Journal of Diabetology, June 2010; 3 :4

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Review Article:

Diabetes in Prevention
Abstract:

Pakistan:

Epidemiology,

Determinants

and

* R. Hakeem 1 , 2 , A . Fawwad 2

Epidemiology and determinants of diabetes in Pakistan have peculiar combination of risk factors. Strong gene and environment interplay along with in-utero programming in context of low birth weight and gestational diabetes are the main contributors of a high prevalence of type 2 diabetes in Pakistan. The real burden of diabetes is due to its chronic complications leading to increased morbidity and mortality. The unique combination of various risk factors necessitates research studies to make appropriate risk assessment tools to control this diabetes pandemic. Better understanding of aetio-pathological genetic and environmental factors are suggesting prevention should begin much before the start of disease process and interventions in high-risk subjects alone will not be sufficient. It is necessary to initiate population based programmes for primary prevention of diabetes including a range of activities targeted at different age groups from fetal life to old age. Synchronized and coordinated efforts from public and private sectors are needed to combat this mammoth health and economic issue. Key words: Diabetes, Pakistan, Introduction: Escalation in rates of diabetes, especially type 2 diabetes in Pakistan is posing threats to the economy and quality of life of people due to poor glycemic control and very high rates of complications (1-6). Cost of care is estimated to be very high. Resource constraints society, lack of medical reimbursement and insufficient allocation of health budget are barriers to quality care. Most often the patient is unable to afford the high cost of treatment (7-9). This review was conducted to study research evidence regarding peculiarities of diabetes in Pakistan and to identify the cost effective, appropriate and publicly available preventive strategies required for controlling the situation. Coordinated and integrated efforts are needed both from governmental and non-governmental organizations to overcome the limitations and embark on diabetes monitoring and surveillance programs as soon as possible. Methodology
1 Rana

Liaquat Ali Khan Government College of Home economics. Stadium Road Karachi, Pakistan
2 Baqai

Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan. *Corresponding Author: Prof. Rubina Hakeem Professor Nutrition Rana Liaquat Ali Khan Government College of Home economics. Stadium Road Karachi, Pakistan. Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan. Email: rubina.hakeem@gmail.com
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For reviewing this topic, information was needed firstly about research evidence on epidemiology, determinants and prevention and secondly, literature on local situations relevant to these aspects and actions being taken at various levels. Search strategies used for retrieving the information is given below: A. Retrieving research evidence regarding epidemiology, determinants and prevention Data base searched for medical research articles For studying epidemiology and determinants of diabetes in Pakistan basic search for research studies was initiated by finding abstracts from medical research articles database PubMed (10). This database is managed by the National Library of Medicine (NLM), of US National Institutes of Health that is the world's largest

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Journal of Diabetology, June 2010; 3 :4 medical library. PubMed comprise more than 20 million citations for biomedical literature from MEDLINE, life science journals and online books. Use of citation manager for searching articles Citation manger software named Reference Manger was used for searching, storing, and sorting the articles as well as for citing the articles in the manuscript. Method of retrieving research abstracts from Medline At first step abstracts were retrieved form Medline by putting the two search terms (key words) Diabetes and Pakistan together using Booleans logic operator and in-between. Using and in between the terms ensures retrieval of all articles having any of the two terms. This search retrieved information about four hundred and eighty articles. These articles were screened to find out articles having information about epidemiology, determinants and prevention of diabetes in Pakistan. Method of screening the retrieved articles The 480 articles retrieved were screened to find out those articles where information about epidemiology, determinants and/or Prevention of diabetes in Pakistan was likely to be available. As the situation of diabetes among expatriates has been reviewed by others and the focus of this review is only on diabetes in Pakistan, articles about Pakistani immigrants were excluded. Articles having the term of diabetes were used in relation to other diseases or testing of nutraceuticals and medicines were also excluded. Only those reports that have relevance to epidemiology, determinants or prevention of diabetes in Pakistan were included in this review. Useful information about epidemiology, determinants and prevention of diabetes in Pakistan was available in 113 references retrieved from PubMed. Full texts of most of the articles were reviewed. B. Retrieving information about relevant local situations and actions being taken by private and public sector for preventing and controlling diabetes.

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national and international NGOs. Relevant websites and reports were retrieved by using the search engine Google (11). The basic key words used for this area were diabetes and Pakistan with the addition of specific terms as required for retrieving required information. Twenty two items were thus retrieved from websites of government of Pakistan and other agencies. Results Epidemiology Prevalence of diabetes is high ranging from 7.6 to 11% in Pakistan (12-14). Variations according to age, sex, location and urbanization have been noted. Reports from National diabetes survey (13) and National health survey (12) differ both in observations regarding prevalence of diabetes and in relative burden of diabetes in various provinces and among males and females. Incidence of type 1 diabetes was estimated to be 1.02/100000 per year in Karachi, Pakistan (15). Rates of gestational diabetes in Pakistan range from 3.2% to 3.5%, comparable to Western populations but the rates of complications both to mother and foetus were found to be higher possibly due to poor glycaemic control (16-18). Determinants 1) Genetics Role of genetics in predisposition of South Asians to diabetes has been indicated (19-21) and some studies on immigrant Pakistani population showed the association of certain genetic variants with type 2 diabetes (22). Within the country ethnic differences have been noted but as the studies were neither controlled nor recorded lifestyle factors role within the country; genetic variations in the occurrence of diabetes could not be ascertained (12,13). 2) Maternal Hyperglycemia Gestational diabetes increases possibilities of macrosomia and metabolic syndrome in the offspring (23-26). Gestational diabetes is also found to affect the gross morphology of placenta (27). Regardless of the presence of diabetes, risk for macrosomia and preeclampsia increases with increasing fasting plasma glucose levels. Among non-diabetic women risk of pre-eclampsia, macrosomia and caesarian birth was higher

For studying actions being taken for prevention of diabetes relevant information was retrieved from websites of government of Pakistan and

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Journal of Diabetology, June 2010; 3 :4 among those having abnormal glucose screening test (28) and among normoglycemic women, the incidence of macrosomia increased with increasing plasma glucose values in the GCT (29). 3) Maternal Undernutrition Malnourishment among pregnant mothers is common that exposes the offspring to Intrauterine Growth Retardation (IUGR) and compromised metabolic potential (30). Maternal mortality rate and low birth weight are the two important indicators of maternal nutrition and rates of both of these indicators were high (27.6% and 26% respectively) in Pakistan (31). It has been observed that even Pakistani infants who had low birth weight had higher risk for metabolic disorders (32). About quarter of the Pakistani population had low birth weight and thus born with at least one risk factor. 4) Gender According to the national diabetes survey the prevalence of diabetes is higher in males as compared to females while the prevalence of impaired glucose tolerance (IGT) is higher among females as compared to males (33). 5) Age Incidence of type 2diabetes increases with age universally however diabetes occurs at lower ages among Pakistanis as compared to the western countries (DAP, article of all four provinces) (33). 6) Lifestyle and development in childhood Catch up growth of children born malnourished may expose them to higher risk if it results in increase in the proportion of body fat rather than increase in bone length and muscle mass. Stunting is an indicator of early malnutrition (34) thus combination of stunting and overweight among children indicates accumulation of fat in a child who has been malnourished in early life. In Pakistan occurrence of overweight or body fat percentage among children with low birth weight has not been estimated at national level. Nevertheless nutrition indicators i.e. high rates of stunting (61.9%) and lower rates for underweight for age (44.6%) and for height (11.7%) demonstrate that around 20 percent of children would be stunted and overweight (35). Stunted children even at bodyweight falling within normal ranges are more likely to have higher body fat

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percentage leading to central obesity and type 2 diabetes (36-42). Small local studies have shown that risk for developing diabetes in Pakistani children is high not only due to family history but also due to their life style. According to a small study, 58% children had at least one modifiable risk factor (43). Frequency of certain modifiable risk factors e.g. overweight and physical inactivity was observed to be higher among children with positive family history for diabetes, children belonging to upper income group and those living in urban areas (44-46). Children from lower income groups and those from rural areas are potentially at risk of diabetes as they were found to have poor nutrient density of diets (47) and are more likely to have low birth weight (32). Activity level of children is assessed to be low in urban areas (48,49). Positive impact of behavioral interventions have been noted (50). 7) Life style in adulthood National nutrition survey conducted in 1988 did not indicate high intake of either calories or fats but did indicate high intake of carbohydrates and saturated fats, low intake of complete protein and very low intake of fruits and vegetables (51). High intake of carbohydrates exposes the population to the risk of developing diabetes through higher risk for developing insulin resistance, and low intake vitamin and minerals increases the likelihood of developing oxidative stress. Low intake of protein and certain vitamin and minerals also decreases immunity. Thus even the national dietary pattern on average is prodiabetic and the risk would be higher among those who have lower than average intakes of protein and micronutrients. There are no prospective observations to verify this association in Pakistani population but several small studies have shown that micronutrient status was poorer (52-54) and risk of toxicity from certain minerals was higher (55) among diabetics as compared to non-diabetics leading to higher level of oxidative stress (56-59). 8) Obesity Obesity is one of the strongest predictors of type 2 diabetes and also rates of type 2 diabetes are higher among overweight individuals in Pakistan. High rates of obesity among children and women (60,61)and association of obesity with insulin

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Journal of Diabetology, June 2010; 3 :4 levels and observed. metabolic risk have also been

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level is a basic hindrance to control the epidemic of type 2 diabetes. Such concerns have been identified by many international agencies and local professionals (82). Nutrition Targeting malnutrition found in young women of child bearing age, children and adults in Pakistan, appears to be a promising primary prevention strategy for type 2 diabetes. Research evidence about exploring this association in Pakistan is rare. Nevertheless reports from other parts of the world specially from other south Asian countries, highlights the need for paying attention to quality of diets of Pakistani population as the core primary prevention strategy. For example exercise potential of people who have been low birth weight is estimated to be lower (83-86) than their normal birth weight counterparts and they have compromised metabolic potential and are more likely to have lower muscle mass. Eradicating maternal malnutrition through provision of nutrient dense diets could have significant impact on controlling IUGR and propensity to develop diabetes (86-88). Similarly among Pakistanis children and adults a large number of people are likely to be only metabolically obese at relatively lower BMIs as South Asians elsewhere have demonstrated this tendency leading to a higher risk for diabetes, metabolic syndrome, and cardiovascular disease. (89-95). Awareness programs for the community to promote the consumption of a nutrient dense diet are needed for the prevention of type 2 diabetes and metabolic syndrome. Diabetes Education Diabetes education has been wellacknowledged as an indispensible tool for the management and prevention of diabetes (96) . In Pakistan, level of awareness at both physicians and patients along with other community people level has been observed to be very low (97-107). Diabetes care practices are also observed to be inadequate. (108-111) Level of awareness, physical activity and availability of professional dietetic services has shown potential for better management of diabetes or its complications (107,112,113).

9) Physical Inactivity No report could be found about assessment of physical activity level of Pakistani adults in general. However among specific groups there are observations that metabolic risk was associated with lower level of activity (62,63). 10) Malnutrition Though all recommendations for diabetes care mention that diet should be nutritionally adequate. Attention to impact of malnutrition on occurrence of diabetes has only now been given and several evidences of associations between micronutrient deficiencies and risk for diabetes have been published (64-76). Role of undernutrition in the development of type 2 diabetes in Pakistan is yet to be explored. 11) Depression and Diabetes Depression is found to be significantly associated with newly diagnosed type 2 diabetics (77). 12) Association of diabetes prevalence to social situations Though there is no research evidence about socio-cultural determinants of diabetes in Pakistan the available information about socioeconomic situations e.g. poverty, gender bias, lack of educational facilities, deficiencies in health care system, peoples belief in nonevidence based prevention and care strategies indicates that in Pakistan risk for diabetes is being propelled from areas other than those in the domain of healthcare professionals and actions are needed at a much wider scale to prevent diabetes and other chronic disease in Pakistan (78). Prevention Opportunities for primary prevention are rare for type 1 diabetes but enough evidence is now present for type 2 diabetes (79-81). Secondary prevention is feasible in both types of diabetes through appropriate care and self-management (79-81) Prevention of type 2 diabetes requires a reliable system not only to collect local data but also to assess and monitor the situation in order to design evidence based culturally appropriate diabetes management guidelines. In Pakistan, lack of surveillance and diabetes research at national

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Journal of Diabetology, June 2010; 3 :4 These observations highlight the importance of measures to be taken for the diabetes education in preventing diabetes in Pakistan. Actions taken by Public Sector As in most developing countries, health policies and services in Pakistan need to put more emphasis on non-communicable diseases such as diabetes. The researchers should play an active role to provide scientific evidence to draw attention of decision makers on the cost effectiveness of prevention in type 2 diabetes at local level. Diabetes has not yet achieved the due focus of health department of Government of Pakistan. Focus of health department is still on combating under nutrition, however there are certain programs that could have impact on reducing diabetes in future generations e.g. maternal and child health program, girls nutrition program etc (114,115). National action plans had been made for control of diabetes in 1995 (116) and for control of diabetes as one of the main chronic disease in 2004 (117). These plans recommended evidence based strategies for control of diabetes but actions in this regard are far from desired. Federal health department of Government of Pakistan is working for establishment of a National Commission for Prevention of Cardiac & Non Communicable Diseases. Since first half of the year 2009 health department has held several meetings to move towards creation of a national Commission to address the burden of NCDs with public private partnership and volunteerism as its guiding principles (118). The following major actions has been taken within the public sector to combat this mammoth increase in the prevalence of type 2 diabetes Establishment of National Institute of Diabetes and Endocrinology (NIDE) in a medical university and offering of masters in diabetes program by the institute. NIDE provides services to diabetic patients and conducts public awareness programs frequently besides workshops for postgraduates students (119). Jinnah Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) was inaugurated in November, 2009 at Allama Iqbal Medical College, Lahore. This institute is also recognized as the accredited endocrinology

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fellowship site by College of Physician and Surgeons Pakistan (CPSP)(120) Dedicated medical units are now present in most of the tertiary care hospitals of Pakistan e.g. Endocrinology units at Hayatabad Medical Complex Peshawar and Pakistan Institute of Medical Sciences, Islamabad.

Health professionals have been active in highlighting the diabetes care needs (121) and it could be hoped that concentrated and coordinated request and demands by health professionals, civil society and relevant international agencies may result in establishment of an effective and functional framework within the public sector for the monitoring and control of diabetes. Actions taken by Private Sector Several nongovernmental organizations and institutions are actively seeking to contribute in prevention and control of diabetes in Pakistan by delivering services through training of general physician and other healthcare professionals and creating awareness at patient and community level through educational material and awareness programmes.(122-125). Worthwhile attempts have also been made at national level like Diabetic Association of Pakistan (DAP) (124) made major contribution by serving as WHO collaborating center for diabetes by conducting national diabetes surveys (13,126-129). Baqai Institute of Diabetetology and Endocrinology (BIDE) of Karachi (122) has succeeded in expanding it service to whole of Sind in relation to management of type 1 diabetes through Insulin My Life project (130) and several areas of Pakistan through National Diabetes and Diabetic Foot Programme, both supported by WDF (131). BIDE is also endeavoring to enhance diabetes care by educating the health professionals and offering diabetes educator course. On the basis of its services BIDE succeeded in getting the status of International Diabetes Federation (IDF) recognized center of diabetes education (96). Recently National Association for Diabetes Educators of Pakistan (NADEP) has also been established with an aim to empower people to prevent and control diabetes (132). Discussion This paper has reviewed available research evidence regarding epidemiology, determinants

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Journal of Diabetology, June 2010; 3 :4 and prevention of diabetes in Pakistan. Epidemiology and determinants of diabetes in Pakistan has a peculiar combination of features e.g. genetic, intrauterine programming (as a result of poverty, lack of education, and culture), high carbohydrate diet lacking in certain amino acids and micronutrients, low physical activity among certain groups, etc. As the combination of these features is unique it necessitates investigations and surveillance to explore most cost effective measures to control the diabetes pandemic. The situation calls for three dimensional activities to control the situation as discussed below: 1. Monitoring and surveillance system to identify trends, patterns and high risk groups, plan cost effective interventions and evaluate impact of interventions. Research to explore cost-effective and environmentally befitting diabetes care strategies appropriate for Pakistan Coordination of diabetes care efforts at local and national level and develop collaborative strategies at the regional level.

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Pakistan having type 2 diabetes risks at lower levels of obesity. While focus of controlling body fatness is justified, risk assessment tools should also include genetic and prenatal predisposition along with diet and physical activity assessment. Risk calculators with special emphasis on lifestyle factors could be more helpful in motivating behavioral changes. Consuming at least five serving of fresh fruit and vegetable increases nutrient density of diet and is also one of the main features of dietary guidelines for the management of diabetes. Production of fruit and vegetable in Pakistan is not sufficient to provide five servings per person even if distribution is 100% accurate. Fruits and non-starchy vegetables are usually more expensive than starchy vegetables. This situation calls for exploring clinically effective and affordable dietary guidelines for the prevention of type 2 diabetes. Interventions focusing more on body composition, micronutrient status, nutrient density of diets and exercise potential are likely to be more effective as compared to general interventions focusing only on bodyweight and assessment of diet in terms of energy and fat contents calculations. Coordination of diabetes care efforts at national level Cost effective, appropriate and publicly available preventive strategies are required for controlling the situation and prevention of type 2 diabetes in Pakistan. Coordinated and integrated efforts are needed both from governmental and non-governmental organizations to overcome the limitations and embark on diabetes monitoring and surveillance programs as soon as possible. Strategies developed in demographically, culturally and economically similar population needs to be assessed for efficacy in Pakistani population. Efforts made in this direction need to be augmented. Many of the needs explored in this review are among the top three items included by IDF in its list of long term vision in relation to specific requirements from the UN Summit on NCDs in September 2011. This includes: NCD national plans for all, improved lifestyles, a strengthened health systems. IDF also plans to ask the UN summit 2011 to make Governments accountable and measured on NCD plans (133). It could be

2.

3.

Monitoring and surveillance Monitoring and surveillance is essential to assess the situation and trends. Absence of valid data limits the possibilities for prevention and control. This activity needs to be organized at national level through central body so that uniformity in methods could be assured and trends in various areas could be compared. National diabetes survey should include assessment of birth weight and life style risk factors also so that association between these factors and rates of incidence or prevalence could be explored. Exploring diabetes care strategies appropriate for Pakistan Diet and activity has potential to prevent or delay the onset of diabetes for most individuals. Unfolding of genetic potential and progression of prenatal dispositions is greatly dependent on lifestyle factors. Degree and design of fat of accumulation in the body is a reflection of lifestyle factors in most but not in all cases. As there are observations confirming the presence of metabolic syndrome in normal weight person, exclusive attention to body weight may disguise a large number of people with normal weight, at risk of developing type 2 diabetes. This is particularly true for people of countries like
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Journal of Diabetology, June 2010; 3 :4 hoped that these global actions would trigger mobilization of resources for the prevention of type 2 diabetes in Pakistan. Once national alliance has been established it can benefit for action plans designed by experts for their regions. For example many of the elements included in action plan for prevention of diabetes in Europe titled IMAGE (134) could be incorporated in similar plan of diabetes in Pakistan. Reference 1. Basit A, Hydrie MZ, Hakeem R, Ahmedani MY, Masood Q. Frequency of chronic complications of type II diabetes. J Coll Physicians Surg Pak 2004;14:79-83. Ahmed N, Khan J, Siddiqui TS. Frequency of dyslipidaemia in type 2 diabetes mellitus in patients of Hazara division. J Ayub Med Coll Abbottabad 2008;20:51-4. Khoharo HK, Qureshi F. Frequency of cardiac autonomic neuropathy in patients with type 2 diabetes mellitus reporting at a teaching hospital of Sindh. J Coll Physicians Surg Pak 2008;18:751-4. Wahab S, Mahmood N, Shaikh Z, Kazmi WH. Frequency of retinopathy in newly diagnosed type 2 diabetes patients. J Pak Med Assoc 2008;58:557-61. Ahmed N, Jadoon SA, Khan RM, Mazahar UD, Javed M. Type 2 diabetes mellitus: how well controlled in our patients? J Ayub Med Coll Abbottabad 2008;20:70-2. Moin S, Gondal GM, Bano U. Risk of development of chronic kidney disease in patients with type 2 diabetes having metabolic syndrome. J Coll Physicians Surg Pak 2008;18:472-6. Govender VM, Ghaffar A, Nishtar S. Measuring the economic and social consequences of CVDs and diabetes in India and Pakistan. Biosci Trends 2007;1:1217. Khowaja LA, Khuwaja AK, Cosgrove P. Cost of diabetes care in out-patient clinics of Karachi, Pakistan. BMC Health Serv Res 2007;7:189. 9.

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