NDSP 09: Risk Assessment of Pakistani Individual for Diabetes (RAPID) - Findings from Second National Diabetes Survey of Pakistan (NDSP) 2016-2017.

OBJECTIVE: To elucidate the effectiveness of Risk Assessment of Pakistani individuals with diabetes (RAPID) tool in epidemiological and population-based second National Diabetes Survey of Pakistan (NDSP) 2016-2017 for identifying risk of developing type 2 diabetes. METHODOLOGY: This observational study was a sub-analysis of the second National Diabetes Survey of Pakistan (NDSP) 2016-2017 conducted from February 2016 to August 2017 in all four provinces of Pakistan. Ethical approval was obtained from National Bioethics Committee Pakistan. RAPID score, a validated and published scoring scale to assess risk of diabetes, originally developed from community-based surveys was used. The risk score is assessed by parameters namely: age, waist circumference, and positive family history of diabetes. Subjects with score greater ≥4 were considered at risk of diabetes. RESULTS: A total of 4904 individuals were assessed (2205 males and 2699 females). Mean age of participants was 41.8±14.2 years. Positive family history of diabetes was seen in 1379 (28.1%) people. According to RAPID score 1268 (25.9%) individuals scored ≥4 and were at risk of diabetes. OGTT status of people at risk of diabetes according to RAPID score showed that 18.1% people with diabetes and 29.2% were prediabetic. Whereas, OGTT status of people not at risk of diabetes showed that only 7.6% people with diabetes, 20% were prediabetic. CONCLUSION: A simple diabetes risk score can be used for identification of high-risk individuals for diabetes so that timely intervention can be implemented. Community-based awareness programs are needed to educate people regarding healthy lifestyle in order to reduce risk of diabetes.

Costs and outcomes of "intermediate" vs "minimal" care for youth-onset type 1 diabetes in six countries.

OBJECTIVE: Data are needed to demonstrate that providing an "intermediate" level of type 1 diabetes (T1D) care is cost-effective compared to "minimal" care in less-resourced countries. We studied these care scenarios in six countries. METHODS: We modeled the complications/costs/mortality/healthy life years (HLYs) associated with "intermediate" care including two blood glucose tests/day (mean HbA1c 9.0% [75 mmol/mol]) in three lower-gross domestic product (GDP) countries (Mali, Tanzania, Pakistan), or three tests/day (mean HbA1c 8.5% [69 mmol/mol]) in three higher-GDP countries (Bolivia, Sri Lanka, Azerbaijan); and compared findings to "minimal" care (mean HbA1c 12.5% [113 mmol/mol]). A discrete time Markov illness-death model with age and calendar-year-dependent transition probabilities was developed, with inputs of 30 years of complications and Standardized Mortality Rate data from the youth cohort in the Pittsburgh Epidemiology of Diabetes Complications Study, background mortality, and costs determined from international and local prices. RESULTS: Cumulative 30 years incidences of complications were much lower for "intermediate care" than "minimal care", for example, for renal failure incidence was 68.1% (HbA1c 12.5%) compared to 3.9% (9%) and 2.4% (8.5%). For Mali, Tanzania, Pakistan, Bolivia, Sri Lanka, and Azerbaijan, 30 years survival was 50.1%/52.7%/76.7%/72.5%/82.8%/89.2% for "intermediate" and 8.5%/10.1%/39.4%/25.8%/45.5%/62.1% for "minimal" care, respectively. The cost of a HLY gained as a % GDP/capita was 141.1%/110.0%/52.3%/41.8%/17.0%/15.6%, respectively. CONCLUSIONS: Marked reductions in complications rates and mortality are achievable with "intermediate" T1D care achieving mean clinic HbA1c of 8.5% to 9% (69-75 mmol/mol). This is also "very cost-effective" in four of six countries according to the WHO "Fair Choices" approach which costs HLYs gained against GDP/capita.

Current management strategies to target the increasing incidence of diabetes within Pakistan.

According to the recently published National Diabetes Survey of Pakistan (NDSP 2016-2017), the prevalence of diabetes is 26.3%. Hence, Pakistan has around 27.4 million people >20 years of age suffering with diabetes. Compared to previous estimation of having around 7 million diabetic patients based on a survey done in 1994-1998, the figures are disturbingly alarming. The four main strategies to tackle the rising incidence of diabetes in Pakistan are as follows: 1) creating multidisciplinary teams through capacity building of the health care professionals (HCPs), including doctors, dieticians, diabetes educators, diabetes foot assistants, and program managers in standardized evidence-based protocols, enhancing their knowledge and skills in managing diabetes and their related comorbidities; 2) promoting primary prevention and awareness all over Pakistan using screening methods such as Risk Assessment of Pakistani Individuals for Diabetes (RAPID); 3) defining strategies for the management and prevention of diabetes and its complication through forums such as the Pakistan Diabetes Leadership Forum (PDLF); and 4) implementing a nationwide diabetes care program including registration, treatment, and referral protocols. The epidemic of diabetes in an under-resourced and overburdened health care system of Pakistan poses a serious challenge not only for the doctors but also for the multiple stakeholders involved in the community systems. There is a need for promoting and screening the population using RAPID and registering people with diabetes through Diabetes Registry of Pakistan (DROP). Future priority areas and interventional strategies shall include the following: implementing a diabetes health care service model in both rural and urban population using evidence-based clinical guidelines along with lifestyle modifications (LSMs) and prevention policies. Current management strategies and proposed future directions may successfully target the increasing incidence of diabetes.

Improvement in Neuropathy Specific Quality of Life in Patients with Diabetes after Vitamin D Supplementation.

OBJECTIVE: To assess the effect of vitamin D supplementation on neuropathy specific quality of life (NeuroQoL) in patients with painful diabetic neuropathy. METHODS: This prospective, open label study was conducted between June 2012 and April 2013. Patients with symptomatic diabetic neuropathy were given a single dose of 600,000 IU intramuscular vitamin D, and NeuroQol was assessed at baseline and at five follow-up visits every 4 weeks. RESULTS: Of 143 participants, 41.3% were vitamin D deficient (vitamin D < 20 ng/ml). Treatment with vitamin D resulted in a significant increase in 25(OH)D (P < 0.0001) and a significant improvement in the NeuroQoL subscale score for emotional distress (P = 0.04), with no significant change in the other NeuroQoL domains of painful symptoms and paresthesia, loss of temperature and touch sensation, unsteadiness, limitation in daily activities, and interpersonal problems. There was a significant reduction in patient perception about foot problems on QoL of "quite a lot" (P < 0.05) and "very much" (P < 0.0001) with a significant reduction in the baseline response of having a "poor" QoL from 5.2% to 0.7% (P < 0.0001) and an increase in the response of an "excellent QoL" from 1.5% to 7.4% (P < 0.0001). CONCLUSION: Vitamin D is effective in improving quality of life in patients with painful diabetic neuropathy.

Use of locally made off-loading techniques for diabetic plantar foot ulcer in Karachi, Pakistan.

The aim of this study was to evaluate the effectiveness of applying locally made pressure off-loading techniques on plantar foot ulcer in individuals with diabetes. This prospective study of 70 diabetic patients was conducted at the foot clinic of Baqai Institute of Diabetology & Endocrinology. Plantar foot ulcer, stages 1A and 2A according to the University of Texas classification, was treated by using three off-loading techniques: modified foot wear (sandal), modified plaster of Paris cast with plywood platform and Scotchcast boot. The outcome was assessed at either complete wound healing (defined as complete epithelialisation) or at 12 weeks, whichever came first. Of the 70 patients, 24 were in modified foot wear group, 23 in modified plaster of Paris cast and 23 in Scotchcast boot group. There was almost equal proportion of patients healed within 12 weeks period treated with these three off-loading techniques, i.e. 22 (95·7%) for modified foot wear group, 19 (95%) for modified plaster cast and 18 (94·7%) for Scotchcast boot group. No significant difference was observed in median healing time and cumulative wound survival at 12 weeks in the three off-loading techniques. Modified foot wear group was the most cost effective ($7) amongst the three off-loading techniques. It is concluded that in this cohort, no significant difference in healing time was observed in the three off-loading techniques, although modified foot wear (sandal) was found to be a more cost-effective treatment modality.

Efficacy of dietetics in low resource communities: dietary intake and BMI of type 2 diabetics living in Karachi before and after receiving dietician's guidance.

This study was planned to assess the dietary intake of diabetic subjects and kind of dietary modification they have made after individualised dietary guidance. Information on clinical and dietary profile of 200 subjects was recorded at first visit of BIDE. Dietary guidance was given by dietician. Second visit was done after 3 months. Subjects having adequate intake of fruit and vegetable, milk and meat was 68, 38 and 63% for males and 52, 40 and 35% for females, respectively. Only 20.4% males and 5.9% females had usual adequate consumption of the four food groups. Overall adequacy of diet improved for 11.1% of males and 27% of females. Weight reduction was observed in 54.8% of females and 32.2% of males. Rate of BMI reduction was significantly higher in the group who had reduced their caloric intake. This first of its kind study from Pakistan, has documented the efficacy of dietary guidance and highlighted the need for further attention to assure balanced intake of foods form various food groups.