- Email: [email protected]
Prevalence of diabetes in Pakistan
Diabetes Research and Clinical Practice 76 (2007) 219–222 www.elsevier.com/locate/diabres
Prevalence of diabetes in Pakistan A.S. Shera *, F. Jawad, A Maqsood Diabetic Association of Pakistan and WHO Collaborating Centre for Diabetes, 5 E/3, Nazimabad, Karachi 74600, Pakistan Received 11 August 2006; accepted 21 August 2006 Available online 26 September 2006
Abstract The prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) and the contributing risk factors were estimated by performing a cross-sectional survey conducted earlier in the rural and urban areas of all the four provinces of Pakistan. The statistical analysis was performed from the obtained results by using SPSS version 12.0. The total number of subjects examined were 5433 which included 1893 males (1208 in rural and 685 in urban areas) and 3540 females (2243 in rural and 1297 in urban areas). The prevalence of diabetes in the urban versus the rural areas was 6.0% in men and 3.5% in women against 6.9% in men and 2.5% in women, respectively. Newly diagnosed diabetes was 5.1% in men and 6.8% in women in urban areas and 5.0% in men and 4.8% in women in rural areas. IGT in the urban versus the rural areas was 6.3% in men and 14.2% in women against 6.9% in men and 10.9% in women, respectively. Overall glucose intolerance (DM + IGT) was 22.04% in urban and 17.15% in rural areas. The major risk factors identified were age, positive family history and obesity especially central obesity. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Diabetes mellitus; Impaired glucose tolerance; Obesity; Prevalence; Asians
1. Introduction The WHO has estimated a rise of 170% in the incidence of diabetes in the developing countries. This gives a figure of 228 million people with diabetes and accounts for 75% of the world diabetic population [1]. The greatest increase will be seen in India from 19 million to 57 million. Pakistan will have an increase from 4.3 million in 1995 to 14.5 million in 2025. Thus by the year 2025 over 75% of all people with diabetes will belong to the developing countries [1].
It is also been established that the world population is ageing and the number of people over 65 years has risen in the last two decades. This is another cause for the increasing incidence of diabetes, especially in developing countries [1]. To assess the true picture of the metabolic disorder in Pakistan, the results of the Pakistan National Diabetes Survey, conducted in four phases in both rural and urban areas of the four provinces, published independently [2–4], have been amalgamated, to achieve a total figure. 2. Methods
* Corresponding author. Tel.: +92 21 6616890; fax: +92 21 6680959. E-mail address: [email protected] (A.S. Shera).
The Pakistan National Diabetes Survey was conducted in four phases, through randomised and cluster sampling in the provinces of Sindh, Baluchistan, Punjab and NWFP to
0168-8227/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2006.08.011
220
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
estimate the prevalence of diabetes mellitus (DM) Type 2 and impaired glucose tolerance (IGT) in subjects of age 25 years and above, in both urban and rural areas. Methods for estimating blood glucose, blood pressure, body mass index (BMI) and waist hip ratio (WHR) along with the cut-off values have been published earlier [3–5]. The data was analysed on SPSS version 12.0 software. Descriptive analysis was done for demographic features. Results are expressed as mean S.D. for continuous variables and numbers (percentages) for categorical variables. Relative risk was analysed by multiple logistic regression. Univariate analysis was performed by Pearson chi-square test corresponding to proportions. Confidence interval was estimated to identify the strength of association with independent factors.
3. Results A total of 5433 subjects were examined in all four provinces of the country. The total number of women was 3540 (rural = 2243, urban = 1297). Total number of men was 1893 (rural = 1208, urban = 685). The prevalence of diabetes in the urban areas was 3.50% in women and 6% in men, whereas in the rural areas it was 2.5% in women and 3.3% in men. IGT in the urban areas was 14.2% in women and 6.3% in men versus 10.9% in women and 6.9% in men in the rural areas. Newly diagnosed diabetes was found in 6.8% in women and 5.1% in men in urban areas and 4.8% in women and 5% in men in rural areas. The overall prevalence of abnormal glucose tolerance (IGT + DM) was 20.5% in women and 15.9% in
men. A larger percentage of subjects, both women and men, belonged to the age group 45–54 years (27%) (Table 1). The figures of a positive family history, obesity estimated by body mass index and waist hip ratio and hypertension, both in males and females in urban areas are shown in Table 2. The results of the rural areas can be seen in Table 3. The relative risk for developing diabetes was 0.39 and 0.51 times in females with a positive family history of the urban and rural areas, respectively. Males had the relative risk of 0.37 and 0.18 in the similar settings. Obesity estimated by BMI + WHR in females presented a relative risk for diabetes of 2.40 and 2.60 times in urban and rural areas, respectively. In males the relative risk was 0.55 and 0.60 times in the two areas, respectively. It was observed that there was a higher prevalence of central obesity in women with normal glucose tolerance, diabetes and IGT (rural = 73.2%, urban = 74.2%), compared to the males (rural = 31.4%, urban = 28.5%). The relative risk for hypertension in relation to diabetes was 0.35 and 0.65 times in females of urban and rural areas, respectively. The figures for males were found to be insignificant. 4. Discussion The presented results are based on the overall prevalence figures of Type 2 diabetes reported by the Pakistan National Diabetes Survey and published
Table 1 Diabetes and impaired glucose tolerance (IGT) prevalence by age and sex in urban and rural Pakistan Age
Women 25–34 35–44 45–54 55–64 65–74 75+ All ages Men 25–34 35–44 45–54 55–64 65–74 75+ All ages
No. examined
Total no. with diabetes (%)
New cases of diabetes (%)
IGT (%)
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
323 353 302 211 87 21
728 556 457 306 142 54
4 10 14 14 3 1
6 13 16 11 7 3
7 23 24 20 11 3
6 30 32 23 12 6
27 45 54 33 19 6
54 56 53 46 25 10
1297
2243
171 153 135 120 74 32
360 255 228 188 126 51
685
1208
(1.2) (2.8) (4.6) (6.7) (3.4) (4.8)
(0.86) (2.3) (3.5) (3.6) (4.9) (5.5)
(2.2) (6.5) (7.9) (9.5) (12.6) (14.3)
46 (3.5)
56 (2.5)
88 (6.8)
3 11 14 7 6 0
2 1 13 11 7 6
0 5 14 8 5 3
(1.7) (7.2) (10.4) (5.8) (8.1)
41 (6.0)
(0.5) (0.4) (5.7) (5.8) (5.5) (11.8)
40 (3.3)
(3.3) (10.4) (6.7) (6.8) (9.4)
35 (5.1)
(0.8) (5.4) (7.0) (7.5) (8.4) (11.1)
109 (4.8)
7 13 14 14 9 3
(1.9) (5.1) (14.0) (7.4) (7.1) (5.9)
60 (5.0)
(8.3) (12.7) (18.0) (15.6) (21.8) (28.6)
184 (14.2)
3 6 6 12 11 5
(1.7) (3.9) (4.4) (10.0) (14.9) (15.6)
43 (6.3)
(7.1) (10.1) (11.6) (15.0) (17.6) (18.5)
244 (10.9)
7 12 21 14 23 6
(1.9) (4.7) (9.2) (7.4) (18.2) (11.8)
83 (6.9)
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
221
Table 2 Means and proportion for selected variables in women and men with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and diabetes mellitus (DM) in Pakistan (urban area) Variable
NGT
IGT
DM
New cases
Total population
Women No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.85 (%) F/H of DM (%) Hypertensive (%)
979 43 0.8 24.22 0.33 0.91 0.006 40.0 71.0 6.6 14.5
184 48 1.90 24.95 0.75 0.93 0.02 44.6 81.5 5.4 16.8
46 50 3.34 25.71 1.39 0.96 0.02 47.8 93.5 28.3 26.1
88 50 2.68 25.92 1.15 0.98 0.02 55.70 87.50 5.70 17.04
1297 44 0.69 24.49 0.28 0.92 0.005 41.7 74.2 7.2 15.4
Men No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.95 (%) F/H of DM (%) Hypertensive (%)
566 45 1.2 22.26 0.34 0.90 0.004 23.3 24.9 8.1 7.2
43 57 4.56 22.87 1.49 0.93 0.03 30.2 37.2 11.6 11.6
41 49 3.60 22.81 1.20 0.93 0.02 29.3 41.5 26.8 17.1
35 55 4.02 24.02 1.20 0.96 0.03 48.6 51.4 22.8 8.6
685 47 1.13 22.42 0.31 0.91 0.005 25.5 28.5 10.2 8.3
Values shown are means or proportions 95% confidence interval (CI). BMI, body mass index; WHR, waist hip ratio; F/H family history. P < 0.05.
earlier [2–4]. The high figures of abnormal glucose tolerance (DM + IGT) seen as 20.5% in women and 15.9% in men, majority being in the age group of 45– 54 years, is alarming. Demographic projections by WHO with reference to the prevalence data of Pakistan, 1995, National Diabetes Survey, estimate an increase in Type 2 diabetes in Pakistan from 4.3 million in 1995 to 14.5 million in 2025, making
Pakistan the fourth country among the top 10 countries of the world [5]. The reason for this steep rise can be attributed to a number of factors, the most important being industrialization and urbanization and a change in lifestyle, both in urban and rural areas [6]. Family aggregation of diabetes, reflected by a positive history in first degree relatives is a known
Table 3 Means and proportion for selected variables in women and men with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and diabetes mellitus (DM) in Pakistan (rural area) Variable
NGT
IGT
DM
New cases
Total population
Women No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.85 (%) F/H of DM (%) Hypertensive (%)
1834 41 0.62 24.68 0.54 1.08 0.06 32.4 70.5 10.8 12.6
244 47 1.90 26.37 1.39 1.05 0.12 47.5 80.3 11.5 26.6
56 50 3.50 25.88 1.47 0.99 0.03 55.3 89.3 33.9 39.3
109 51 2.50 27.48 1.06 0.99 0.02 66.1 91.7 25.7 32.1
2243 43 0.58 25.03 0.46 1.07 0.05 36.3 73.21 12.2 15.8
Men No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.95 (%) F/H of DM (%) Hypertensive (%)
1025 44 0.89 22.34 0.25 0.91 0.006 23.8 27.8 9.4 7.8
83 55 3.34 23.40 1.03 0.94 0.02 38.5 50.6 18.1 18.1
40 58 4.36 23.32 1.27 0.95 0.02 32.5 42.5 15.0 20.0
60 52 3.65 24.95 1.28 0.98 0.02 52.0 62.0 37.0 27.0
1208 45 0.86 22.56 0.23 0.91 0.005 26.5 31.4 11.6 9.8
Values shown are means or proportions 95% confidence interval (CI). BMI, body mass index; WHR, waist hip ratio; F/H family history. P < 0.05.
222
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
risk factor for Type 2 diabetes in the Asian population. This shows a strong association of the genetic factor more so as inter-family and cousin marriages are very common in the culture of the country. Obesity has a close association with diabetes especially due to insulin resistance. The results of this survey show a high prevalence of both central and peripheral obesity in diabetics. Figures of obesity according to BMI were stated as 28.6% in non-diabetic patients attending the outpatient clinic of a government hospital in Karachi. The mean age of the study population was 30.54 years [7]. The Pakistan National Diabetes Survey showed that in urban areas 40% women and 23.3% men with normal glucose tolerance were obese. Studies from India have shown that Asian Indians have a significantly greater proportion of body fat than is found in western populations [8]. Women with diabetes and IGT had a significantly high prevalence of peripheral obesity (47.8% and 44.6% DM and IGT, respectively in urban areas and 55.3% and 47.5% DM and IGT in rural areas, respectively). Similar results were shown in the study on the Prevalence of chronic complications, i.e. 61% diabetics being peripherally obese [9]. Another hospital-based study on 100 obese subjects showed 65% of them had diabetes [10]. Hypertension is an important affiliate of diabetes. The aggregate results of the survey showed hypertension to be present in 37%. Much higher figures were encountered in the study on chronic complications (64.6%) [9]. The results of the survey with prevalence figures of abnormal glucose tolerance (DM + IGT) of 20.5% in females and 15.9% in males along with the predicted rise in incidence of diabetes in developing countries and Pakistan has to be given a serious consideration. The age group affected will be between 45 and 64 years, the most productive period of life. It is also known that diabetes care in these regions is not optimal. Both factors together will cause disabilities
and human suffering along with a huge economic burden [11]. Acknowledgement The assistance provided by Dr. Kamran Zaman for the statistical analysis of the data, is gratefully acknowledge. References [1] H. King, R.E. Aubert, W.H. Herman, Global burden of diabetes, 1995–2025, Diabetes Care 21 (1998) 1414–1431. [2] A.S. Shera, G. Rafique, I.A. Khwaja, J. Ara, S. Baqai, H. King, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh province, Diabetic Med. 12 (1995) 1116–1121. [3] A.S. Shera, G. Rafique, I.A. Khwaja, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Baluchistan province, Diabetes Res. Clin. Pract. 44 (1999) 49– 58. [4] A.S. Shera, G. Rafique, I.A. Khwaja, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in North West Frontier Province (NWFP) of Pakistan, J. Pakistan Med. Assoc. 49 (1999) 206–211. [5] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030, Diabetes Care 27 (2004) 1047–1053. [6] A. Ramachandran, C. Snehalatha, V. Viswanathan, Explosion of Type 2 diabetes in the Indian subcontinent, Int. Diabetes Monitor. 15 (2003) 1–6. [7] C. Snehalatha, V. Vijay, A. Ramachandran, Cut-off values for normal anthroprometric variables in Asian Indian adults, Diabetes Care 26 (2003) 1380–1384. [8] S. Shafi, M.H. Rao, I.B.M. Soomroo, The effect of lifestyle and socio-economic factors in the development of obesity in young adults, Pakistan J. Med. Res. 43 (2004) 65–69. [9] A.S. Shera, F. Jawad, A. Maqsood, S. Jamal, M. Azfar, U. Ahmed, Prevalence of chronic complications and associated factors in Type 2 diabetes, J. Pakistan Med. Assoc. 54 (2004) 54–59. [10] M. Khurram, S. Javed, J. Paracha, H.B. Khar, H. Zubair, Obesity related complications in 100 obese subjects and their age matched controls, J. Pakistan Med. Assoc. 56 (2006) 50–53. [11] International Diabetes Federation, Diabetes Atlas, 2nd ed., International Diabetes Federation, Brussels, 2003.
Prevalence of diabetes in Pakistan A.S. Shera *, F. Jawad, A Maqsood Diabetic Association of Pakistan and WHO Collaborating Centre for Diabetes, 5 E/3, Nazimabad, Karachi 74600, Pakistan Received 11 August 2006; accepted 21 August 2006 Available online 26 September 2006
Abstract The prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) and the contributing risk factors were estimated by performing a cross-sectional survey conducted earlier in the rural and urban areas of all the four provinces of Pakistan. The statistical analysis was performed from the obtained results by using SPSS version 12.0. The total number of subjects examined were 5433 which included 1893 males (1208 in rural and 685 in urban areas) and 3540 females (2243 in rural and 1297 in urban areas). The prevalence of diabetes in the urban versus the rural areas was 6.0% in men and 3.5% in women against 6.9% in men and 2.5% in women, respectively. Newly diagnosed diabetes was 5.1% in men and 6.8% in women in urban areas and 5.0% in men and 4.8% in women in rural areas. IGT in the urban versus the rural areas was 6.3% in men and 14.2% in women against 6.9% in men and 10.9% in women, respectively. Overall glucose intolerance (DM + IGT) was 22.04% in urban and 17.15% in rural areas. The major risk factors identified were age, positive family history and obesity especially central obesity. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Diabetes mellitus; Impaired glucose tolerance; Obesity; Prevalence; Asians
1. Introduction The WHO has estimated a rise of 170% in the incidence of diabetes in the developing countries. This gives a figure of 228 million people with diabetes and accounts for 75% of the world diabetic population [1]. The greatest increase will be seen in India from 19 million to 57 million. Pakistan will have an increase from 4.3 million in 1995 to 14.5 million in 2025. Thus by the year 2025 over 75% of all people with diabetes will belong to the developing countries [1].
It is also been established that the world population is ageing and the number of people over 65 years has risen in the last two decades. This is another cause for the increasing incidence of diabetes, especially in developing countries [1]. To assess the true picture of the metabolic disorder in Pakistan, the results of the Pakistan National Diabetes Survey, conducted in four phases in both rural and urban areas of the four provinces, published independently [2–4], have been amalgamated, to achieve a total figure. 2. Methods
* Corresponding author. Tel.: +92 21 6616890; fax: +92 21 6680959. E-mail address: [email protected] (A.S. Shera).
The Pakistan National Diabetes Survey was conducted in four phases, through randomised and cluster sampling in the provinces of Sindh, Baluchistan, Punjab and NWFP to
0168-8227/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2006.08.011
220
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
estimate the prevalence of diabetes mellitus (DM) Type 2 and impaired glucose tolerance (IGT) in subjects of age 25 years and above, in both urban and rural areas. Methods for estimating blood glucose, blood pressure, body mass index (BMI) and waist hip ratio (WHR) along with the cut-off values have been published earlier [3–5]. The data was analysed on SPSS version 12.0 software. Descriptive analysis was done for demographic features. Results are expressed as mean S.D. for continuous variables and numbers (percentages) for categorical variables. Relative risk was analysed by multiple logistic regression. Univariate analysis was performed by Pearson chi-square test corresponding to proportions. Confidence interval was estimated to identify the strength of association with independent factors.
3. Results A total of 5433 subjects were examined in all four provinces of the country. The total number of women was 3540 (rural = 2243, urban = 1297). Total number of men was 1893 (rural = 1208, urban = 685). The prevalence of diabetes in the urban areas was 3.50% in women and 6% in men, whereas in the rural areas it was 2.5% in women and 3.3% in men. IGT in the urban areas was 14.2% in women and 6.3% in men versus 10.9% in women and 6.9% in men in the rural areas. Newly diagnosed diabetes was found in 6.8% in women and 5.1% in men in urban areas and 4.8% in women and 5% in men in rural areas. The overall prevalence of abnormal glucose tolerance (IGT + DM) was 20.5% in women and 15.9% in
men. A larger percentage of subjects, both women and men, belonged to the age group 45–54 years (27%) (Table 1). The figures of a positive family history, obesity estimated by body mass index and waist hip ratio and hypertension, both in males and females in urban areas are shown in Table 2. The results of the rural areas can be seen in Table 3. The relative risk for developing diabetes was 0.39 and 0.51 times in females with a positive family history of the urban and rural areas, respectively. Males had the relative risk of 0.37 and 0.18 in the similar settings. Obesity estimated by BMI + WHR in females presented a relative risk for diabetes of 2.40 and 2.60 times in urban and rural areas, respectively. In males the relative risk was 0.55 and 0.60 times in the two areas, respectively. It was observed that there was a higher prevalence of central obesity in women with normal glucose tolerance, diabetes and IGT (rural = 73.2%, urban = 74.2%), compared to the males (rural = 31.4%, urban = 28.5%). The relative risk for hypertension in relation to diabetes was 0.35 and 0.65 times in females of urban and rural areas, respectively. The figures for males were found to be insignificant. 4. Discussion The presented results are based on the overall prevalence figures of Type 2 diabetes reported by the Pakistan National Diabetes Survey and published
Table 1 Diabetes and impaired glucose tolerance (IGT) prevalence by age and sex in urban and rural Pakistan Age
Women 25–34 35–44 45–54 55–64 65–74 75+ All ages Men 25–34 35–44 45–54 55–64 65–74 75+ All ages
No. examined
Total no. with diabetes (%)
New cases of diabetes (%)
IGT (%)
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
323 353 302 211 87 21
728 556 457 306 142 54
4 10 14 14 3 1
6 13 16 11 7 3
7 23 24 20 11 3
6 30 32 23 12 6
27 45 54 33 19 6
54 56 53 46 25 10
1297
2243
171 153 135 120 74 32
360 255 228 188 126 51
685
1208
(1.2) (2.8) (4.6) (6.7) (3.4) (4.8)
(0.86) (2.3) (3.5) (3.6) (4.9) (5.5)
(2.2) (6.5) (7.9) (9.5) (12.6) (14.3)
46 (3.5)
56 (2.5)
88 (6.8)
3 11 14 7 6 0
2 1 13 11 7 6
0 5 14 8 5 3
(1.7) (7.2) (10.4) (5.8) (8.1)
41 (6.0)
(0.5) (0.4) (5.7) (5.8) (5.5) (11.8)
40 (3.3)
(3.3) (10.4) (6.7) (6.8) (9.4)
35 (5.1)
(0.8) (5.4) (7.0) (7.5) (8.4) (11.1)
109 (4.8)
7 13 14 14 9 3
(1.9) (5.1) (14.0) (7.4) (7.1) (5.9)
60 (5.0)
(8.3) (12.7) (18.0) (15.6) (21.8) (28.6)
184 (14.2)
3 6 6 12 11 5
(1.7) (3.9) (4.4) (10.0) (14.9) (15.6)
43 (6.3)
(7.1) (10.1) (11.6) (15.0) (17.6) (18.5)
244 (10.9)
7 12 21 14 23 6
(1.9) (4.7) (9.2) (7.4) (18.2) (11.8)
83 (6.9)
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
221
Table 2 Means and proportion for selected variables in women and men with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and diabetes mellitus (DM) in Pakistan (urban area) Variable
NGT
IGT
DM
New cases
Total population
Women No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.85 (%) F/H of DM (%) Hypertensive (%)
979 43 0.8 24.22 0.33 0.91 0.006 40.0 71.0 6.6 14.5
184 48 1.90 24.95 0.75 0.93 0.02 44.6 81.5 5.4 16.8
46 50 3.34 25.71 1.39 0.96 0.02 47.8 93.5 28.3 26.1
88 50 2.68 25.92 1.15 0.98 0.02 55.70 87.50 5.70 17.04
1297 44 0.69 24.49 0.28 0.92 0.005 41.7 74.2 7.2 15.4
Men No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.95 (%) F/H of DM (%) Hypertensive (%)
566 45 1.2 22.26 0.34 0.90 0.004 23.3 24.9 8.1 7.2
43 57 4.56 22.87 1.49 0.93 0.03 30.2 37.2 11.6 11.6
41 49 3.60 22.81 1.20 0.93 0.02 29.3 41.5 26.8 17.1
35 55 4.02 24.02 1.20 0.96 0.03 48.6 51.4 22.8 8.6
685 47 1.13 22.42 0.31 0.91 0.005 25.5 28.5 10.2 8.3
Values shown are means or proportions 95% confidence interval (CI). BMI, body mass index; WHR, waist hip ratio; F/H family history. P < 0.05.
earlier [2–4]. The high figures of abnormal glucose tolerance (DM + IGT) seen as 20.5% in women and 15.9% in men, majority being in the age group of 45– 54 years, is alarming. Demographic projections by WHO with reference to the prevalence data of Pakistan, 1995, National Diabetes Survey, estimate an increase in Type 2 diabetes in Pakistan from 4.3 million in 1995 to 14.5 million in 2025, making
Pakistan the fourth country among the top 10 countries of the world [5]. The reason for this steep rise can be attributed to a number of factors, the most important being industrialization and urbanization and a change in lifestyle, both in urban and rural areas [6]. Family aggregation of diabetes, reflected by a positive history in first degree relatives is a known
Table 3 Means and proportion for selected variables in women and men with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and diabetes mellitus (DM) in Pakistan (rural area) Variable
NGT
IGT
DM
New cases
Total population
Women No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.85 (%) F/H of DM (%) Hypertensive (%)
1834 41 0.62 24.68 0.54 1.08 0.06 32.4 70.5 10.8 12.6
244 47 1.90 26.37 1.39 1.05 0.12 47.5 80.3 11.5 26.6
56 50 3.50 25.88 1.47 0.99 0.03 55.3 89.3 33.9 39.3
109 51 2.50 27.48 1.06 0.99 0.02 66.1 91.7 25.7 32.1
2243 43 0.58 25.03 0.46 1.07 0.05 36.3 73.21 12.2 15.8
Men No. examined Age BMI (kg/m2) WHR BMI > 25.0 (%) WHR > 0.95 (%) F/H of DM (%) Hypertensive (%)
1025 44 0.89 22.34 0.25 0.91 0.006 23.8 27.8 9.4 7.8
83 55 3.34 23.40 1.03 0.94 0.02 38.5 50.6 18.1 18.1
40 58 4.36 23.32 1.27 0.95 0.02 32.5 42.5 15.0 20.0
60 52 3.65 24.95 1.28 0.98 0.02 52.0 62.0 37.0 27.0
1208 45 0.86 22.56 0.23 0.91 0.005 26.5 31.4 11.6 9.8
Values shown are means or proportions 95% confidence interval (CI). BMI, body mass index; WHR, waist hip ratio; F/H family history. P < 0.05.
222
A.S. Shera et al. / Diabetes Research and Clinical Practice 76 (2007) 219–222
risk factor for Type 2 diabetes in the Asian population. This shows a strong association of the genetic factor more so as inter-family and cousin marriages are very common in the culture of the country. Obesity has a close association with diabetes especially due to insulin resistance. The results of this survey show a high prevalence of both central and peripheral obesity in diabetics. Figures of obesity according to BMI were stated as 28.6% in non-diabetic patients attending the outpatient clinic of a government hospital in Karachi. The mean age of the study population was 30.54 years [7]. The Pakistan National Diabetes Survey showed that in urban areas 40% women and 23.3% men with normal glucose tolerance were obese. Studies from India have shown that Asian Indians have a significantly greater proportion of body fat than is found in western populations [8]. Women with diabetes and IGT had a significantly high prevalence of peripheral obesity (47.8% and 44.6% DM and IGT, respectively in urban areas and 55.3% and 47.5% DM and IGT in rural areas, respectively). Similar results were shown in the study on the Prevalence of chronic complications, i.e. 61% diabetics being peripherally obese [9]. Another hospital-based study on 100 obese subjects showed 65% of them had diabetes [10]. Hypertension is an important affiliate of diabetes. The aggregate results of the survey showed hypertension to be present in 37%. Much higher figures were encountered in the study on chronic complications (64.6%) [9]. The results of the survey with prevalence figures of abnormal glucose tolerance (DM + IGT) of 20.5% in females and 15.9% in males along with the predicted rise in incidence of diabetes in developing countries and Pakistan has to be given a serious consideration. The age group affected will be between 45 and 64 years, the most productive period of life. It is also known that diabetes care in these regions is not optimal. Both factors together will cause disabilities
and human suffering along with a huge economic burden [11]. Acknowledgement The assistance provided by Dr. Kamran Zaman for the statistical analysis of the data, is gratefully acknowledge. References [1] H. King, R.E. Aubert, W.H. Herman, Global burden of diabetes, 1995–2025, Diabetes Care 21 (1998) 1414–1431. [2] A.S. Shera, G. Rafique, I.A. Khwaja, J. Ara, S. Baqai, H. King, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh province, Diabetic Med. 12 (1995) 1116–1121. [3] A.S. Shera, G. Rafique, I.A. Khwaja, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Baluchistan province, Diabetes Res. Clin. Pract. 44 (1999) 49– 58. [4] A.S. Shera, G. Rafique, I.A. Khwaja, Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in North West Frontier Province (NWFP) of Pakistan, J. Pakistan Med. Assoc. 49 (1999) 206–211. [5] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030, Diabetes Care 27 (2004) 1047–1053. [6] A. Ramachandran, C. Snehalatha, V. Viswanathan, Explosion of Type 2 diabetes in the Indian subcontinent, Int. Diabetes Monitor. 15 (2003) 1–6. [7] C. Snehalatha, V. Vijay, A. Ramachandran, Cut-off values for normal anthroprometric variables in Asian Indian adults, Diabetes Care 26 (2003) 1380–1384. [8] S. Shafi, M.H. Rao, I.B.M. Soomroo, The effect of lifestyle and socio-economic factors in the development of obesity in young adults, Pakistan J. Med. Res. 43 (2004) 65–69. [9] A.S. Shera, F. Jawad, A. Maqsood, S. Jamal, M. Azfar, U. Ahmed, Prevalence of chronic complications and associated factors in Type 2 diabetes, J. Pakistan Med. Assoc. 54 (2004) 54–59. [10] M. Khurram, S. Javed, J. Paracha, H.B. Khar, H. Zubair, Obesity related complications in 100 obese subjects and their age matched controls, J. Pakistan Med. Assoc. 56 (2006) 50–53. [11] International Diabetes Federation, Diabetes Atlas, 2nd ed., International Diabetes Federation, Brussels, 2003.