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Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan
diabetes research and clinical practice 94 (2011) 456–462
Contents lists available at ScienceDirect
Diabetes Research and Clinical Practice jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es
Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan Abdul Basit a,*, S. Faraz Danish Alvi b, Asher Fawwad b, Khursheed Ahmed c, Muhammad Yakoob Ahmedani a, Rubina Hakeem b a
Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University., Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi 74600, Pakistan b Research Department, Baqai Institute of Diabetology and Endocrinology, Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi 74600, Pakistan c Primary Health Unit, Hub, Baluchistan, Pakistan
article info
abstract
Article history:
Aims: To observe temporal changes in the prevalence of diabetes, impaired fasting glucose
Received 19 January 2011
and its associated risk factors in the rural area of Baluchistan province of Pakistan according
Received in revised form
to American Diabetes Association criteria by comparing the two surveys done in 2002 and
5 August 2011
2009.
Accepted 8 August 2011
Methodology: This community based survey of 1264 subjects aged 25 years and above was
Published on line 3 September 2011
conducted from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed in comparison with a similar survey conducted seven
Keywords:
years previously. Data from 2002 survey was also re-analyzed according to the latest ADA
Diabetes
criteria.
Prevalence
Results: A two-fold increase in the prevalence of diabetes (from 7.2% to 14.2%) was seen in 2009 survey and the prevalence of impaired fasting glucose also increased significantly (6.5–
Pakistan
11.0%). An important finding was the number of hypertensives and subjects with positive family history of diabetes also increased significantly ( p < 0.000) from the previous survey. Conclusion: Coordinated National Programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Further large scale studies with proper risk factor assessment are needed to ascertain the reasons of rising prevalence of glucose intolerance. # 2011 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Diabetes is one of the major public health challenges of the 21st century. Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and is expected to rise to 5.4% by the year 2025. According to the World Health Organization
(WHO), the major part of this increase will occur in developing countries with a projected rise of 170%. Pakistan will have an increase from 4.3 million in 1995 to an anticipated 14.5 million in the year 2025 [1]. Epidemiological studies in different parts of the world have shown an increase in the prevalence of diabetes. In India
* Corresponding author. Tel.: +92 21 36688897/+92 21 36608565/+92 21 36707179; fax: +92 21 36608568. E-mail address: [email protected] (A. Basit). 0168-8227/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2011.08.009
diabetes research and clinical practice 94 (2011) 456–462
prevalence of diabetes in urban areas increased from 8.2% (1988) to 11.6% (1995) [2]. Similarly another study conducted in the rural areas of India showed a three-fold increase in ageand sex-adjusted prevalence of diabetes (from 2.20% to 6.36%) over 14 years, however prevalence of IGT did not change significantly [3]. In rural Bangladesh, prevalence of diabetes increased from 2.3 to 6.8% in five years [4]. Rural population of Malaysia also showed an increase in the prevalence of diabetes from 3.9% to 12.2% over a study period of 10 years [5]. Pakistan is a country with diverse economic, cultural, social and educational patterns and has a vast rural population. Some population based studies conducted in rural and semi urban areas of the four provinces of Pakistan at different periods revealed the sex-specific prevalence of diabetes ranging from 3.7% to 16.2% in men and 4.8–11.7% in women. Similarly prevalence of IGT varied between 4.54% and 8.2% in men and 5.8–14.3% in women [6–10]. To our knowledge none of the epidemiological surveys done in Pakistan looked at temporal changes in the prevalence of diabetes in the same geographical location. A study was undertaken to determine the prevalence of diabetes and impaired fasting glucose according to the American Diabetes Association (ADA) criteria in the rural area of Baluchistan in the year 2002 [11]. A similar study was conducted seven years later at the same geographical location. Hence the aim of this study was to compare the results of the two surveys and to observe sequential changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors.
457
randomly select households. All men and women 25 years of age who gave informed consent were considered eligible to take part in the survey. The eligible participants were informed about the objectives of the study. One day before the survey all the selected participants were advised to come to a specified location after an overnight fast of 8–14 h. On the day of the survey, after registration of the participants a fasting blood sample was drawn. The performa containing the details of demography, anthropometry and medical history was completed by personal interview carried out by doctors.
2.3.
Anthropometry
2.
Materials and methods
Anthropometric measurement for height and weight was taken by paramedical staff. Weight was taken with subjects in light clothes and without shoes by a digital bathroom scale placed on a flat surface, to the nearest of 0.1 kg. For height, the subjects stood in erect posture vertically touching the occiput, back, hip, and heels on the wall. Height was taken to the nearest of 0.1 cm. Body mass index (BMI) was calculated as weight in kg/height in m2. Blood pressure was measured with the precaution to reduce variation of blood pressure value with resting values: individuals were requested to take 10 min rest at a sitting position before measuring the blood pressure. Adult-fitted standard cuffs were used with mercury sphygmomanometer for all individuals to minimize the difference. Hypertension was defined as blood pressure 130/85 mmHg [13]. Hypertensives also included subjects with known hypertension who were already on antihypertensive medications prescribed by a doctor.
2.1.
Study area and population
2.4.
This community-based survey was conducted over a period of one year from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed by comparing the data with a similar survey conducted in 2002 at the same location. The data obtained in 2002 was also reanalyzed according to the current ADA criteria. All the villages were within the distance of 2.5 km from the Hub city. Baluchistan is the largest province of Pakistan with an area of 347,190 km2, making 44% of the country and located in the southwest of Pakistan [12]. It mostly consists of dry mountainous areas that are sparsely populated compared to the other provinces. Majority of the population live together as extended families in one compound and the inhabitants are relatively poor [6]. The population follows a more laborious work habits including working in the factories, fishing, poultry, agriculture and cattle herding.
2.2.
Methodology
The ethical approval for this survey was taken from Institutional Review Board (IRB) of the institution. Team for the survey composed of doctors, lady health workers, lab technicians and paramedical staff. Lady health workers who were the residents of those villages were assigned the task to
Laboratory assays
Within 1 h of blood collection, the samples were centrifuged, separated and taken to the laboratory. Fasting blood glucose was performed by the glycose oxidase GOD PAP method.
2.5. Classification of diabetes and impaired fasting glucose Using the ADA criteria, diabetes was defined as fasting plasma glucose 126 mg/dl. Impaired fasting glucose (IFG) was defined as fasting plasma glucose between 100 and 125 mg/ dl. Non-diabetics were defined as subjects with fasting plasma glucose <100 mg/dl [14]. Diabetes was considered to be present previously if diagnosed by a physician or if the patient was taking any diabetic medicines.
2.6.
Statistical analysis
Data analysis was conducted on Statistical Package for Social Sciences (SPSS), version 13.0. Continuous variables, i.e. age, BMI, height, weight, systolic and diastolic blood pressures presented as Mean SD. Categorical variables like gender, hypertension and family history of diabetes presented in the form of frequency and percentage. Groups: Normal glucose tolerance (NGT), Impaired fasting glucose (IFG) and diabetes mellitus (DM) were analyzed for
458
diabetes research and clinical practice 94 (2011) 456–462
Table 1 – Comparison of baseline anthropometric & clinical variables of the two surveys.
statistical difference by ANOVA with post hoc test and chisquare was used for categorical variables, p < 0.05 was considered statistically significant.
(424 men and 840 women) participated in 2009 survey where as 2032 subjects (670 men and 1362 women) took part in 2002 survey. Statistically significant differences ( p < 0.000) were seen in mean age, height, weight and BMI of the subjects in the two surveys. In 2009 survey more than half (54.27%) of the studied subjects were found to be hypertensive, which increased significantly from the previous study ( p < 0.0001). A significant increase in the positive family history of diabetes ( p < 0.000) was also seen in 2009 survey. Tables 2a and 2b show comparison of anthropometric and clinical variables of the two surveys in men and women respectively in relation to glucose tolerance status. Subjects with impaired fasting glucose (IFG) and diabetes (DM) were older, had increased weight, BMI, systolic and diastolic blood pressures ( p < 0.005) than subjects with normal glucose tolerance (NGT) in both men and women in 2009 survey. An increase in mean weight, BMI, systolic and diastolic blood pressures ( p < 0.005) was seen in both men and women during the time period between the two surveys. Fig. 1 shows the prevalence of diabetes and impaired fasting glucose in 2002 and 2009 surveys. The prevalence of IFG increased from 6.5% to 11.05% ( p < 0.000) and diabetes increased from 7.2% to 14.2% ( p < 0.000). Fig. 2 shows age specific prevalence of diabetes and IFG in both the surveys. When the two surveys were compared the prevalence of diabetes increased in age groups 55 years and above in men. The highest prevalence of diabetes in men was observed in 55–64 years age group as shown in Fig. 2a; whereas in women the highest prevalence of diabetes was observed at an older age, i.e. >65 years, Fig. 2b. The age specific prevalence of IFG in men and women is shown in Fig. 2c and d respectively. The highest prevalence of IFG in both the sexes was seen in 55–64 years age group in 2009 survey.
3.
4.
n Men:women Age (years) Men Women Overall Height (cm) Men Women Overall Weight (kg) Men Women Overall Body mass index Men Women Overall Family history of Men Women Overall Hypertension Men Women Overall
2002 Survey
2009 Survey
2032 670:1362
1264 424:840
40.4 11.85 38.1 11.51 38.85 11.67
43.47 13.91 41.67 11.73 42.27 12.53
0.000 0.000 0.000
167.16 6.52 162.95 7.66 164.33 7.56
165.6 6.45 161.38 7.63 162.79 7.52
0.000 0.000 0.000
62.55 13.43 52.77 12.42 55.99 13.56 (kg/m2) 22.4 4.74 19.98 5.04 20.78 5.07 diabetes mellitus 9 (1.3%) 9 (0.7%) 18 (0.88%)
69.87 14.54 65.72 14.83 67.11 14.86
0.000 0.000 0.000
25.62 5.46 25.32 6.06 25.42 5.89
0.000 0.000 0.000
129 (30.4%) 285 (33.9%) 414 (32.75%)
0.000 0.000 0.000
160 (23.88%) 252 (18.50%) 412 (20.27%)
244 (57.54%) 442 (52.61%) 686 (54.27%)
0.000 0.000 0.0001
p-Value
Values are Mean SD; n (%). p < 0.05 considered statistically significant.
Results
Table 1 shows comparison of the baseline anthropometric and clinical variables of the two surveys. A total of 1264 subjects
Discussion
A comparison of the two surveys in the rural area of Baluchistan showed that the prevalence of diabetes increased
Table 2a – Comparison of the anthropometric and clinical variables of the two surveys in men in relation to glucose tolerance status. Men n Age (years) Height (cm) Weight (kg) Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Years
2002 2009 2002 2009 2002 2009 2002 2009 2002 2009 2002 2009
Data is in the form of mean sd and n (%). For p value <0.05 NGT vs. IFG and NGT vs. DM. ** For p value <0.05 year 2002 vs. year 2009. *
Normal glucose tolerance (NGT)
Impaired fasting glucose (IFG)
Diabetes mellitus (DM)
842 (77.2%) 38.64 11.54 38.81 12.16 167.19 6.51 165.62 6.25** 62.08 13.05 68.25 13.87 22.24 4.66 25.03 5.21** 115.97 16.65 127.1 14.85** 74.01 11.12 83.46 8.89**
100 (9.2%) 45.73 12.46* 57.51 11.17*,** 168.29 6.27 164.73 6.27 65.92 15.4 72.35 14.34** 23.24 5.21 26.8 5.92** 120.39 20.87 137.04 16.64*,** 76.08 11.5 89.29 8.66*,**
149 (13.7%) 48.8 8.61* 54.43 9.57*,** 166.24 6.64 166.24 6.64 63.6 14.39 75.19 16.39*,** 23.0 4.94 27.36 6.28*,** 119.25 17.34 135.94 12.40*,** 77.76 12.15* 88.33 7.46*,**
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diabetes research and clinical practice 94 (2011) 456–462
Table 2b – Comparison of the anthropometric and clinical variables of the two surveys in women in relation to glucose tolerance status. Women
Years
n Age (years)
2002 2009 2002 2009 2002 2009 2002 2009 2002 2009 2002 2009
Height (cm) Weight (kg) Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Normal glucose tolerance (NGT)
Impaired fasting glucose (IFG)
Diabetes mellitus (DM)
1850 (84.1%) 37.19 11.09 38.64 10.54** 163.06 7.63 161.39 7.6** 52.13 11.78 64.80 14.47** 19.69 4.69 24.92 5.50** 113.02 16.51 126.23 14.49** 72.21 10.48 82.41 8.86**
172 (7.8%) 44.8 12.73* 51.18 10.17*,** 161.34 8.14 161.79 7.07 56.98 15.01* 69.17 14.6*,** 22.07 6.52* 26.42 5.4** 122.68 22.77* 137.67 19.77*,** 76.95 16.3* 88.06 9.79*,**
177 (8.0%) 46.25 11.6* 51.34 10.07*,** 162.9 7.42 160.85 8.48 59.37 16.81* 68.36 16.51** 22.57 7.25* 26.78 8.84*,** 124.03 20.38* 138.62 15.64*,** 78.21 12.66* 88.95 8.98*,**
Data is in the form of mean sd and n (%). For p value <0.05 NGT vs. IFG and NGT vs. DM. ** For p value <0.05 year 2002 vs. year 2009. *
two fold over a period of seven years, similarly a significant increase in impaired fasting glucose (IFG) was also observed. Similar results were shown in other studies in the region. For instance, in rural Bangladesh prevalence of diabetes increased three fold in five years [4]. Likewise in Southern India, comparison of the two rural surveys demonstrated that the prevalence of diabetes also increased three fold over a period of fourteen years [3]. Similarly rural population of Malaysia also showed an increase in the diabetes prevalence from 3.9% to 12.2% over ten years period [5]. It has been postulated that the number of people with diabetes are increasing worldwide as a result of population growth, aging, transitional changes in lifestyle resulting in urbanization, increasing prevalence of obesity and physical inactivity [15]. Similarly, the rising prevalence of diabetes in the rural population of Baluchistan can be attributed to these factors. It was interesting to observe that mean height of both men and women decreased in 2009 survey compared to 2002 survey. Although the geographical location for the two surveys was the same but the studied subjects were different and this may be a random finding. In our study, mean BMI of the population increased significantly over a period of seven years. It is a well established fact that overweight, obesity, and 15
2002
14.2
2009
Prevalence (%)
11.05 10 6.5
7.2
5
0 Impaired Fasting Glucose
Diabetes Mellitus
Fig. 1 – Prevalence of impaired fasting glucose (IFG) and diabetes mellitus (DM) in 2002 and 2009 surveys.
weight gain are the major predictors for the development of diabetes [16–18]. A study in India also showed that higher BMI is independently associated as a risk for the occurrence of type 2 diabetes among both men and women [2]. Thus increase in obesity can be one of the major contributors to the rise in diabetes prevalence in rural Baluchistan. Another important finding in our study was that the number of men and women with positive family history of diabetes increased significantly. Positive family history of diabetes can result in increased prevalence of diabetes as suggested in several studies [19–21]. Moreover this shows a strong association of genetic factors with glucose tolerance [22]. Hypertension increased more than two fold in our study over a period of seven years. A study in the western world hypothesized that being overweight is associated with 2–6 fold increase in the risk of developing hypertension [23]. This raise in hypertension in our population can also be attributed to increase in obesity [24]. Furthermore, the prevalence of hypertension was also significantly associated with glucose tolerance status in our study similar to findings of other studies [25–27]. It has been postulated that the majority of diabetic subjects in the developing countries would be younger, i.e. in 45–64 years age group, whereas in developed countries majority of them would be >65 years [28], similar findings were observed in our surveys in men. However, it was interesting to note that the highest prevalence of diabetes in women was observed at an age of >65 years; the results need to be validated through further large scale studies. Our study has some limitations; we did not observe transitional changes in the lifestyle of the population of rural Baluchistan over a period of time including changes in the dietary habits, educational status, occupation as well as physical activity levels, which may contribute to the rising prevalence of diabetes. Moreover, further studies are needed adjusting age and obesity to confirm the study findings of increasing prevalence of diabetes in the rural areas of Baluchistan.
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diabetes research and clinical practice 94 (2011) 456–462
Age specific prevalence of Diabetes Mellitus in Men
Prevalence (%)
50
(a)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years) Age specific prevalence of Diabetes Mellitus in Women
Prevalence (%)
50
(b)
2002
2009
55-64
>65
40 30 20 10 0 25-34
35-44
45-54
Age groups (years) Age specific prevalence of Impaired Fasting Glucose in Men
Prevalence (%)
50
(c)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years) Age specific prevalence of Impaired Fasting Glucose in Women
Prevalence (%)
50
(d)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years)
Fig. 2 – (a) Age-specific prevalence of diabetes mellitus (DM) in men in 2002 and 2009. (b) Age-specific prevalence of diabetes mellitus (DM) in women in 2002 and 2009. (c) Age-specific prevalence of impaired fasting glucose (IFG) in men in 2002 and 2009. (d) Age-specific prevalence of impaired fasting glucose (IFG) in women in 2002 and 2009.
diabetes research and clinical practice 94 (2011) 456–462
5.
Conclusion
The present study showed that diabetes increased two fold in the rural population of southern Baluchistan over a study period of seven years. Exposure of genetically high risk population to the environmental factors could be responsible for increasing prevalence of diabetes. Coordinated National programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Furthermore prospective studies with the aim to identify the risk factors are needed to ascertain the reasons of rising prevalence of glucose intolerance.
Acknowledgements We acknowledge the support of Merck Marker (Pvt) Ltd. for this survey. We would also like to appreciate the hard work and dedicated commitment of lady health workers, lab technicians and paramedical staff from Hub Baluchistan and also acknowledge the support of Mr. Bilal Tahir (Research Coordinator) and Ms. Fariha Shaheen (Statistician), Research Department of Baqai Institute of Diabetology and Endocrinology in data entry and analysis.
Conflict of interest The authors declare that they have no conflict of interest.
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[8] Shera AS, Basit A, Fawwad A, Hakeem R, Ahmedani MY, Hydrie MZ. et al. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan. Prog Cardiovasc Dis 2010;4:79–83. [9] Shera AS, Rafique G, Khwaja IA, Baqai S, Khan IA, King H. Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province (NWFP) of Pakistan. J Pakistan Med Assoc 1999;49:206–11. [10] Naeem Z, Bjorgulf C, Akhtar H. Diabetes and impaired glucose tolerance in a rural area in Pakistan and associated risk factors. Diabetes Metab Synd Clin Res Rev 2008;2:125–30. [11] Basit A, Hydrie MZI, Ahmed K, Hakeem R. Prevalence of diabetes, impaired fasting glucose and associated risk factors in a rural area of Baluchistan according to new ADA criteria. J Pakistan Med Assoc 2002;52:357–60. [12] Population, area and density by region/province (PDF). Federal Bureau of Statistics. Government of Pakistan; 1998, http://www.statpak.gov.pk/depts/fbs/publications/ yearbook2008/Population/16-5.pdf (retrieved 20.07.2009). [13] Anoop M, Jasjeet SW, Ravinder MP. An evaluation of candidate definitions of the metabolic syndrome in adult Asian Indians. Diabetes Care 2005;28:398–403. [14] American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2006;29:s43–8. [15] Sarah W, Gojka R, Anders G, Richard S, Hilary K. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047–53. [16] Hu G, Lindstrom J, Valle TT, Eriksson JG, Jousilahti P, Silventoinen K, et al. Physical activity, body mass index, and risk of type 2 diabetes in patients with normal or impaired glucose regulation. Arch Intern Med 2004;164:892–6. [17] Hartemink N, Boshuizen HC, Nagelkerke NJ, Jacobs MA, Houwelingen HC. Combining risk estimates from observational studies with different exposure cutpoints: a meta-analysis on body mass index and diabetes type 2. Am J Epidemiol 2006;163:1042–52. [18] Hu G, Jousilahti P, Peltonen M, Bidel S, Tuomilehto J. Joint association of coffee consumption and other factors to the risk of type 2 diabetes: a prospective study in Finland. Int J Obes 2006;30:1742–9. [19] Hussain A, Rahim MA, Khan AK, Ali SM, Vaaler S. Type 2 diabetes in rural and urban population. Diverse prevalence and associated risk factors in Bangladesh. Diabet Med 2005;22:931–6. [20] Viswanathan M, McCarthy MI, Snehalatha C, Hitman GA, Ramachandran A. Familial aggregation of Type 2 (noninsulin-dependent) diabetes mellitus in south India: absence of excess maternal transmission. Diabet Med 1996;13:232–7. [21] Sudha SD, Avinash Z, Rajashree M, Shilpa M, Sujata R, Kalpana T. To identify the risk factors for high prevalence of diabetes and impaired glucose tolerance in Indian rural population. Int J Diabetes Dev Countries 2006;26:19–23. [22] Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract 2007;76:219–22. [23] World Health Organization. Hypertension control. Geneva, Switzerland: World Health Organization; 1996 (Tech Rep Ser. No. 862). [24] Shera AS, Jawad F, Maqsood A, Jamal S, Azfar M, Ahmed U. Prevalence of chronic complications and associated factors in Type 2 diabetes. J Pakistan Med Assoc 2004;54:54–9. [25] Hussain A, Rahim MA, Azad KAK, Ali SMK. Type 2 diabetes in rural and urban population: diverse prevalence and
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Contents lists available at ScienceDirect
Diabetes Research and Clinical Practice jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es
Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan Abdul Basit a,*, S. Faraz Danish Alvi b, Asher Fawwad b, Khursheed Ahmed c, Muhammad Yakoob Ahmedani a, Rubina Hakeem b a
Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University., Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi 74600, Pakistan b Research Department, Baqai Institute of Diabetology and Endocrinology, Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi 74600, Pakistan c Primary Health Unit, Hub, Baluchistan, Pakistan
article info
abstract
Article history:
Aims: To observe temporal changes in the prevalence of diabetes, impaired fasting glucose
Received 19 January 2011
and its associated risk factors in the rural area of Baluchistan province of Pakistan according
Received in revised form
to American Diabetes Association criteria by comparing the two surveys done in 2002 and
5 August 2011
2009.
Accepted 8 August 2011
Methodology: This community based survey of 1264 subjects aged 25 years and above was
Published on line 3 September 2011
conducted from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed in comparison with a similar survey conducted seven
Keywords:
years previously. Data from 2002 survey was also re-analyzed according to the latest ADA
Diabetes
criteria.
Prevalence
Results: A two-fold increase in the prevalence of diabetes (from 7.2% to 14.2%) was seen in 2009 survey and the prevalence of impaired fasting glucose also increased significantly (6.5–
Pakistan
11.0%). An important finding was the number of hypertensives and subjects with positive family history of diabetes also increased significantly ( p < 0.000) from the previous survey. Conclusion: Coordinated National Programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Further large scale studies with proper risk factor assessment are needed to ascertain the reasons of rising prevalence of glucose intolerance. # 2011 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Diabetes is one of the major public health challenges of the 21st century. Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and is expected to rise to 5.4% by the year 2025. According to the World Health Organization
(WHO), the major part of this increase will occur in developing countries with a projected rise of 170%. Pakistan will have an increase from 4.3 million in 1995 to an anticipated 14.5 million in the year 2025 [1]. Epidemiological studies in different parts of the world have shown an increase in the prevalence of diabetes. In India
* Corresponding author. Tel.: +92 21 36688897/+92 21 36608565/+92 21 36707179; fax: +92 21 36608568. E-mail address: [email protected] (A. Basit). 0168-8227/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2011.08.009
diabetes research and clinical practice 94 (2011) 456–462
prevalence of diabetes in urban areas increased from 8.2% (1988) to 11.6% (1995) [2]. Similarly another study conducted in the rural areas of India showed a three-fold increase in ageand sex-adjusted prevalence of diabetes (from 2.20% to 6.36%) over 14 years, however prevalence of IGT did not change significantly [3]. In rural Bangladesh, prevalence of diabetes increased from 2.3 to 6.8% in five years [4]. Rural population of Malaysia also showed an increase in the prevalence of diabetes from 3.9% to 12.2% over a study period of 10 years [5]. Pakistan is a country with diverse economic, cultural, social and educational patterns and has a vast rural population. Some population based studies conducted in rural and semi urban areas of the four provinces of Pakistan at different periods revealed the sex-specific prevalence of diabetes ranging from 3.7% to 16.2% in men and 4.8–11.7% in women. Similarly prevalence of IGT varied between 4.54% and 8.2% in men and 5.8–14.3% in women [6–10]. To our knowledge none of the epidemiological surveys done in Pakistan looked at temporal changes in the prevalence of diabetes in the same geographical location. A study was undertaken to determine the prevalence of diabetes and impaired fasting glucose according to the American Diabetes Association (ADA) criteria in the rural area of Baluchistan in the year 2002 [11]. A similar study was conducted seven years later at the same geographical location. Hence the aim of this study was to compare the results of the two surveys and to observe sequential changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors.
457
randomly select households. All men and women 25 years of age who gave informed consent were considered eligible to take part in the survey. The eligible participants were informed about the objectives of the study. One day before the survey all the selected participants were advised to come to a specified location after an overnight fast of 8–14 h. On the day of the survey, after registration of the participants a fasting blood sample was drawn. The performa containing the details of demography, anthropometry and medical history was completed by personal interview carried out by doctors.
2.3.
Anthropometry
2.
Materials and methods
Anthropometric measurement for height and weight was taken by paramedical staff. Weight was taken with subjects in light clothes and without shoes by a digital bathroom scale placed on a flat surface, to the nearest of 0.1 kg. For height, the subjects stood in erect posture vertically touching the occiput, back, hip, and heels on the wall. Height was taken to the nearest of 0.1 cm. Body mass index (BMI) was calculated as weight in kg/height in m2. Blood pressure was measured with the precaution to reduce variation of blood pressure value with resting values: individuals were requested to take 10 min rest at a sitting position before measuring the blood pressure. Adult-fitted standard cuffs were used with mercury sphygmomanometer for all individuals to minimize the difference. Hypertension was defined as blood pressure 130/85 mmHg [13]. Hypertensives also included subjects with known hypertension who were already on antihypertensive medications prescribed by a doctor.
2.1.
Study area and population
2.4.
This community-based survey was conducted over a period of one year from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed by comparing the data with a similar survey conducted in 2002 at the same location. The data obtained in 2002 was also reanalyzed according to the current ADA criteria. All the villages were within the distance of 2.5 km from the Hub city. Baluchistan is the largest province of Pakistan with an area of 347,190 km2, making 44% of the country and located in the southwest of Pakistan [12]. It mostly consists of dry mountainous areas that are sparsely populated compared to the other provinces. Majority of the population live together as extended families in one compound and the inhabitants are relatively poor [6]. The population follows a more laborious work habits including working in the factories, fishing, poultry, agriculture and cattle herding.
2.2.
Methodology
The ethical approval for this survey was taken from Institutional Review Board (IRB) of the institution. Team for the survey composed of doctors, lady health workers, lab technicians and paramedical staff. Lady health workers who were the residents of those villages were assigned the task to
Laboratory assays
Within 1 h of blood collection, the samples were centrifuged, separated and taken to the laboratory. Fasting blood glucose was performed by the glycose oxidase GOD PAP method.
2.5. Classification of diabetes and impaired fasting glucose Using the ADA criteria, diabetes was defined as fasting plasma glucose 126 mg/dl. Impaired fasting glucose (IFG) was defined as fasting plasma glucose between 100 and 125 mg/ dl. Non-diabetics were defined as subjects with fasting plasma glucose <100 mg/dl [14]. Diabetes was considered to be present previously if diagnosed by a physician or if the patient was taking any diabetic medicines.
2.6.
Statistical analysis
Data analysis was conducted on Statistical Package for Social Sciences (SPSS), version 13.0. Continuous variables, i.e. age, BMI, height, weight, systolic and diastolic blood pressures presented as Mean SD. Categorical variables like gender, hypertension and family history of diabetes presented in the form of frequency and percentage. Groups: Normal glucose tolerance (NGT), Impaired fasting glucose (IFG) and diabetes mellitus (DM) were analyzed for
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Table 1 – Comparison of baseline anthropometric & clinical variables of the two surveys.
statistical difference by ANOVA with post hoc test and chisquare was used for categorical variables, p < 0.05 was considered statistically significant.
(424 men and 840 women) participated in 2009 survey where as 2032 subjects (670 men and 1362 women) took part in 2002 survey. Statistically significant differences ( p < 0.000) were seen in mean age, height, weight and BMI of the subjects in the two surveys. In 2009 survey more than half (54.27%) of the studied subjects were found to be hypertensive, which increased significantly from the previous study ( p < 0.0001). A significant increase in the positive family history of diabetes ( p < 0.000) was also seen in 2009 survey. Tables 2a and 2b show comparison of anthropometric and clinical variables of the two surveys in men and women respectively in relation to glucose tolerance status. Subjects with impaired fasting glucose (IFG) and diabetes (DM) were older, had increased weight, BMI, systolic and diastolic blood pressures ( p < 0.005) than subjects with normal glucose tolerance (NGT) in both men and women in 2009 survey. An increase in mean weight, BMI, systolic and diastolic blood pressures ( p < 0.005) was seen in both men and women during the time period between the two surveys. Fig. 1 shows the prevalence of diabetes and impaired fasting glucose in 2002 and 2009 surveys. The prevalence of IFG increased from 6.5% to 11.05% ( p < 0.000) and diabetes increased from 7.2% to 14.2% ( p < 0.000). Fig. 2 shows age specific prevalence of diabetes and IFG in both the surveys. When the two surveys were compared the prevalence of diabetes increased in age groups 55 years and above in men. The highest prevalence of diabetes in men was observed in 55–64 years age group as shown in Fig. 2a; whereas in women the highest prevalence of diabetes was observed at an older age, i.e. >65 years, Fig. 2b. The age specific prevalence of IFG in men and women is shown in Fig. 2c and d respectively. The highest prevalence of IFG in both the sexes was seen in 55–64 years age group in 2009 survey.
3.
4.
n Men:women Age (years) Men Women Overall Height (cm) Men Women Overall Weight (kg) Men Women Overall Body mass index Men Women Overall Family history of Men Women Overall Hypertension Men Women Overall
2002 Survey
2009 Survey
2032 670:1362
1264 424:840
40.4 11.85 38.1 11.51 38.85 11.67
43.47 13.91 41.67 11.73 42.27 12.53
0.000 0.000 0.000
167.16 6.52 162.95 7.66 164.33 7.56
165.6 6.45 161.38 7.63 162.79 7.52
0.000 0.000 0.000
62.55 13.43 52.77 12.42 55.99 13.56 (kg/m2) 22.4 4.74 19.98 5.04 20.78 5.07 diabetes mellitus 9 (1.3%) 9 (0.7%) 18 (0.88%)
69.87 14.54 65.72 14.83 67.11 14.86
0.000 0.000 0.000
25.62 5.46 25.32 6.06 25.42 5.89
0.000 0.000 0.000
129 (30.4%) 285 (33.9%) 414 (32.75%)
0.000 0.000 0.000
160 (23.88%) 252 (18.50%) 412 (20.27%)
244 (57.54%) 442 (52.61%) 686 (54.27%)
0.000 0.000 0.0001
p-Value
Values are Mean SD; n (%). p < 0.05 considered statistically significant.
Results
Table 1 shows comparison of the baseline anthropometric and clinical variables of the two surveys. A total of 1264 subjects
Discussion
A comparison of the two surveys in the rural area of Baluchistan showed that the prevalence of diabetes increased
Table 2a – Comparison of the anthropometric and clinical variables of the two surveys in men in relation to glucose tolerance status. Men n Age (years) Height (cm) Weight (kg) Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Years
2002 2009 2002 2009 2002 2009 2002 2009 2002 2009 2002 2009
Data is in the form of mean sd and n (%). For p value <0.05 NGT vs. IFG and NGT vs. DM. ** For p value <0.05 year 2002 vs. year 2009. *
Normal glucose tolerance (NGT)
Impaired fasting glucose (IFG)
Diabetes mellitus (DM)
842 (77.2%) 38.64 11.54 38.81 12.16 167.19 6.51 165.62 6.25** 62.08 13.05 68.25 13.87 22.24 4.66 25.03 5.21** 115.97 16.65 127.1 14.85** 74.01 11.12 83.46 8.89**
100 (9.2%) 45.73 12.46* 57.51 11.17*,** 168.29 6.27 164.73 6.27 65.92 15.4 72.35 14.34** 23.24 5.21 26.8 5.92** 120.39 20.87 137.04 16.64*,** 76.08 11.5 89.29 8.66*,**
149 (13.7%) 48.8 8.61* 54.43 9.57*,** 166.24 6.64 166.24 6.64 63.6 14.39 75.19 16.39*,** 23.0 4.94 27.36 6.28*,** 119.25 17.34 135.94 12.40*,** 77.76 12.15* 88.33 7.46*,**
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Table 2b – Comparison of the anthropometric and clinical variables of the two surveys in women in relation to glucose tolerance status. Women
Years
n Age (years)
2002 2009 2002 2009 2002 2009 2002 2009 2002 2009 2002 2009
Height (cm) Weight (kg) Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Normal glucose tolerance (NGT)
Impaired fasting glucose (IFG)
Diabetes mellitus (DM)
1850 (84.1%) 37.19 11.09 38.64 10.54** 163.06 7.63 161.39 7.6** 52.13 11.78 64.80 14.47** 19.69 4.69 24.92 5.50** 113.02 16.51 126.23 14.49** 72.21 10.48 82.41 8.86**
172 (7.8%) 44.8 12.73* 51.18 10.17*,** 161.34 8.14 161.79 7.07 56.98 15.01* 69.17 14.6*,** 22.07 6.52* 26.42 5.4** 122.68 22.77* 137.67 19.77*,** 76.95 16.3* 88.06 9.79*,**
177 (8.0%) 46.25 11.6* 51.34 10.07*,** 162.9 7.42 160.85 8.48 59.37 16.81* 68.36 16.51** 22.57 7.25* 26.78 8.84*,** 124.03 20.38* 138.62 15.64*,** 78.21 12.66* 88.95 8.98*,**
Data is in the form of mean sd and n (%). For p value <0.05 NGT vs. IFG and NGT vs. DM. ** For p value <0.05 year 2002 vs. year 2009. *
two fold over a period of seven years, similarly a significant increase in impaired fasting glucose (IFG) was also observed. Similar results were shown in other studies in the region. For instance, in rural Bangladesh prevalence of diabetes increased three fold in five years [4]. Likewise in Southern India, comparison of the two rural surveys demonstrated that the prevalence of diabetes also increased three fold over a period of fourteen years [3]. Similarly rural population of Malaysia also showed an increase in the diabetes prevalence from 3.9% to 12.2% over ten years period [5]. It has been postulated that the number of people with diabetes are increasing worldwide as a result of population growth, aging, transitional changes in lifestyle resulting in urbanization, increasing prevalence of obesity and physical inactivity [15]. Similarly, the rising prevalence of diabetes in the rural population of Baluchistan can be attributed to these factors. It was interesting to observe that mean height of both men and women decreased in 2009 survey compared to 2002 survey. Although the geographical location for the two surveys was the same but the studied subjects were different and this may be a random finding. In our study, mean BMI of the population increased significantly over a period of seven years. It is a well established fact that overweight, obesity, and 15
2002
14.2
2009
Prevalence (%)
11.05 10 6.5
7.2
5
0 Impaired Fasting Glucose
Diabetes Mellitus
Fig. 1 – Prevalence of impaired fasting glucose (IFG) and diabetes mellitus (DM) in 2002 and 2009 surveys.
weight gain are the major predictors for the development of diabetes [16–18]. A study in India also showed that higher BMI is independently associated as a risk for the occurrence of type 2 diabetes among both men and women [2]. Thus increase in obesity can be one of the major contributors to the rise in diabetes prevalence in rural Baluchistan. Another important finding in our study was that the number of men and women with positive family history of diabetes increased significantly. Positive family history of diabetes can result in increased prevalence of diabetes as suggested in several studies [19–21]. Moreover this shows a strong association of genetic factors with glucose tolerance [22]. Hypertension increased more than two fold in our study over a period of seven years. A study in the western world hypothesized that being overweight is associated with 2–6 fold increase in the risk of developing hypertension [23]. This raise in hypertension in our population can also be attributed to increase in obesity [24]. Furthermore, the prevalence of hypertension was also significantly associated with glucose tolerance status in our study similar to findings of other studies [25–27]. It has been postulated that the majority of diabetic subjects in the developing countries would be younger, i.e. in 45–64 years age group, whereas in developed countries majority of them would be >65 years [28], similar findings were observed in our surveys in men. However, it was interesting to note that the highest prevalence of diabetes in women was observed at an age of >65 years; the results need to be validated through further large scale studies. Our study has some limitations; we did not observe transitional changes in the lifestyle of the population of rural Baluchistan over a period of time including changes in the dietary habits, educational status, occupation as well as physical activity levels, which may contribute to the rising prevalence of diabetes. Moreover, further studies are needed adjusting age and obesity to confirm the study findings of increasing prevalence of diabetes in the rural areas of Baluchistan.
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diabetes research and clinical practice 94 (2011) 456–462
Age specific prevalence of Diabetes Mellitus in Men
Prevalence (%)
50
(a)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years) Age specific prevalence of Diabetes Mellitus in Women
Prevalence (%)
50
(b)
2002
2009
55-64
>65
40 30 20 10 0 25-34
35-44
45-54
Age groups (years) Age specific prevalence of Impaired Fasting Glucose in Men
Prevalence (%)
50
(c)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years) Age specific prevalence of Impaired Fasting Glucose in Women
Prevalence (%)
50
(d)
2002
2009
40 30 20 10 0 25-34
35-44
45-54
55-64
>65
Age group (years)
Fig. 2 – (a) Age-specific prevalence of diabetes mellitus (DM) in men in 2002 and 2009. (b) Age-specific prevalence of diabetes mellitus (DM) in women in 2002 and 2009. (c) Age-specific prevalence of impaired fasting glucose (IFG) in men in 2002 and 2009. (d) Age-specific prevalence of impaired fasting glucose (IFG) in women in 2002 and 2009.
diabetes research and clinical practice 94 (2011) 456–462
5.
Conclusion
The present study showed that diabetes increased two fold in the rural population of southern Baluchistan over a study period of seven years. Exposure of genetically high risk population to the environmental factors could be responsible for increasing prevalence of diabetes. Coordinated National programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Furthermore prospective studies with the aim to identify the risk factors are needed to ascertain the reasons of rising prevalence of glucose intolerance.
Acknowledgements We acknowledge the support of Merck Marker (Pvt) Ltd. for this survey. We would also like to appreciate the hard work and dedicated commitment of lady health workers, lab technicians and paramedical staff from Hub Baluchistan and also acknowledge the support of Mr. Bilal Tahir (Research Coordinator) and Ms. Fariha Shaheen (Statistician), Research Department of Baqai Institute of Diabetology and Endocrinology in data entry and analysis.
Conflict of interest The authors declare that they have no conflict of interest.
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