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Improving diabetes care in developing countries: The example of Pakistan
Accepted Manuscript Title: Improving diabetes care in developing countries: The example of Pakistan Author: Abdul Basit Musarrat Riaz Asher Fawwad PII: DOI: Reference:
S0168-8227(14)00473-2 http://dx.doi.org/doi:10.1016/j.diabres.2014.10.013 DIAB 6228
To appear in:
Diabetes Research and Clinical Practice
Received date: Accepted date:
14-10-2014 21-10-2014
Please cite this article as: A. Basit, M. Riaz, A. Fawwad, Improving diabetes care in developing countries: The example of Pakistan, Diabetes Research and Clinical Practice (2014), http://dx.doi.org/10.1016/j.diabres.2014.10.013 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Article type: Review Article Title: Improving diabetes care in developing countries: The example of Pakistan
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Musarrat Riaz, F.C.P.S Consultant Physician Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University. Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi-74600
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Abdul Basit, F.R.C.P. Professor of Medicine, Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan
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Authors:
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Asher Fawwad, M.phil Assistant Professor Baqai Medical University Senior Research Scientist Research Department Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan
Author for Correspondence
Abdul Basit, F.R.C.P. Professor of Medicine, Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan Phone: 92 21 36688897, 92 21 36608565, 92 21 36707179 Fax: 92 21 36608568 Email: [email protected]
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Summary Pakistan is a developing country with limited recourses and diverse economic social patterns. Pakistan has high prevalence of diabetes and its complication, which is a huge challenge to the
lifestyle, maternal and fetal malnutrition and genetic factors.
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existing health care system. The major contributing risk factors are urbanization and change in
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National action plans for control of diabetes have been made since 1995 but actions in this regard
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were not perfect. Training of primary care physicians and development of multidisciplinary diabetes care teams was initiated. Prioritization strategies were defined according to the
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International Diabetes Federation (IDF) guidance, mainly focusing on diabetic foot, diabetes education and children with diabetes. Researches for better understanding and management of
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diabetes in Pakistan were undertaken. Collaboration between various stakeholders was promoted at national and international level. In summary, public private relationships and development of
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multifaceted approaches is expected to improve the lives of millions of diabetics of Pakistan.
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Introduction Pakistan is a developing country with limited resources and diverse economic and social patterns. It has a population of 161.66 million (1), of whom 68%live in rural areas, 33% of the population
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lives below the poverty line and 40% have no access to even basic health services (2). Public expenditure on health and health infrastructure represents 0.7 -0.8% of GDP and 3.5% of total
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government expenditure. Pakistan spends less than 30% of health budget on the development of
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health infra-structure (2). The Government provides funding for diabetes as part of the general health system budget but diabetes itself receives an insignificant share. Specific funding through
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private and international collaborators is also very limited. There is no framework for diabetes monitoring and surveillance. Private partners and associations are carrying out some monitoring
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efforts but these are not sufficient.
A mixed public private health care system which exists in Pakistan is not equipped to cope with
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the rising prevalence of non- communicable diseases. Government has employed around 100,000 lady health workers for basic maternal and preventive child care services in rural areas (3), but
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these are only maximally matriculate in education. Also they are not trained to provide care for non-communicable diseases. Similarly there is shortage of qualified health care professionals in urban areas and private family physicians with no formal training of diabetes management provide the primary care services to the majority of diabetic patients. Pakistan has an estimated 6.7 million people affected with diabetes, according to the International Diabetes Federation (IDF) and this number is predicted to increase to 12.8 million by the year 2035 (4). Diabetic Association of Pakistan (DAP) has contributed significantly by serving as WHO collaborating center for diabetes and was involved in conducting national diabetes surveys (5-9).
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There is also an enormously high rate of chronic complications of diabetes. The reported frequency of coronary artery disease (CAD) is 15.1% and the projected increase in mortality per 100,000 population is from 125.5 to 144.4 (10). Similarly, peripheral vascular disease (PVD),
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and cerebrovascular disease is 5.5% and 4.5% respectively (11,12). As regards the micro vascular complications, 15.9% patients had retinopathy, 8.4% had nephropathy and 4% were affected by
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diabetic foot ulcer (11,12). The situation is further aggravated by the rising prevalence of
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Metabolic Syndrome (MS), childhood obesity and younger ages of onset of type 2 diabetes like in many other developing countries worldwide specially South Asian countries (13).
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The rapid increased prevalence of diabetes can partly be attributed to environmental and behavioral changes resulting from lifestyle changes. The highest rates of urbanization are seen in
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Korea, Malaysia, Singapore, Philippines and Indonesia while India, Pakistan, China and Thailand have intermediate rates followed by Sri Lanka and Bangladesh having slow rates of urbanization
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(14). These changes result in various adverse outcomes mainly physical inactivity, increase usage of electronic media like internet and television, unhealthier foods rich in calories and increase in
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obesity. As an example, in the World Health Survey 2002, inadequate consumption of fruits and vegetables was identified among masses in Pakistan compared with other countries (15). High rates of obesity among children and women and association of obesity with metabolic risk including diabetes have been observed. The South Asian population specifically has shown to have one of the highest risks (16). Approximately one in every four subjects aged 15 years or above is already overweight or obese in Pakistan. These changes in lifestyle are not limited to urban areas but rural population is also showing a similar trend worldwide, Pakistan being no exception. A recent study was carried out in the rural area of Hub, Baluchistan, to observe the temporal charges in the prevalence of diabetes, and its associated risk factors. In this community based survey of 1264 subjects aged 25 years and above, a two fold increase in the prevalence of
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diabetes (from 7.2% in 2002 to 14.2 in 2010) and impaired fasting glucose (from 6.5% to 11%) was observed over a period of 5 years with positive family history of diabetes showing significant increase from 7.6% to 16.52% (17). Obesity increased from 10.15% to 27.82%, and
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smoking was seen in 21.3% compared to 4.06% in 2002.Similar pattern of metabolic derangements leading to T2DM were observed in young adults aged 15-25 years (18).
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Malnourishment among pregnant mothers is another modifiable risk factor unfortunately still
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prevalent in Pakistan. Maternal mortality rate is 27.6%, while low birth weight (LBW) is reported to be 26%, both of which are very high reflecting the state of maternal nutrition (19). These
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factors predispose the offspring to Intrauterine Growth Retardation (IUGR) and expose the baby to higher risk of developing type 2 diabetes (20). In fact, it is the extra rate of catch up growth
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that at times results in increase in body fat rather than muscle mass and bone length. The resultant stunting is an indicator of early malnutrition. The reported frequency of stunting in Pakistani
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children is around 61.9% and nutrition indicators demonstrate that around 20% of children would be stunted and overweight predisposing them to central obesity and type 2 diabetes (21).
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Contribution of genetic factors in predisposition of South Asians to diabetes has been specified (22-24) and data on immigrant Pakistani population confirmed the association of certain genetic variants with type 2 diabetes (25). In Pakistan, ethnic differences have been noted but the studies were neither controlled nor accounting for all the risk factors. Genetic component in the occurrence of diabetes could not be verified. National Action Plans Pakistan was one of the first developing countries to have formulated an integrated national action plan (NAP) for non-communicable diseases, main contributors being Ministry of Health (MOH), WHO and Heart File an NGO (non-governmental organization) (26). The NAP was a comprehensive strategy involving all the stakeholders for the prevention of non-communicable
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diseases (27). The government could not maintain enough high level thrust to the NAP mainly because of lack of political will, conflict of interest with tobacco and food industries and inability to prioritize NCDs in health policies like Millennium Development Goals resulting in failure to
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attract donor agencies (28). Capacity Building
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According to the WHO, Pakistan has 3 times lower numbers of health care professionals as
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compared to the average numbers in the whole world (1.4/1000 vs 4.5/1000 people) (29).Pakistan till 1996 lacked any formal training programme in diabetes for medical and allied health
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professionals. BIDE was then established as the first diabetes based institute in Pakistan (30). It gave the concept that for around 7million diabetics, primary care diabetes setups ought to be
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developed and strengthened .Hence one year university based diploma in diabetes (Diploma in Diabetology for family physicians (DDM) was started in 1999 and majority of 300 plus doctors
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qualified so far are working at primary care level. Some actions have been taken within the public sector to address the rising epidemic of diabetes
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in Pakistan. In 2010, College of Physicians and Surgeons of Pakistan (CPSP) recognized diabetes and endocrinology as a sub-specialty for post fellowship programmes (31). Government of Pakistan established National Institute of Diabetes and Endocrinology (NIDE) offering Masters programme in Diabetes and Endocrinology (32). Jinnah Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) were inaugurated in November, 2009 at Allama Iqbal Medical College, Lahore. This institute is also recognized as the accredited endocrinology fellowship site by the CPSP (33). 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 providing services to diabetic patients, besides conducting public awareness programmes and disseminating knowledge.
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Another important step was the initiative taken with the collaboration of University of Oslo (UIO) called Norad’s Programme for Master Studies (NOMA). The goal of NOMA is to contribute to the academic training of faculty in public and private sectors as well as civil society
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in selected developing countries (34). This is achieved through building capacity at the Master’s level in higher education institutions in the south and Pakistan has benefitted from this
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programme offering Master and PhD degrees and the research work assigned to these students is
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mainly focused on exploring the scientific solutions for the unaddressed community based issues
Concept of multidisciplinary diabetes care team
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related to diabetes and other NCDs.
BIDE was the first to give the concept of multidisciplinary care team and is the pioneer institute
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in the field of diabetes education offering one year diploma, the first of its kind in Pakistan (30). Fifteen batches of Diploma in Diabetes Education (DDE) have completed so far. The course
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initiation was highly supported by the senior IDF colleagues specially Ms. Marg McGill and Ms. Anne Belton and the curriculum designing was in line with the IDF developed education modules
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with local customizations where deemed appropriate. Special attention was given to the training and development of diabetic foot care teams. Diabetic foot care assistants (DFCAs) training course of six weeks was designed considering the local resources and requirements and have got due recognition with time. International working group on diabetic foot (IWGDF) and IDF diabetic foot Consultative section (CS) have generously supported mainly in the Advisory Capacity. Realizing the fact that primary care physicians are the main contributors to the diabetes care delivery system and formal podiatry training is neither available locally nor affordable at present, DFCAs were trained to work under the supervision of doctors.
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Prioritization Strategies International Diabetes Federation (IDF) mission is “to promote diabetes care, prevention and cure worldwide”. The three top most priority sections identified by the IDF in the first decade of the
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new millennium were diabetic foot, diabetes education and diabetes & children. Such strategies are primarily defined considering the disease burden and limitations of resources in developing
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countries like Pakistan.
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The first diabetic foot clinic in the country was established in 1996. Diabetic foot care team was developed by training the foot care assistants and diabetes educators. Primary care physicians
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were especially trained for the management of diabetic foot. A concept of physician trained in diabetic foot surgeries specially was engineered reducing the surgical management cost
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tremendously without comprising the quality (35). Similarly low cost off-loading devices were developed locally (36). All these measures helped in reducing the amputation rate from 27.5% to
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13.6% over a period of 12 years (35).
Pakistan Working Group on the Diabetic Foot (PWGDF) was established in 2006, under the
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guidance of Dr. Karel Bakker (the then chairman of IWGDF). It involved leading diabetologists from across the country in response to an emerging need for co-ordination at the national level. In 2007, the National Diabetes and Diabetic Foot Programme funded by the World Diabetes Foundation was launched on the pattern of Step by Step foot care programme following its tremendous success in India and Tanzania (37). The most important achievement of the programme was the training of the diabetic foot care teams, each consisting of a doctor and a paramedic trained through basic and advanced courses. As a result, a nationwide network of 115 diabetic foot clinics was established and resulted in the reduction of amputation rate from 11.3% to 6.6% (35).
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Diabetes education has been considered the cornerstone for the management of diabetes (38). However, various studies and surveys conducted in Pakistan have shown that the level of awareness among patients as well as health care professional regarding diabetes is inadequate
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(39-41) and there is a need to implement measures which will enhance the level of diabetes education at community level (42,43). BIDE has so far trained 100 plus educators. Majority of
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these educators are working in close collaboration with the physicians serving a pivotal role in
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the multidisciplinary team providing patients the much needed infrastructure at grass root level. DAP has been conducting annual public awareness programmes on World Diabetes Day (44).
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BIDE initiated diabetes awareness walks 16 years ago. Uptil now more than 50,000 people have joined the walks. Now countrywide such awareness walks and programmes are being conducted
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under the umbrella of various institutions, associations and projects. The concept of twenty four hours helpline service for diabetic patients was given from the
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beginning and has developed gradually, though still far from perfection. This service has now been upgraded with the availability of stationed diabetes educators. The service provides help
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regarding insulin dose adjustments, treatment of hypo and hyperglycemia, queries regarding oral hypoglycemic agents as well as dose adjustments during special situations like travelling, Ramadan and Hajj etc. The salient feature of this service has been saving cost through reduction in emergency and hospital admissions (30). In 2010, National Association for Diabetes Educators of Pakistan (NADEP) was established (45). The aims of NADEP is to facilitate and promote the education of personal involved in the care of people with diabetes and those who are at risk of developing diabetes. The main objective of this association is to promote standardization, development and delivery of structured diabetes educational programs, to setup national and international collaborations for diabetes educational
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activities in Pakistan and to organize meeting, workshops and conferences in diabetes education and related disciplines. Recognizing BIDE services for diabetes education in Pakistan, the IDF honored it as one of the
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six centers of diabetes education for the period of 2009-2013 in World Congress in Montreal, Canada in 2009 (46). It has been renewed till 2015 in the World Congress in Melbourne,
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Australia in 2013. Noteworthy is also the fact that Pakistan is the only country in IDF MENA
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region with this designation.
Unfortunately majority of children with TIDM living in developing countries do not have access
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to the standardized care. Furthermore, unavailability of insulin to these patients results in life threatening complications. A study conducted in Pakistan by Shera et al., (47) to assess the mode
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of presentation and prevalence of acute and chronic complications in TIDM showed a very high
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complication rate. Over 40% were hypertensive, 20% had nephropathy, 25% retinopathy and
In December 2006, the General Assembly of United Nations passed a landmark resolution
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recognizing the management of diabetes as the right of the patients with diabetes (48).In the year 2010, BIDE initiated a programme “Insulin my life (IML)” to serve people with TIDM (49). This project was initially funded by the WDF. The main objective of IML was to provide integrated and comprehensive management to those children / people with T1DM who did not have access to insulin and other medical supplies.
Through this project, 34 model Type 1 diabetes clinics were established all over the Sindh province having a population of around 38 million. Thirty doctors and diabetes educators were trained for these clinics. A dedicated website “www.insulinmylife.com” was developed and provided information regarding TIDM to patients, health care providers and general public in English as well as in local languages for the first time. An insulin bank has been established and
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T1DM registry is being developed under this project. Educational material in local languages specifically for T1DMwas prepared and distributed not only to patients but to the general public as well.Three hundred thousand plus teachers were also sensitized through this material.
through educationimproved the glycemic control and quality of life.
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Research Avenues
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Provision of free insulin along with HbA1c and micro-albumin testingand increasing awareness
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There was a paucity of diabetes related data in Pakistan till early 90s as there were only a few scientifically well designed, properly randomized, and prospective studies .The only exception
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was prevalence surveys from the collaboration of the WHO and DAP. Research department of BIDE at that stage took the initiative and hence, some noteworthy work came into being.
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Prevalence of diabetes (as per the ADA criteria), and its associated risk factors were assessed in the adult population of sixteen Goths (Villages) from the rural area of Hub, Baluchistan in the
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year 2002 and 2009 (17). All parameters increased two to three folds over a study period of seven years. On the same note, published data from the population of Lyari, Karachi, a semi urban area
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and representative of all five major ethnic groups of Pakistani, showed a noticeably high prevalence of metabolic syndrome. A study in 15-25 years Pakistani adolescents from rural settings showed alarmingly high predisposing clinical and biochemical abnormalities (18). Same was found in school going children aged 8-10 years having modifiable risks factors for diabetes such as physical inactivity, unhealthy dietary habits and increased BMI (50). Now a multinational study to assess the role of intrauterine programming in the determination of cardio metabolic diseases, has been started and the analysis of preliminary data showed that the nutritional status of the mother affects the birth weight of the baby, an established determinant for future NCDs (51). The findings of these studies would not only help in the identification of the roots of these
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metabolic abnormalities but also would provide basis for the legislation and policy makers to address the associated psychosocial and economic factors. Currently, among Pakistani people with diabetes, it is estimated that nearly 4-10% people
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develop foot ulcers and around 10% of them undergo lower extremity amputations (LEAs) (52).Evidence from local published data ascertains that only the direct cost of treating foot ulcer
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may be more than the whole family`s average health budget for ten tears (53).With the
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establishment of the first diabetic foot clinic in the country at BIDE, aiming to standardizethe care of diabetic foot , the amputation rate decreased from 27.5% in the period 1997 to 2003, to
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13.6% in the period 2004 to 2009 and to 6.6% in 2010 (35). Custom made, cost effective offloading devices were developed and healing time of planter foot ulcers using them was found
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comparable to standard international techniques. Likewise, studies were done to understand the local culture and sensitivity patterns of organisms involved. Overall, these studies helped to
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determine the peculiarity of diabetic foot with respect to local population hence, giving directions to tackle the burden and associated morbidity and mortality.
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Surveys conducted in Pakistani diabetic subjects from both rural and urban population reported a significantly high prevalence of depression (54). Another cross-sectional, multi-center study conducted in urban setting, identified a large proportion of diabetics suffering from anxiety and/or depression along with associated risk factors. The preliminary results from an interventional study focusing the effect of the simultaneous management of depression in diabetic foot subjects showed favorable results in the outcome of both. These results alert clinicians to identify and treat both conditions with holistic approach. Fasting in Ramadan is one of the five pillars of Islam and all healthy adult Muslims are obligated to fast during Ramadan. According to the 2009 estimates, Muslims constitute 1.57 billion of the world’s population and growing by 3% per year. Globally, around 50 million and in Pakistan
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around three million Muslim diabetics fast (55). Most of the studies in Ramadan uptil now have been retrospective and observational (56). A Ramadan study group was formed lead by Prof. Muhammad Yakoob Ahmedani in the year 2004, to conduct research in this specific subset. So
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far this group has five publications (55, 57-60) highlighting different aspects of safe fasting for diabetics during Ramadan. Based on the findings and in collaboration with other international
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groups, practical recommendations are already being developed for family physicians.
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Genetic bases of diabetes and associated biochemical imbalance in Pakistani population is studied with the collaboration of University of Birmingham, UK and Karachi University of
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Pakistan (61). So far the candidate gene studies show comparable results with other Asian and western populations with some unique findings such as association of FTO gene polymorphism
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with T2DM are independent of BMI. Still a lot of data is emerging that will help to identify the targeted high risk group even before the appearance of clinical and biochemical abnormalities.
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Moreover pharmacogentics will be helpful in future for individualized pharmacotherapy. One of the most important aspects of diabetes research in a developing country is to help define
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effective measures for primary prevention. A study done with the collaboration ofUIO showed lifestyle modification as the best modality in preventing diabetes at least in study settings; a finding almost universally accepted through published studies (62). A risk score by the name of RAPID (Risk Assessment of Pakistani Individuals for Diabetes), based on a self-assessment questionnaire has recently been published (63). The RAPID risk score was developed by using simple parameters namely age, waist circumference and family history of diabetes. Odds ratio of the model was used to assign a score value for each variable and the diabetes risk score was calculated as the sum of those scores. A cut point of 4 is used for the identification of high risk individuals for early intervention to delay or prevent type 2 diabetes
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inPakistanipopulation and is expected to create a base for initiating cost effective national screening programme. Special Developments
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Advisory Board for the Care of Diabetes (ABCD) in Pakistan has been established in publicprivate relationship in 2012 (64). This board consists of leading diabetologists of tenleading
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teaching hospitals in ten different cities throughout Pakistan. A memorandum of understanding
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(MOU) has been signed with a pharmaceutical industry to provide unrestricted grant to digitally link the diabetes units of these 10 institutions to exchange academic, clinical and research
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programmes.
There were lacks of national recommendations for self-monitoring of blood glucose (SMBG). A
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project by the name of BRIGHT (Better Recommendations, Implementation and Guideline development for Health care providers and their Training) has been initiated (64).
Advisory
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Board (ABCD) has developed the SMBG recommendations endorsed by NADEP. The aim of the project is to train family Physicians on the best usage of SMBG. Special considerations have
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been given to affordability at each step.
Diabetes like many other non-communicable diseases is largely preventable through modifiable risk factors such as unhealthy diets, physical inactivity, obesity, tobacco use etc. There is enough evidence that regular physical activity and healthy diets can delay or prevent the occurrence of type 2 diabetes (65,66). This is particularly relevant in Pakistan because of younger age of onset of diabetes, increased incidence of abdominal adiposity, insulin resistance and metabolic syndrome compared with other populations. Added to this is the lack of effective primary health care services and equitable access of masses to these facilities, further emphasizing its importance (67).
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BRIDGES (Bringing Research in Diabetes to Global Environments and Systems) is an IDF programme dedicated to the translational research projects. The Aga Khan University, Karachi in collaboration with the University of Helsinki has started Karachi based Pakistan Diabetes
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Prevention Programme (PDPP) funded by the BRIDGES which addresses key issues in the prevention of type 2 diabetes (68).
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A large scale awareness programme by the name of “Stop Diabetes in Pakistan” is being initiated
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by NADEP (79). Multiple stakeholders especially pharmaceutical industry, corporate sector and philanthropic NGOs have been approached. The aim of the project is to involve whole
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community by initiating a media campaign emphasizing self-assessment of diabetes risk using RAPID score and developing strategies to modify their lifestyle in order to reduce their chances
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of developing diabetes.
Gestational Diabetes Mellitus (GDM) has not been given due importance in Pakistan. A
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prevalence as high as 9.9% - 17.8% has been reported from Tamil Nadu, India (70). Considering the ethnic commonalities and similarities between Pakistani and Indian populations, it would not
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be unjustifiable to believe that actual prevalence of GDM in Pakistani women may be much higher than reported. Moreover, complication rates in Pakistani GDM subjects have been found to be higher possibly due to poor glycemiccontrol (71), as compared to the western world. These include maternal complications like eclampsia (19%), polyhydramnios (4.6%), and threatened abortion (3.4%) and fetal complications like macrosomia (13.1%), intrauterine growth retardation (7.1%) and intrauterine deaths (5.3%) (71). Despite this situation, multidisciplinary GDM clinics are almost non-existent. Hence, a GDM project has been initiated by Baqai Medical University (BMU) funded by the WDF for three years (72). The collaborating partners include Baqai Medical University, Karachi and Fatima Bai hospital, Karachi (under the management of Fatima
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Bai Trust), countess of Dufferin Fund Hospital, Hyderabad (Managed by Local Government, Hyderabad), Society of Obstetrician and Gynecologist of Pakistan (SOGP) and NADEP. Establishment of GDM Advocacy Board, consisting of eminent obstetricians, diabetologists, and
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leaders of public opinionhas been done in January 2014 (73).The main objectives of this 3 years project are to create awareness in the community, regarding GDM, to train health care
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professionals in prevention, screening, diagnosis and management of GDM, to Institutionalize
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GDM screening and to organize integrated GDM services. The planned project activities include Public Awareness Campaign on GDM through print and electronic media, development of
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awareness literature on GDM and its dissemination through public awareness programmes and training courses in GDM for doctors, midwives and paramedics involved in obstetric care.
GDM clinics, screening of pregnant
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Other objectives of the project includes establishment of three major GDM centers and 30 minor women for GDM, dietary and educational counseling,
Manual” .
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management and monitoring of identified GDM cases, and development of “GDM Reference
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Pakistan Endocrine Society (PES) was established in 2001 (74) and has been holding annual symposia, monthly clinical meetings, and educational seminars for physicians, and public awareness campaigns throughout the country. It promotes educational and research activities in Endocrinology, Diabetes and Metabolism. PES represents endocrine specialists working in universities, teaching hospitals, and private practice. Its members also include general physicians, research scholars, post graduate trainees, surgeons, gynecologists, nurses and educators. Currently more than 500 registered members are actively involved with the society. Special honors for Pakistan The IDF Young Leaders in Diabetes (YLD) Programme aims at improving the lives of young people with diabetes, through the development of tomorrow’s leaders in the diabetes
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community(75). The Young Leaders are committed to raise awareness of diabetes by being a powerful voice for prevention, education, access to quality care, improved quality of life, and the end of discrimination worldwide. Mrs. Sana Ajmal, a type 1 diabetic from Pakistan is currently
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the President Elect of the IDF YLD project. Her success story is strength for type 1 diabetics of the country and the developing world (76).
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IDF has implemented a diabetes education programme of Conversation Map Tools (DCM) in
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2008 (77). IDF has trained six expert trainers to represent centers of education in different countries. Ms. Erum Ghafoor has been trained as an IDFexpert trainer from Pakistan in 2009. She
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has trained 850 facilitators and 30,000 people with diabetes across the country. She is also serving as faculty member for young leaders in diabetes programme by the platform of IDF -
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center of Education in Pakistan (78). Future directions
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Major headway to deal with diabetes and other NCDs in developing countries lies in broadening the canvas of capacity building. Four weeks certified courses have been started for doctors and
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educators since January 2014 aiming to ensure that primary health care is geared up for provision of quality diabetes care at the grass root level. In future, these certified GPs will form the basis of primary care diabetes clinics. The proposal is to develop 3000 such clinics across the country. These clinics are to be supervised by the secondary care setups run by the diabetes diploma holders(DDM). ABCD linking the tertiary care diabetes units of major teaching hospitals will serve as the academic, research and clinical support and guidance providers as part of the National Health Network for diabetes. Master of Science in Public Health (MSPH) focusing only on NCDs is the way forward for the development of such network. MSPH program aims to develop leaders in public health with special emphasis on implementation of preventive strategies for NCDs at community level.
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PWGDF is aiming to develop 1700 foot clinics nationwide. Considering the success of 115 such clinics through WDF funded SbS programme, next step of training 600 diabetic foot care teams has already taken place. Stepwise training through basic and advance courses of 1700 such foot
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care teams is expected to be complete by the year 2018. These specialized foot care setups shall not only lower the LEA rates further but, a step forward, will help preventing diabetic foot ulcers.
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Recognition as IDF center of education has paved the way for wider acceptability of
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internationally proven cost-effective interventional strategies. These in particular include role of educators and educational materials in streamlining self-management. Development of national
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level 24 hours helpline and centralizing information through national network can lead to better care and outcomes. In Singapore, IDF DECS meeting in June 2014, each IDF center of education
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has been given the task not only to improve and build diabetes education status in their countries
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operation.
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but to facilitate the same in their respective IDF regions through mutual and integrated co-
The IML project has already sensitized many stakeholders for better T1DM care. Punjab, the
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largest province of Pakistan has actively initiated plans while Khyber Pakhtoon Khwaa(KPK), another province has through the efforts of PES and provincial government developed a mutual agreement for free insulin supplies. It is hoped that Insulin Bank will be established at the National level for provision of free insulin for people with T1DM along with free consultation, SMBG & laboratory facilities. In future, IML will continue collaborating with IDF “Life for a child programme” for improving the care of people with T1DM in Pakistan. Successful primary prevention of diabetes is the key to future directions. “Stop Diabetes in Pakistan” will specially focus on children to assess translation of lifestyle behaviors to diseases. This activity will establish a foundation for lifelong tracks into adulthood. Material for education and awareness for sustainable behavioral changes and training curriculum for preventive
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managers focusing on communication and organization skills will be developed. Web based information portal “www.stopdiabetesinpakistan.com” and in addition, the electronic media will be used to disseminate key information.
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Various collaborative programmes with blindness prevention group, kidney foundation, Pakistan Hypertension League, Pakistan Cardiac Society, Pakistan Chest Society, Molecular Biology
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department of Karachi University etc. are in different stages of development. These programs are
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expected to contribute in diabetes and more comprehensively in NCD management and prevention across Pakistan.
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After the 18th Constitutional Amendment in Pakistan, health sectors have been given under the provincial government. This has provided much more autonomy than before. Reasonable
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reduction in morbidity and mortality can now be targeted and followed. Prescription policies can be developed by bodies like DAP, BIDE, PES, NADEP and ABCD in collaboration and
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government can ensure implementation. Anti-hypertensive, aspirin and statin can be combined as recommended by WHO and other bodies. Cross financing models and bulk manufacturing of
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diagnostic kits and medicines can be very effective simple strategies for remarkable improvement in provision of care in low resource settings. Energy saving activities like walking and cycling, intake of fruits and vegetables and lesser consumption of oil and fats would lead to reduction not only of deaths but also of diabetes and NCDs. In March 2014, Pakistan Diabetes leadership Forum (PDLF) was launched in collaboration with World Health Organization (WHO), IDF, WDF,Health Ministry of Pakistan, DAP, BIDE,Sakina Institute of Diabetes,Endocrine and Research (SIDER), Pakistan Institute of Medical Sciences(PIMS) and PES. A proposed outline of the “Islamabad Call to Commitment and Action” which will eventually lead to the formulation of the National Diabetes Action Plan and policy document for Pakistan was presented at PDLF. The forum highlighted the importance of
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capacity building to tackle the rising epidemic of diabetes. Proposed actions included development of National guidelines on diabetes management for all levels of care i.e., training primary, secondary and tertiary care physicians, training diabetes educators, utilizing lady health
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workers (LHW), training technicians and paramedics, implementers and mid-level management along with sensitizing policy makers and including a holistic approach to management of NCDs
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in general and diabetes in particular in undergraduate medical, nursing and paramedical curricula.
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It was also recommended that a Diabetes Training Unit will be established at each District Headquarter Hospital (DHQ) which will serve as a local training resource. In essence, future
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directions provide enough optimism to all the stakeholders to dedicate their strengths and pool
lives of millions of diabetics of Pakistan.
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Nothing to declare
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Declaration of Competing Interests
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their resources for much needed concerted and streamlined efforts to make a visible change in the
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47. Shera AS, Miyan Z, Basit A, Maqsood A, Ahmedani MY, Fawwad A,et al. Trends of Type 1 Diabetes in Karachi, Pakistan. Journal of Pediatrics Diabetes, 2008; (Part-II) 9(4): 401-406 48. United Nations GA. Resolution 61/225. Diabetes Day. 2006. Ref Type: Bill/Resolution. 49. Insulin my life. Available from www.insulinmylife.com (accessed August 11, 2014). 50. Hydrie MZI, Basit A, Badaruddin N, Ahmedani MY. Diabetes risk factors in middle income Pakistani school children Pakistan Journal of Nutrition, 2004; 3(1): 43-49 51. Shaikh F, Zeeshan F, Hakeem R, Basit A, Fawwad A Hussain A. Maternal Dietary Intake and Anthropometric Measurements of Newborn at Birth. Accepted for publication in The Open Diabetes Journal, 2014, 7, 14-19
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S0168-8227(14)00473-2 http://dx.doi.org/doi:10.1016/j.diabres.2014.10.013 DIAB 6228
To appear in:
Diabetes Research and Clinical Practice
Received date: Accepted date:
14-10-2014 21-10-2014
Please cite this article as: A. Basit, M. Riaz, A. Fawwad, Improving diabetes care in developing countries: The example of Pakistan, Diabetes Research and Clinical Practice (2014), http://dx.doi.org/10.1016/j.diabres.2014.10.013 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Article type: Review Article Title: Improving diabetes care in developing countries: The example of Pakistan
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Musarrat Riaz, F.C.P.S Consultant Physician Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University. Plot No. 1-2, II-B, Block 2, Nazimabad, Karachi-74600
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Abdul Basit, F.R.C.P. Professor of Medicine, Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan
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Authors:
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Asher Fawwad, M.phil Assistant Professor Baqai Medical University Senior Research Scientist Research Department Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan
Author for Correspondence
Abdul Basit, F.R.C.P. Professor of Medicine, Department of Medicine Baqai Institute of Diabetology and Endocrinology Baqai Medical University Plot No. 1-2, II-B, Nazimabad No2, Karachi-74600, Pakistan Phone: 92 21 36688897, 92 21 36608565, 92 21 36707179 Fax: 92 21 36608568 Email: [email protected]
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Summary Pakistan is a developing country with limited recourses and diverse economic social patterns. Pakistan has high prevalence of diabetes and its complication, which is a huge challenge to the
lifestyle, maternal and fetal malnutrition and genetic factors.
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existing health care system. The major contributing risk factors are urbanization and change in
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National action plans for control of diabetes have been made since 1995 but actions in this regard
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were not perfect. Training of primary care physicians and development of multidisciplinary diabetes care teams was initiated. Prioritization strategies were defined according to the
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International Diabetes Federation (IDF) guidance, mainly focusing on diabetic foot, diabetes education and children with diabetes. Researches for better understanding and management of
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diabetes in Pakistan were undertaken. Collaboration between various stakeholders was promoted at national and international level. In summary, public private relationships and development of
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multifaceted approaches is expected to improve the lives of millions of diabetics of Pakistan.
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Introduction Pakistan is a developing country with limited resources and diverse economic and social patterns. It has a population of 161.66 million (1), of whom 68%live in rural areas, 33% of the population
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lives below the poverty line and 40% have no access to even basic health services (2). Public expenditure on health and health infrastructure represents 0.7 -0.8% of GDP and 3.5% of total
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government expenditure. Pakistan spends less than 30% of health budget on the development of
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health infra-structure (2). The Government provides funding for diabetes as part of the general health system budget but diabetes itself receives an insignificant share. Specific funding through
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private and international collaborators is also very limited. There is no framework for diabetes monitoring and surveillance. Private partners and associations are carrying out some monitoring
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efforts but these are not sufficient.
A mixed public private health care system which exists in Pakistan is not equipped to cope with
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the rising prevalence of non- communicable diseases. Government has employed around 100,000 lady health workers for basic maternal and preventive child care services in rural areas (3), but
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these are only maximally matriculate in education. Also they are not trained to provide care for non-communicable diseases. Similarly there is shortage of qualified health care professionals in urban areas and private family physicians with no formal training of diabetes management provide the primary care services to the majority of diabetic patients. Pakistan has an estimated 6.7 million people affected with diabetes, according to the International Diabetes Federation (IDF) and this number is predicted to increase to 12.8 million by the year 2035 (4). Diabetic Association of Pakistan (DAP) has contributed significantly by serving as WHO collaborating center for diabetes and was involved in conducting national diabetes surveys (5-9).
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There is also an enormously high rate of chronic complications of diabetes. The reported frequency of coronary artery disease (CAD) is 15.1% and the projected increase in mortality per 100,000 population is from 125.5 to 144.4 (10). Similarly, peripheral vascular disease (PVD),
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and cerebrovascular disease is 5.5% and 4.5% respectively (11,12). As regards the micro vascular complications, 15.9% patients had retinopathy, 8.4% had nephropathy and 4% were affected by
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diabetic foot ulcer (11,12). The situation is further aggravated by the rising prevalence of
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Metabolic Syndrome (MS), childhood obesity and younger ages of onset of type 2 diabetes like in many other developing countries worldwide specially South Asian countries (13).
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The rapid increased prevalence of diabetes can partly be attributed to environmental and behavioral changes resulting from lifestyle changes. The highest rates of urbanization are seen in
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Korea, Malaysia, Singapore, Philippines and Indonesia while India, Pakistan, China and Thailand have intermediate rates followed by Sri Lanka and Bangladesh having slow rates of urbanization
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(14). These changes result in various adverse outcomes mainly physical inactivity, increase usage of electronic media like internet and television, unhealthier foods rich in calories and increase in
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obesity. As an example, in the World Health Survey 2002, inadequate consumption of fruits and vegetables was identified among masses in Pakistan compared with other countries (15). High rates of obesity among children and women and association of obesity with metabolic risk including diabetes have been observed. The South Asian population specifically has shown to have one of the highest risks (16). Approximately one in every four subjects aged 15 years or above is already overweight or obese in Pakistan. These changes in lifestyle are not limited to urban areas but rural population is also showing a similar trend worldwide, Pakistan being no exception. A recent study was carried out in the rural area of Hub, Baluchistan, to observe the temporal charges in the prevalence of diabetes, and its associated risk factors. In this community based survey of 1264 subjects aged 25 years and above, a two fold increase in the prevalence of
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diabetes (from 7.2% in 2002 to 14.2 in 2010) and impaired fasting glucose (from 6.5% to 11%) was observed over a period of 5 years with positive family history of diabetes showing significant increase from 7.6% to 16.52% (17). Obesity increased from 10.15% to 27.82%, and
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smoking was seen in 21.3% compared to 4.06% in 2002.Similar pattern of metabolic derangements leading to T2DM were observed in young adults aged 15-25 years (18).
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Malnourishment among pregnant mothers is another modifiable risk factor unfortunately still
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prevalent in Pakistan. Maternal mortality rate is 27.6%, while low birth weight (LBW) is reported to be 26%, both of which are very high reflecting the state of maternal nutrition (19). These
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factors predispose the offspring to Intrauterine Growth Retardation (IUGR) and expose the baby to higher risk of developing type 2 diabetes (20). In fact, it is the extra rate of catch up growth
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that at times results in increase in body fat rather than muscle mass and bone length. The resultant stunting is an indicator of early malnutrition. The reported frequency of stunting in Pakistani
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children is around 61.9% and nutrition indicators demonstrate that around 20% of children would be stunted and overweight predisposing them to central obesity and type 2 diabetes (21).
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Contribution of genetic factors in predisposition of South Asians to diabetes has been specified (22-24) and data on immigrant Pakistani population confirmed the association of certain genetic variants with type 2 diabetes (25). In Pakistan, ethnic differences have been noted but the studies were neither controlled nor accounting for all the risk factors. Genetic component in the occurrence of diabetes could not be verified. National Action Plans Pakistan was one of the first developing countries to have formulated an integrated national action plan (NAP) for non-communicable diseases, main contributors being Ministry of Health (MOH), WHO and Heart File an NGO (non-governmental organization) (26). The NAP was a comprehensive strategy involving all the stakeholders for the prevention of non-communicable
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diseases (27). The government could not maintain enough high level thrust to the NAP mainly because of lack of political will, conflict of interest with tobacco and food industries and inability to prioritize NCDs in health policies like Millennium Development Goals resulting in failure to
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attract donor agencies (28). Capacity Building
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According to the WHO, Pakistan has 3 times lower numbers of health care professionals as
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compared to the average numbers in the whole world (1.4/1000 vs 4.5/1000 people) (29).Pakistan till 1996 lacked any formal training programme in diabetes for medical and allied health
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professionals. BIDE was then established as the first diabetes based institute in Pakistan (30). It gave the concept that for around 7million diabetics, primary care diabetes setups ought to be
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developed and strengthened .Hence one year university based diploma in diabetes (Diploma in Diabetology for family physicians (DDM) was started in 1999 and majority of 300 plus doctors
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qualified so far are working at primary care level. Some actions have been taken within the public sector to address the rising epidemic of diabetes
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in Pakistan. In 2010, College of Physicians and Surgeons of Pakistan (CPSP) recognized diabetes and endocrinology as a sub-specialty for post fellowship programmes (31). Government of Pakistan established National Institute of Diabetes and Endocrinology (NIDE) offering Masters programme in Diabetes and Endocrinology (32). Jinnah Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) were inaugurated in November, 2009 at Allama Iqbal Medical College, Lahore. This institute is also recognized as the accredited endocrinology fellowship site by the CPSP (33). 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 providing services to diabetic patients, besides conducting public awareness programmes and disseminating knowledge.
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Another important step was the initiative taken with the collaboration of University of Oslo (UIO) called Norad’s Programme for Master Studies (NOMA). The goal of NOMA is to contribute to the academic training of faculty in public and private sectors as well as civil society
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in selected developing countries (34). This is achieved through building capacity at the Master’s level in higher education institutions in the south and Pakistan has benefitted from this
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programme offering Master and PhD degrees and the research work assigned to these students is
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mainly focused on exploring the scientific solutions for the unaddressed community based issues
Concept of multidisciplinary diabetes care team
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related to diabetes and other NCDs.
BIDE was the first to give the concept of multidisciplinary care team and is the pioneer institute
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in the field of diabetes education offering one year diploma, the first of its kind in Pakistan (30). Fifteen batches of Diploma in Diabetes Education (DDE) have completed so far. The course
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initiation was highly supported by the senior IDF colleagues specially Ms. Marg McGill and Ms. Anne Belton and the curriculum designing was in line with the IDF developed education modules
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with local customizations where deemed appropriate. Special attention was given to the training and development of diabetic foot care teams. Diabetic foot care assistants (DFCAs) training course of six weeks was designed considering the local resources and requirements and have got due recognition with time. International working group on diabetic foot (IWGDF) and IDF diabetic foot Consultative section (CS) have generously supported mainly in the Advisory Capacity. Realizing the fact that primary care physicians are the main contributors to the diabetes care delivery system and formal podiatry training is neither available locally nor affordable at present, DFCAs were trained to work under the supervision of doctors.
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Prioritization Strategies International Diabetes Federation (IDF) mission is “to promote diabetes care, prevention and cure worldwide”. The three top most priority sections identified by the IDF in the first decade of the
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new millennium were diabetic foot, diabetes education and diabetes & children. Such strategies are primarily defined considering the disease burden and limitations of resources in developing
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countries like Pakistan.
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The first diabetic foot clinic in the country was established in 1996. Diabetic foot care team was developed by training the foot care assistants and diabetes educators. Primary care physicians
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were especially trained for the management of diabetic foot. A concept of physician trained in diabetic foot surgeries specially was engineered reducing the surgical management cost
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tremendously without comprising the quality (35). Similarly low cost off-loading devices were developed locally (36). All these measures helped in reducing the amputation rate from 27.5% to
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13.6% over a period of 12 years (35).
Pakistan Working Group on the Diabetic Foot (PWGDF) was established in 2006, under the
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guidance of Dr. Karel Bakker (the then chairman of IWGDF). It involved leading diabetologists from across the country in response to an emerging need for co-ordination at the national level. In 2007, the National Diabetes and Diabetic Foot Programme funded by the World Diabetes Foundation was launched on the pattern of Step by Step foot care programme following its tremendous success in India and Tanzania (37). The most important achievement of the programme was the training of the diabetic foot care teams, each consisting of a doctor and a paramedic trained through basic and advanced courses. As a result, a nationwide network of 115 diabetic foot clinics was established and resulted in the reduction of amputation rate from 11.3% to 6.6% (35).
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Diabetes education has been considered the cornerstone for the management of diabetes (38). However, various studies and surveys conducted in Pakistan have shown that the level of awareness among patients as well as health care professional regarding diabetes is inadequate
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(39-41) and there is a need to implement measures which will enhance the level of diabetes education at community level (42,43). BIDE has so far trained 100 plus educators. Majority of
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these educators are working in close collaboration with the physicians serving a pivotal role in
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the multidisciplinary team providing patients the much needed infrastructure at grass root level. DAP has been conducting annual public awareness programmes on World Diabetes Day (44).
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BIDE initiated diabetes awareness walks 16 years ago. Uptil now more than 50,000 people have joined the walks. Now countrywide such awareness walks and programmes are being conducted
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under the umbrella of various institutions, associations and projects. The concept of twenty four hours helpline service for diabetic patients was given from the
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beginning and has developed gradually, though still far from perfection. This service has now been upgraded with the availability of stationed diabetes educators. The service provides help
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regarding insulin dose adjustments, treatment of hypo and hyperglycemia, queries regarding oral hypoglycemic agents as well as dose adjustments during special situations like travelling, Ramadan and Hajj etc. The salient feature of this service has been saving cost through reduction in emergency and hospital admissions (30). In 2010, National Association for Diabetes Educators of Pakistan (NADEP) was established (45). The aims of NADEP is to facilitate and promote the education of personal involved in the care of people with diabetes and those who are at risk of developing diabetes. The main objective of this association is to promote standardization, development and delivery of structured diabetes educational programs, to setup national and international collaborations for diabetes educational
Page 9 of 28
activities in Pakistan and to organize meeting, workshops and conferences in diabetes education and related disciplines. Recognizing BIDE services for diabetes education in Pakistan, the IDF honored it as one of the
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six centers of diabetes education for the period of 2009-2013 in World Congress in Montreal, Canada in 2009 (46). It has been renewed till 2015 in the World Congress in Melbourne,
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Australia in 2013. Noteworthy is also the fact that Pakistan is the only country in IDF MENA
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region with this designation.
Unfortunately majority of children with TIDM living in developing countries do not have access
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to the standardized care. Furthermore, unavailability of insulin to these patients results in life threatening complications. A study conducted in Pakistan by Shera et al., (47) to assess the mode
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of presentation and prevalence of acute and chronic complications in TIDM showed a very high
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17.2% had neuropathy (47).
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complication rate. Over 40% were hypertensive, 20% had nephropathy, 25% retinopathy and
In December 2006, the General Assembly of United Nations passed a landmark resolution
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recognizing the management of diabetes as the right of the patients with diabetes (48).In the year 2010, BIDE initiated a programme “Insulin my life (IML)” to serve people with TIDM (49). This project was initially funded by the WDF. The main objective of IML was to provide integrated and comprehensive management to those children / people with T1DM who did not have access to insulin and other medical supplies.
Through this project, 34 model Type 1 diabetes clinics were established all over the Sindh province having a population of around 38 million. Thirty doctors and diabetes educators were trained for these clinics. A dedicated website “www.insulinmylife.com” was developed and provided information regarding TIDM to patients, health care providers and general public in English as well as in local languages for the first time. An insulin bank has been established and
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T1DM registry is being developed under this project. Educational material in local languages specifically for T1DMwas prepared and distributed not only to patients but to the general public as well.Three hundred thousand plus teachers were also sensitized through this material.
through educationimproved the glycemic control and quality of life.
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Research Avenues
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Provision of free insulin along with HbA1c and micro-albumin testingand increasing awareness
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There was a paucity of diabetes related data in Pakistan till early 90s as there were only a few scientifically well designed, properly randomized, and prospective studies .The only exception
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was prevalence surveys from the collaboration of the WHO and DAP. Research department of BIDE at that stage took the initiative and hence, some noteworthy work came into being.
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Prevalence of diabetes (as per the ADA criteria), and its associated risk factors were assessed in the adult population of sixteen Goths (Villages) from the rural area of Hub, Baluchistan in the
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year 2002 and 2009 (17). All parameters increased two to three folds over a study period of seven years. On the same note, published data from the population of Lyari, Karachi, a semi urban area
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and representative of all five major ethnic groups of Pakistani, showed a noticeably high prevalence of metabolic syndrome. A study in 15-25 years Pakistani adolescents from rural settings showed alarmingly high predisposing clinical and biochemical abnormalities (18). Same was found in school going children aged 8-10 years having modifiable risks factors for diabetes such as physical inactivity, unhealthy dietary habits and increased BMI (50). Now a multinational study to assess the role of intrauterine programming in the determination of cardio metabolic diseases, has been started and the analysis of preliminary data showed that the nutritional status of the mother affects the birth weight of the baby, an established determinant for future NCDs (51). The findings of these studies would not only help in the identification of the roots of these
Page 11 of 28
metabolic abnormalities but also would provide basis for the legislation and policy makers to address the associated psychosocial and economic factors. Currently, among Pakistani people with diabetes, it is estimated that nearly 4-10% people
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develop foot ulcers and around 10% of them undergo lower extremity amputations (LEAs) (52).Evidence from local published data ascertains that only the direct cost of treating foot ulcer
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may be more than the whole family`s average health budget for ten tears (53).With the
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establishment of the first diabetic foot clinic in the country at BIDE, aiming to standardizethe care of diabetic foot , the amputation rate decreased from 27.5% in the period 1997 to 2003, to
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13.6% in the period 2004 to 2009 and to 6.6% in 2010 (35). Custom made, cost effective offloading devices were developed and healing time of planter foot ulcers using them was found
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comparable to standard international techniques. Likewise, studies were done to understand the local culture and sensitivity patterns of organisms involved. Overall, these studies helped to
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determine the peculiarity of diabetic foot with respect to local population hence, giving directions to tackle the burden and associated morbidity and mortality.
Ac ce p
Surveys conducted in Pakistani diabetic subjects from both rural and urban population reported a significantly high prevalence of depression (54). Another cross-sectional, multi-center study conducted in urban setting, identified a large proportion of diabetics suffering from anxiety and/or depression along with associated risk factors. The preliminary results from an interventional study focusing the effect of the simultaneous management of depression in diabetic foot subjects showed favorable results in the outcome of both. These results alert clinicians to identify and treat both conditions with holistic approach. Fasting in Ramadan is one of the five pillars of Islam and all healthy adult Muslims are obligated to fast during Ramadan. According to the 2009 estimates, Muslims constitute 1.57 billion of the world’s population and growing by 3% per year. Globally, around 50 million and in Pakistan
Page 12 of 28
around three million Muslim diabetics fast (55). Most of the studies in Ramadan uptil now have been retrospective and observational (56). A Ramadan study group was formed lead by Prof. Muhammad Yakoob Ahmedani in the year 2004, to conduct research in this specific subset. So
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far this group has five publications (55, 57-60) highlighting different aspects of safe fasting for diabetics during Ramadan. Based on the findings and in collaboration with other international
cr
groups, practical recommendations are already being developed for family physicians.
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Genetic bases of diabetes and associated biochemical imbalance in Pakistani population is studied with the collaboration of University of Birmingham, UK and Karachi University of
an
Pakistan (61). So far the candidate gene studies show comparable results with other Asian and western populations with some unique findings such as association of FTO gene polymorphism
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with T2DM are independent of BMI. Still a lot of data is emerging that will help to identify the targeted high risk group even before the appearance of clinical and biochemical abnormalities.
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Moreover pharmacogentics will be helpful in future for individualized pharmacotherapy. One of the most important aspects of diabetes research in a developing country is to help define
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effective measures for primary prevention. A study done with the collaboration ofUIO showed lifestyle modification as the best modality in preventing diabetes at least in study settings; a finding almost universally accepted through published studies (62). A risk score by the name of RAPID (Risk Assessment of Pakistani Individuals for Diabetes), based on a self-assessment questionnaire has recently been published (63). The RAPID risk score was developed by using simple parameters namely age, waist circumference and family history of diabetes. Odds ratio of the model was used to assign a score value for each variable and the diabetes risk score was calculated as the sum of those scores. A cut point of 4 is used for the identification of high risk individuals for early intervention to delay or prevent type 2 diabetes
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inPakistanipopulation and is expected to create a base for initiating cost effective national screening programme. Special Developments
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Advisory Board for the Care of Diabetes (ABCD) in Pakistan has been established in publicprivate relationship in 2012 (64). This board consists of leading diabetologists of tenleading
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teaching hospitals in ten different cities throughout Pakistan. A memorandum of understanding
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(MOU) has been signed with a pharmaceutical industry to provide unrestricted grant to digitally link the diabetes units of these 10 institutions to exchange academic, clinical and research
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programmes.
There were lacks of national recommendations for self-monitoring of blood glucose (SMBG). A
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project by the name of BRIGHT (Better Recommendations, Implementation and Guideline development for Health care providers and their Training) has been initiated (64).
Advisory
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Board (ABCD) has developed the SMBG recommendations endorsed by NADEP. The aim of the project is to train family Physicians on the best usage of SMBG. Special considerations have
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been given to affordability at each step.
Diabetes like many other non-communicable diseases is largely preventable through modifiable risk factors such as unhealthy diets, physical inactivity, obesity, tobacco use etc. There is enough evidence that regular physical activity and healthy diets can delay or prevent the occurrence of type 2 diabetes (65,66). This is particularly relevant in Pakistan because of younger age of onset of diabetes, increased incidence of abdominal adiposity, insulin resistance and metabolic syndrome compared with other populations. Added to this is the lack of effective primary health care services and equitable access of masses to these facilities, further emphasizing its importance (67).
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BRIDGES (Bringing Research in Diabetes to Global Environments and Systems) is an IDF programme dedicated to the translational research projects. The Aga Khan University, Karachi in collaboration with the University of Helsinki has started Karachi based Pakistan Diabetes
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Prevention Programme (PDPP) funded by the BRIDGES which addresses key issues in the prevention of type 2 diabetes (68).
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A large scale awareness programme by the name of “Stop Diabetes in Pakistan” is being initiated
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by NADEP (79). Multiple stakeholders especially pharmaceutical industry, corporate sector and philanthropic NGOs have been approached. The aim of the project is to involve whole
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community by initiating a media campaign emphasizing self-assessment of diabetes risk using RAPID score and developing strategies to modify their lifestyle in order to reduce their chances
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of developing diabetes.
Gestational Diabetes Mellitus (GDM) has not been given due importance in Pakistan. A
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prevalence as high as 9.9% - 17.8% has been reported from Tamil Nadu, India (70). Considering the ethnic commonalities and similarities between Pakistani and Indian populations, it would not
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be unjustifiable to believe that actual prevalence of GDM in Pakistani women may be much higher than reported. Moreover, complication rates in Pakistani GDM subjects have been found to be higher possibly due to poor glycemiccontrol (71), as compared to the western world. These include maternal complications like eclampsia (19%), polyhydramnios (4.6%), and threatened abortion (3.4%) and fetal complications like macrosomia (13.1%), intrauterine growth retardation (7.1%) and intrauterine deaths (5.3%) (71). Despite this situation, multidisciplinary GDM clinics are almost non-existent. Hence, a GDM project has been initiated by Baqai Medical University (BMU) funded by the WDF for three years (72). The collaborating partners include Baqai Medical University, Karachi and Fatima Bai hospital, Karachi (under the management of Fatima
Page 15 of 28
Bai Trust), countess of Dufferin Fund Hospital, Hyderabad (Managed by Local Government, Hyderabad), Society of Obstetrician and Gynecologist of Pakistan (SOGP) and NADEP. Establishment of GDM Advocacy Board, consisting of eminent obstetricians, diabetologists, and
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leaders of public opinionhas been done in January 2014 (73).The main objectives of this 3 years project are to create awareness in the community, regarding GDM, to train health care
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professionals in prevention, screening, diagnosis and management of GDM, to Institutionalize
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GDM screening and to organize integrated GDM services. The planned project activities include Public Awareness Campaign on GDM through print and electronic media, development of
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awareness literature on GDM and its dissemination through public awareness programmes and training courses in GDM for doctors, midwives and paramedics involved in obstetric care.
GDM clinics, screening of pregnant
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Other objectives of the project includes establishment of three major GDM centers and 30 minor women for GDM, dietary and educational counseling,
Manual” .
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management and monitoring of identified GDM cases, and development of “GDM Reference
Ac ce p
Pakistan Endocrine Society (PES) was established in 2001 (74) and has been holding annual symposia, monthly clinical meetings, and educational seminars for physicians, and public awareness campaigns throughout the country. It promotes educational and research activities in Endocrinology, Diabetes and Metabolism. PES represents endocrine specialists working in universities, teaching hospitals, and private practice. Its members also include general physicians, research scholars, post graduate trainees, surgeons, gynecologists, nurses and educators. Currently more than 500 registered members are actively involved with the society. Special honors for Pakistan The IDF Young Leaders in Diabetes (YLD) Programme aims at improving the lives of young people with diabetes, through the development of tomorrow’s leaders in the diabetes
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community(75). The Young Leaders are committed to raise awareness of diabetes by being a powerful voice for prevention, education, access to quality care, improved quality of life, and the end of discrimination worldwide. Mrs. Sana Ajmal, a type 1 diabetic from Pakistan is currently
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the President Elect of the IDF YLD project. Her success story is strength for type 1 diabetics of the country and the developing world (76).
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IDF has implemented a diabetes education programme of Conversation Map Tools (DCM) in
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2008 (77). IDF has trained six expert trainers to represent centers of education in different countries. Ms. Erum Ghafoor has been trained as an IDFexpert trainer from Pakistan in 2009. She
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has trained 850 facilitators and 30,000 people with diabetes across the country. She is also serving as faculty member for young leaders in diabetes programme by the platform of IDF -
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center of Education in Pakistan (78). Future directions
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Major headway to deal with diabetes and other NCDs in developing countries lies in broadening the canvas of capacity building. Four weeks certified courses have been started for doctors and
Ac ce p
educators since January 2014 aiming to ensure that primary health care is geared up for provision of quality diabetes care at the grass root level. In future, these certified GPs will form the basis of primary care diabetes clinics. The proposal is to develop 3000 such clinics across the country. These clinics are to be supervised by the secondary care setups run by the diabetes diploma holders(DDM). ABCD linking the tertiary care diabetes units of major teaching hospitals will serve as the academic, research and clinical support and guidance providers as part of the National Health Network for diabetes. Master of Science in Public Health (MSPH) focusing only on NCDs is the way forward for the development of such network. MSPH program aims to develop leaders in public health with special emphasis on implementation of preventive strategies for NCDs at community level.
Page 17 of 28
PWGDF is aiming to develop 1700 foot clinics nationwide. Considering the success of 115 such clinics through WDF funded SbS programme, next step of training 600 diabetic foot care teams has already taken place. Stepwise training through basic and advance courses of 1700 such foot
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care teams is expected to be complete by the year 2018. These specialized foot care setups shall not only lower the LEA rates further but, a step forward, will help preventing diabetic foot ulcers.
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Recognition as IDF center of education has paved the way for wider acceptability of
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internationally proven cost-effective interventional strategies. These in particular include role of educators and educational materials in streamlining self-management. Development of national
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level 24 hours helpline and centralizing information through national network can lead to better care and outcomes. In Singapore, IDF DECS meeting in June 2014, each IDF center of education
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has been given the task not only to improve and build diabetes education status in their countries
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operation.
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but to facilitate the same in their respective IDF regions through mutual and integrated co-
The IML project has already sensitized many stakeholders for better T1DM care. Punjab, the
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largest province of Pakistan has actively initiated plans while Khyber Pakhtoon Khwaa(KPK), another province has through the efforts of PES and provincial government developed a mutual agreement for free insulin supplies. It is hoped that Insulin Bank will be established at the National level for provision of free insulin for people with T1DM along with free consultation, SMBG & laboratory facilities. In future, IML will continue collaborating with IDF “Life for a child programme” for improving the care of people with T1DM in Pakistan. Successful primary prevention of diabetes is the key to future directions. “Stop Diabetes in Pakistan” will specially focus on children to assess translation of lifestyle behaviors to diseases. This activity will establish a foundation for lifelong tracks into adulthood. Material for education and awareness for sustainable behavioral changes and training curriculum for preventive
Page 18 of 28
managers focusing on communication and organization skills will be developed. Web based information portal “www.stopdiabetesinpakistan.com” and in addition, the electronic media will be used to disseminate key information.
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Various collaborative programmes with blindness prevention group, kidney foundation, Pakistan Hypertension League, Pakistan Cardiac Society, Pakistan Chest Society, Molecular Biology
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department of Karachi University etc. are in different stages of development. These programs are
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expected to contribute in diabetes and more comprehensively in NCD management and prevention across Pakistan.
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After the 18th Constitutional Amendment in Pakistan, health sectors have been given under the provincial government. This has provided much more autonomy than before. Reasonable
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reduction in morbidity and mortality can now be targeted and followed. Prescription policies can be developed by bodies like DAP, BIDE, PES, NADEP and ABCD in collaboration and
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government can ensure implementation. Anti-hypertensive, aspirin and statin can be combined as recommended by WHO and other bodies. Cross financing models and bulk manufacturing of
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diagnostic kits and medicines can be very effective simple strategies for remarkable improvement in provision of care in low resource settings. Energy saving activities like walking and cycling, intake of fruits and vegetables and lesser consumption of oil and fats would lead to reduction not only of deaths but also of diabetes and NCDs. In March 2014, Pakistan Diabetes leadership Forum (PDLF) was launched in collaboration with World Health Organization (WHO), IDF, WDF,Health Ministry of Pakistan, DAP, BIDE,Sakina Institute of Diabetes,Endocrine and Research (SIDER), Pakistan Institute of Medical Sciences(PIMS) and PES. A proposed outline of the “Islamabad Call to Commitment and Action” which will eventually lead to the formulation of the National Diabetes Action Plan and policy document for Pakistan was presented at PDLF. The forum highlighted the importance of
Page 19 of 28
capacity building to tackle the rising epidemic of diabetes. Proposed actions included development of National guidelines on diabetes management for all levels of care i.e., training primary, secondary and tertiary care physicians, training diabetes educators, utilizing lady health
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workers (LHW), training technicians and paramedics, implementers and mid-level management along with sensitizing policy makers and including a holistic approach to management of NCDs
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in general and diabetes in particular in undergraduate medical, nursing and paramedical curricula.
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It was also recommended that a Diabetes Training Unit will be established at each District Headquarter Hospital (DHQ) which will serve as a local training resource. In essence, future
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directions provide enough optimism to all the stakeholders to dedicate their strengths and pool
lives of millions of diabetics of Pakistan.
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Nothing to declare
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Declaration of Competing Interests
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their resources for much needed concerted and streamlined efforts to make a visible change in the
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2. Pakistan economic survey 2012-13, Government of Pakistan, Ministry of finance. (Available at www.finance.gov.pk on January 20, 2014).
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3. Islam A, Malik FA, Basaria S. Strengthening primary health careand family planning services
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inPakistan: some critical issues.J Pak Med Assoc 2002; 52: 2–7. 4. International Diabetes Federation (IDF) atlas 6th edition 2013.
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5. Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract 2007;76:219-22.
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47. Shera AS, Miyan Z, Basit A, Maqsood A, Ahmedani MY, Fawwad A,et al. Trends of Type 1 Diabetes in Karachi, Pakistan. Journal of Pediatrics Diabetes, 2008; (Part-II) 9(4): 401-406 48. United Nations GA. Resolution 61/225. Diabetes Day. 2006. Ref Type: Bill/Resolution. 49. Insulin my life. Available from www.insulinmylife.com (accessed August 11, 2014). 50. Hydrie MZI, Basit A, Badaruddin N, Ahmedani MY. Diabetes risk factors in middle income Pakistani school children Pakistan Journal of Nutrition, 2004; 3(1): 43-49 51. Shaikh F, Zeeshan F, Hakeem R, Basit A, Fawwad A Hussain A. Maternal Dietary Intake and Anthropometric Measurements of Newborn at Birth. Accepted for publication in The Open Diabetes Journal, 2014, 7, 14-19
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52. Ali SM, Basit A, Fawwad A, Ahmedani MY, Miyan Z, Malik RA. Presentation and outcome of diabetic foot at a tertiary care unit. Pakistan Journal of Medical Sciences, 2008; (Part-I) 24 (5): 651-656
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