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ImportanceDiabetes mellitus (DM) is widespread and treatable. Little is known about the diabetes care continuum (diagnosis, treatment, and control) in India, and whether it varies by socio-demographic characteristics and vary at the national, state, and district levels.ObjectiveTo estimate the diabetes care continuum among individuals aged 18-98 years old at national, state, and district-levels, and by socio-demographic group.DesignCross-sectional, nationally representative surveySetting28 states, 8 union territories, and 707 districts of IndiaParticipants1,895,287 approached in the Fifth National Family Health Survey (NFHS-5), 2019-2021ExposuresDistrict, state, urban vs rural residence, age (18-39, 40-64, ≥65 years), sex, household wealth quintileMain Outcomes and MeasuresDiabetes was defined by self-report or high capillary blood glucose (≥126mg/dL [fasting] or ≥220mg/dL [non-fasting]). Of those with diabetes, we estimated proportions that were diagnosed (self-reported). Among those diagnosed, we reported the proportions treated (self-reported medication use) and proportion controlled (blood glucose ResultsAmong 1,651,176 adult respondents (52.6% female; mean age: 41.6 years) with blood glucose measures, the proportion with diabetes was 6.5% (95%CI: 6.4, 6.6). Among adults with diabetes, 74.2% [73.3, 75.0] were diagnosed. Among those diagnosed, 59.4% [58.1, 60.6] reported taking medication and 65.5% [64.5, 66.4] achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Of the 707 districts, 34.8% districts met diagnosis target, while 10.7% districts met the control target among those diagnosed. Most of the variability in diabetes diagnosis (VPC:69.9%), treatment (VPC:51.8%), and control (VPC:66.8%) were between districts in a state, and not between states.Conclusions and RelevanceNationally, the diabetes care continuum masks considerable state- and district-level variation, as well as age- and rural-urban disparities. Surveillance at the district-level can guide state health administrators to prioritize interventions and monitor achievement of global targets.KEY POINTSQuestionHow does the diabetes care continuum (diagnosis, treatment, and control) vary by state, district, and sociodemographic groups in India?FindingsNationally, among 1.65 million respondents in the National Family Health Survey of 2019-2021, 74.2% were diagnosed. Among those diagnosed, 59.4% reported taking medication and 65.5% achieved control. Most of the variability in care continuum was within-state, between districts (% variance explained: 51.8-69.9) and not between-states. Higher diagnosis and treatment, but lower control was observed in urban compared to rural areas and older compared to younger and middle age groups.MeaningConsiderable differences between states, between districts in a state, for rural adults, and by age imply the need for targeted, decentralized solutions to improve the diabetes care continuum in India.