% (2010-20) CAGR% (2013-20) CAGR% (2013-20) CAGR% (2010-16) Mn COPD Prevalence 76.6 25% 2.38% 5.35% 4.4% 10 9.3 80 90 25 83.0 22.0 80 65.0 20 70 60 17.0 60 49.3 15 50 5 40 40 10 30 20 20 5 1.0 10 0 0 0 0 2010 2020 2013 2020 2010 2020 2010 2016  C. 700k people die of cancer annually  Increasing risk factors such as exposure to carcinogens, unhealthy habits such as smoking, tobacco chewing etc.  C. 70-80% patients with cancer are diagnosed late  Underserved market with 40% of cancer centers not adequately equipped  Increasing risk factors such as exposure to high levels of air pollution, industrial chemicals, smoking etc.  Underdiagnosed due to gradual progression and late manifestation of disease  Respiratory disorders such as asthma, sleep apnea, chronic bronchitis are increasing  India has c. 17% of the world’s Diabetes burden  There were 1.2 Mn deaths due to Diabetes in 2011  Increasing risk factors such as dietary habits, sedentary lifestyle etc..  C. 50% patients with Diabetes go undiagnosed  Regular monitoring of glucose levels is critical for proper therapy outcomes  India has c. 60% of the world’s CVD burden  C. 25% of deaths between 25- 69 years occur because of heart diseases  Increasing risk factors such as dietary habits, , stress etc..  Regular monitoring of glucose levels is critical for proper therapy outcomes | | 3 Copyright © Universal Consulting India Pvt Ltd

4. Furthermore, women’s health is an area of growing concern due to the high incidence of cervical and breast cancer and rising infertility amongst the urban population Infertile population Prevalence of HPV Mn Incidence of cervical cancer Incidence of breast cancer Mn 000’s 000’s 29 115 150 120 50 30 134 43 100 40 100 80 20 30 60 20 50 40 10 10 20 0 0 0 0 2011 2011 2011 2011  Majority, c. 82.5% of invasive cervical cancers are due to HPV types 16 and 18  Low diagnosis rates due to lack of education and awareness  Pressing need for screening initiatives  HPV vaccination not yet made compulsory by the govt.  C. 367 Mn women (>15 years) at risk of developing cervical cancer  Third largest cause of cancer mortality with c. 76k deaths annually  c. 2.6% of the at risk population gets screened every three years  Lack of a national screening and immunization program  Low public awareness  Incidence expected to increase to 250k annually  Accounts for c. 16% of cancer deaths  Risk factors include ageing, lack of childbearing or breast feeding, higher levels, late age of menopause, smoking, alcohol etc.  Late diagnosis a key concern of breast cancer  Infertile population constitutes people between 20-45 years  Causes include hormonal imbalances, reproductive system disorders due to stress and chaotic lifestyles, increasing age of marriage & motherhood etc  Hormonal and reproductive disorders lead to issues & difficulties within pregnancy hormone | | 4 Copyright © Universal Consulting India Pvt Ltd

5. There is an increasing onset of various ophthalmic disorders in India Prevalence of AMD Prevalence of diabetic retinopathy Mn Prevalence of Glaucoma Cataract surgeries in India Mn Mn Mn 24 8 25 8 15 7 6 20 10.4 6 6 10 15 4 4 10 5 2 2 5 0 0 0 0 2004 2011 2012 2011  Dry AMD – Prevalence 7.2 Mn  Wet AMD – Prevalence 3.2 Mn  Growth in patient pool due to increasing ageing population  Poor patient awareness results in poor diagnosis rates c. 10- 20%  Prevalence expected to grow substantially along with increasing incidence of Diabetes  Of Diabetes patients that live for more than 5-10 years, 20- 30% are likely to develop diabetic retinopathy  Low diagnosis rates c. 20-30% due to lack of awareness and slow disease progression  Low diagnosis rates, c. 30-40% due to slow onset of disease which does not affect vision directly  Lack of awareness  Pressing requirement for screening initiatives  Risk factors include family history, medical problems such as Diabetes, injury to the eye, medications such as steroids, long term exposure to sunlight  Majority of rural population diagnosed via govt. sponsored screening camps c. 28% of the Indian population requires vision correction and overall c. 76% of people with eye disorders go untreated | | 5 Copyright © Universal Consulting India Pvt Ltd

6. India is the world’s Diabetes capital with a prevalence of c. 65 Mn people Diabetes disease burden in India Patient Population Millions  India is the world’s Diabetes capital with a prevalence of c. 65 Mn people. c. 30 Mn people in the pre-diabetes group  By 2030, the prevalence of diabetic patients in India are expected to cross the 100 Mn mark  An inactive life, which involves lack of exercise and poor calorie management, is one of the biggest contributors to the dreaded disease of Diabetes  There is relatively low awareness about Diabetes in India and this is drawing the attention of global players  An increase in government screening initiatives e.g. the National Programmed for the prevention and control of cancer, Diabetes, CVDs and stroke, will lead to improved diagnosis rates, especially among the semi urban & rural population  The Indian Council of Medical Research estimates that the prevalence of Diabetes is 3.8% in rural India and 11.8% in urban India  The attributable risk for acute myocardial infarction is 9% for people with Diabetes CAGR% (2013-20) Mn 2.38% 76.6 80 65.0 60 40 20 0 2013 2020 | | 6 Copyright © Universal Consulting India Pvt Ltd

7. CVD is the most common concomitant conditions associated with Diabetes Incidence of concomitant conditions (% prevalence) 42 CVD problems • 2-4x as likely to develop cardiovascular diseases than people without Diabetes Cardiovascular disease / stroke 28 Eye problems • Nerve damage common and results in foot and lower leg amputations. • 70% of all lower limb amputations are related to Diabetes. Diabetic neuropathy 7 Nerves / pain • Kidney damage often due to abnormal blood glucose and pressure levels. Can lead to total kidney failure and the need for dialysis or a kidney transplant. Diabetic nephropathy 5 Lipids Respiratory problems 4 Diabetic retinopathy • Incidence of blindness is 25x higher in people with Diabetes 3 Kidney problems • Foot problems , ulcers and amputations due to nerve and blood vessel damage • 25x greater risk of amputations Peripheral vascular disease 36 None Source: IDF Diabetes Atlas 2011 | | 7 Copyright © Universal Consulting India Pvt Ltd

8. India has c. 60% of the world’s cardiovascular disease burden and c. 25% of deaths between 25- 69 years occur because of heart diseases Cardiovascular disease burden in India Patient Population Millions India faces a rapidly rising threat of cardiovascular diseases which is becoming one of the leading causes of death - About 25% of deaths (aged 25-69 years) and 19% of deaths (all age groups) occur due to CVS conditions - In urban areas 32.8% deaths occur due to heart ailments whereas in rural areas the value is 22.9%  CAGR % (2013-20E) 5.35% 90 80 70 60 50 83.0 40 30 WHO estimates that India is likely to lose USD 237 Bn by 2015 in national income from premature deaths due to heart disease, stroke and Diabetes  49.3 20 10 0 National programmes to combat chronic diseases have been initiated by the Govt. - In 2007 the Union Budget allocated USD 4 Mn to a National Program for the Prevention and Control of Diabetes, CVS diseases and stroke, along with USD 9 Mn to a Tobacco Control Program - National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke was introduced in July 2010  2010 2020 Prevalence of hypertension in India Patient population Millions CAGR% (2005-30) 250 2.41% 200 150 214 100 118 50 0 2000 2025E Source: WHO, Public Health Foundation (India) | | 8 Copyright © Universal Consulting India Pvt Ltd

9. A rise in lifestyle diseases such as Diabetes and smoking is driving the disease burden of cardiovascular ailments higher across the country  India is now witnessing adverse dietary and lifestyle changes along with increased sedentary activity, which collectively contribute to the expanding heart disease  There has been an alarming increase in obesity among children in the upper class population due to aggressive marketing by the food industry targeting children which leads to increased consumption of aerated drinks and unhealthy food Increase in chronic heart conditions is linked to increase in unhealthy Lifestyle in India situation in India High tobacco consumption in India is associated with increased incidence of heart disease  In 2009, there were more than 250 Mn tobacco users in India and every year about 800,000 – 900,000 people die due to tobacco use, with the youth beginning to get  Almost 48% of the acute myocardial infarctions, 22% of strokes and 14.8% of diseases have been attributed to tobacco affected ischemic heart Increase in prevalence of hypertension in India is resulting in increased heart disease burden  Prevalence of hypertension in urban India is about 20-40% and is 12-17% in rural India  The attributable risk in India for ischemic heart disease due to hypertension is 16%, for peripheral vascular disease is 21% and for acute myocardial infarction is 24% Source: WHO, Public Health Foundation (India) | | 9 Copyright © Universal Consulting India Pvt Ltd

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