WORLD DIABETES DAY – 14 NOVEMBER 2018
A CANDID ASSESSMENT OF WHERE WE STAND AND WHERE DO WE GO FROM HERE VIS-À-VIS DIABETES CONTROL AND PREVENTION
by
Dr. Ghulam Nabi Kazi
Introduction
World Diabetes Day is an official United Nations Day coinciding with the birthday of Sir Frederick Banting, who co-discovered insulin along with Charles Best in 1922. Nearly a century later, however, there is very little to celebrate concerning diabetes in the world we know, and the day is observed amidst growing concerns about the escalating and diverse threats to health posed by the disease. The World Diabetes Day also constitutes the world’s largest diabetes awareness campaign reaching a global audience of over 1 billion people in more than 160 countries in an effort to keep the disease firmly in the public and political spotlight. Th succeeding paragraphs will endeavor to underline the serious ramifications of diabetes and its public health significance, particularly in the context of Pakistan.
Diabetes and its Sordid Effects
The World Health Organization (WHO) describes diabetes as a chronic, metabolic disease characterized by elevated levels of blood glucose, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. Currently, it is a major public health problem that is fast emerging into a pandemic, which at least doubles a person’s risk of early death and contributes to a higher risk for ischemic heart disease, strokes, blindness, kidney failure, extremity amputations, and other chronic conditions. Furthermore, it can lead to retinopathy, nephropathy or neuropathy, and peripheral vascular diseases. Excess adiposity is the most important risk factor for diabetes. The role of diabetes in exacerbating infectious diseases has been well documented. These significantly include lower respiratory tract infections, urinary tract infections, skin and mucous membrane infections, post-surgical infections, tuberculosis, human immunodeficiency (HIV) syndrome, hepatitis C virus, sepsis, pneumonia, urinary tract infections, dengue hemorrhagic fever, severe acute respiratory syndrome, herpes zoster, herpes simplex, enterovirus and hospital-acquired infections.
Prevalence and the Cost of Diabetes
In terms of numbers, the situation is no less disparaging. As of 2015, an estimated 415 million people or 8.3% of the adult population had diabetes worldwide with highly visible increasing trends, with an estimated 193 million people having undiagnosed diabetes. The global economic cost of diabetes in 2014 was estimated at US$612 billion including expenditure incurred on diabetes care, management of its chronic complications and excess prevalence of general medical conditions attributable to diabetes.
Pakistan’s Diabetes Survey 2016-2017
The second National Diabetes Survey of Pakistan was conducted for 18 months from February 2016 to August 2017 in all provinces of Pakistan, involving citizens aged 20 years or more. With a sample size of 10,834 volunteers selected from 27 clusters and 46 sub-clusters, with 44% males and 56 females from rural and urban areas, the survey was highly representative. More than half of the participants had at least primary level education, while around 30% had positive family history of diabetes, and 14.5% were tobacco users. The overall age-adjusted weighted prevalence of diabetes was found to be over 26%, of which 19% had known diabetes while 7% were newly diagnosed. An additional 14.4% were found to be asymptomatic pre-diabetes at a high risk for developing diabetes. The significant risk factors for diabetes were age (≥43 years), family history of diabetes, hypertension, obesity and dyslipidemia. The survey findings clearly demonstrated that diabetes has reached epidemic proportions underlining the need for urgent primary preventive and control strategies to ensure early diagnosis and effective management.
The Nutrition Fiasco and other Risk Factors in Pakistan
There is a high prevalence of nutritional disorders in Pakistan, with huge and unacceptable proportions of wasting and stunting. Yet these figures also mask and divert attention from the flip side of the coin that is childhood overweight and obesity, which usually continues on to haunt us in other stages of the lifespan, particularly in case of females. The other risk factors for diabetes In Pakistan, mainly include rapid urbanization with unhealthy lifestyle changes, genetic factors and a singular lack of awareness leading to erroneous lifestyles.
What Diabetes is Doing to Us
The large and rapidly growing disease burden of diabetes alone is sufficient to impede efforts for raising the life expectancy in Pakistan. In addition to a huge prevalence, Pakistan has a large burden of sub optimally controlled diabetics having to contend with an ill equipped primary health care system. Mental health symptoms such as depression are also commonly encountered in diabetics in Pakistan. Problems are usually compounded with inadequate health literacy that is often associated with poor management of diabetes particularly its complications such as retinopathy, warranting educational and training programs for diabetics that would result in better treatment adherence as well. Furthermore, substandard diabetes care, heavy burden of undiagnosed diabetes, virtual lack of screening for prediabetics and insufficient clinical monitoring of the complications of diabetes in Pakistan often proves to be very costly both in human and financial terms.
Diabetes and other Noncommunicable Diseases in our health system
This brings us to the larger picture of the health sector in Pakistan. For the greater part of our history, policymakers have focused on maternal, neonatal and child health (MNCH) and communicable diseases control (CDC) as constituting the main agenda of our primary health care system, with few tangible steps taken to address the fearsome burden of non-communicable diseases (NCDs) and mainstreaming them in primary health care in the country, despite the presence of a well-defined strategy and national action plan to control all noncommunicable diseases approved at the highest level in the country years ago. NCDs control has also remained a part of every health policy or strategy drafted or approved at federal or provincial level in the last two decades, yet there appears to be a major unexplained gap between policy and implementation in this regard.
Despite the alarming prevalence of noncommunicable diseases therefore, provincial and district governments seem ill-prepared to cope with the major epidemics of diabetes, cancers, cardiovascular diseases and chronic respiratory illnesses. I understand Punjab is the only province to initiate the process in this direction with an approved allocation of modest resources through a PC-I proforma. The other provinces will also need to simply move beyond their existing agenda and take on greater challenges, within their mandate, to truly improve the health status of their respective population. Taking on the additional challenge relating to diabetes and other NCDs is not likely to strain or overwhelm the health system, which is otherwise well structured though lacking in efficiency due to certain failings.
Imperatives for Action at the Policy level
The World Health Organization has come up with several recommendations to address obesity and diabetes, however, the feasibility of each must be weighed and adapted in the country context. Pakistan needs to facilitate the development of provincial and district food policies, eliminating any subsidies for dietary fats/oils and sugar, taxing sugar-sweetened beverages and high fat foods, implementing mandatory nutritional standards and guidelines for quality assurance and procurement of healthy food alone, effectively limiting oils, sugar and salt while reducing the use of frying and sweetening of foods. At the community level, we need to promote healthy physical activity and environmental action, particularly in schools, extend availability of sports facilities and informal recreational and sporting activities, with less reliance on personal vehicles. Engaging with the private sector food providers and outlets to eliminate trans fats and progressively reduce total and saturated fat, salt and sugars is likely to be beneficial and constitutes the way forward. Promoting exclusive breastfeeding for the first six months of life by empowering women and implementing the International Code of Marketing of Breast-milk Substitutes are some other imperatives for action.
Role of Mass Media
The role of the mass media is particularly crucial in diabetes control as it needs to implement appropriate social marketing campaigns on healthy diet and physical activity in order to foster a dialogue and build the necessary consensus, complementing the other interventions in the package and encourage behavior change.
Programmatic level interventions
The health sector needs to ensure provision of dietary counselling on nutrition, physical activity and healthy weight gain, particularly for expectant mothers and other high-risk individuals, while a high-level multisectoral mechanism needs to define and oversee the implementation of food and physical activity policies for the prevention of obesity and diabetes. Health managers also need to have user-friendly services for diabetics, while ensuring the availability of all essential medicines at the designated facilities, with meaningful counseling allowing persons to take charge of their own lives and make their food choices given the necessary guidance. By profession, pharmacists are best suited to assume this training and counseling role. The high prevalence of smokers amongst diabetics in Pakistan is another trend that needs to be addressed through robust awareness creation and smoking cessation programs.
At the cost of some repetition, operationally such programs may incorporate capacity building and training of primary care physicians, paramedics and outreach workers, surveillance of diabetes trends, behavior modification encompassing awareness regarding healthy diet, nutrition education with increased access to fruits and vegetables, regular physical activity, maintenance of a healthy weight, avoiding smoking, early detection through screening to identify diabetics and high risk pre-diabetics and ensuring access to effective therapies to prevent life threatening complications, nutritional surveillance, focusing on overweight or obese children, and encouraging a healthy lifestyle through community involvement.
Pakistan vis-à-vis its International Commitments
It is pertinent to add that Pakistan has participated in a globally agreed commitment to halt the rise in diabetes and obesity by 2025, through effective measures for surveillance, prevention and control of diabetes and its complications. Suffice it to say, however, that the task in neither simplistic nor easy, yet it is an absolute imperative both in the national and international perspectives for good reasons. With less than seven years left for Pakistan to fulfil its international obligations vis-à-vis diabetes control, efforts are required on a war footing particularly at the provincial and district levels through appropriately devised programs and interventions. With the Government of Pakistan currently headed by a person known for his services for Cancer over the past three decades, there is every reason to hope and believe that diabetes and other major noncommunicable diseases will secure the priority they deserve within the Health Sector and will be mainstreamed in primary health care, to the immense benefit of the country’s entire population.
Copyright: Dr Ghulam Nabi Kazi
