Effectiveness of locally produced ready-to-use supplementary foods on the prevention of stunting in children aged 6-23 months: a community-based trial from Pakistan.

Undernutrition is a major public health problem in developing countries. Around 40·2 % of children are stunted in Pakistan. This longitudinal study aimed to assess the effectiveness of locally produced ready-to-use supplementary foods in the prevention of stunting by detecting change in of children in intervention v. control arm against the 2006 WHO growth reference. A community-based non-randomised cluster-controlled trial was conducted from January 2018 to December 2020 in the district of Kurram, Khyber Pakhtunkhwa, Pakistan. A total of 80 clusters (each cluster comprising ≈ 250-300 households) were defined in the catchment population of twelve health facilities. Children aged 6-18 months were recruited n 1680. The intervention included a daily ration of 50 g - locally produced ready-to-use-supplementary food (Wawa-Mum). The main outcome of this study was a change in length for age z-score (LAZ) v. WHO growth standards. Comparison between the interventions was by t test and ANOVA. Cox proportional hazard models were used to assess the association between stunting occurrence and the utilisation of locally produced supplement. Out of the total 1680, fifty-one out of the total 1680, 51·1 out of the total 1680 and 51·1 % (n 859) were male. Mean age 13·9 months (sd + 859) were male. Mean age 13·9 months (sd + -4·4). At baseline, 36·9 % (n 618) were stunted. In the intervention group, mean LAZ score significantly increased from -1·13(2·2 sd) at baseline to -0·93(1·8 sd) at 6-month follow-up (P value 0·01) compared with the control group. The incidence rate of stunting in the intervention arm was 1·3 v. 3·4 per person year in the control arm. The control group had a significantly increased likelihood of stunting (Hazard Ratio (HR) 1·7, 95 % CI 1·46, 2·05, P value < 0·001) v. the intervention group. Locally produced ready-to-use supplementary food is an effective intervention for reducing stunting in children below 2 years of age. This can be provided as part of a malnutrition prevention package to overcome the alarming rates of stunting in Pakistan.

Understanding ethics of reporting health related events in media: A qualitative phenomenological study in Karachi and Peshawar.

Objective: The specific objectives of this study were to identify the ethical issues in reporting of health-related events in media and suggest ways to improve it. Method: This was a qualitative phenomenological study conducted by APPNA Institute of Public Health, Jinnah Sindh Medical University in collaboration with Institute of Public Health, Khyber Medical University from January to April 2022. A total of 38 focus group discussions and in-depth interviews were conducted either face to face at place of convenience of interviewees or online. The participants were health reporters, healthcare workers (HCWs), and representatives of law enforcement agencies in two cities i.e., Karachi and Peshawar. Data were analyzed by using the deductive and inductive approaches, by four independent experts including the Principal Investigator (PI) and three research fellows. Results: Ethical issues related to health reporting in the field included interference of the reporters in rescue efforts during an emergency and interference in emergency medical care of the victims. In reporting, careless disregard for patient confidentiality and privacy; using unreliable sources of information; using wrong terminology; sensationalizing the news and jumping to conclusions in cases of malpractice were reported as main problems. Negative influences on health reporting included poor training of the reporters on health reporting ethics, organizational pressures, and lack of cooperation by relevant health authorities. Conclusion: The quality of health reporting can be improved by building the capacity of health reporters in understanding the ethical issues and their social responsibilities toward health.

How does postgraduate diploma in Family Medicine impact on primary care doctors?

BACKGROUND: Over the last decade, the emphasis on improving the education and training of family physicians has increased. World Health Organization has also emphasized the importance of a trained primary care workforce. In 2017, Khyber Medical University (KMU) Peshawar initiated a one-year Postgraduate Diploma in Family Medicine for doctors working in primary care, to upgrade their skills and knowledge as Family Physicians. To justify the allocation of resources, there is a need for research on the impact of such programs. This study explores the impact of Diploma in Family Medicine (DFM) on primary care doctors in Khyber Pakhtunkhwa. It also identifies the barriers associated with learning and its translation to practice. METHODS: A mixed-method explanatory study was conducted from February 2019-2020. Forty-five graduates from the DFM program at KMU were invited to participate in this study. The quantitative data was collected through questionnaires (n=30) and the results were then explained further through qualitative focus group interviews (n=24). Descriptive statistics were calculated for the quantitative data and thematic analysis was performed for the qualitative data. RESULTS: The respondents (n=30/45) were satisfied from the course content and delivery. They agreed that the course is useful (93.3%), relevant to their learning needs (86.7%) and they were able apply it to their clinical practice (100%). The qualitative findings also corroborated that the course improved both the clinical and consultation skills of the participants. The learning environment encouraged them to identify their learning needs and attain new competencies. They reported being more patient-centered and evidence-based, which increased patients' satisfaction. The program also resulted in increased career opportunities and other monetary benefits. Despite the blended nature of the program, the participants found it challenging to balance training with the provision of services. CONCLUSION: One-year Postgraduate Diploma in Family Medicine is focused, practical and relevant to the learning needs of primary healthcare physicians. The policymakers should consider provision of such training opportunities in both public and private-sector. Future research should explore the long-term impact of such programs on healthcare outcomes.

Correlation between maternal and neonatal blood Vitamin D level: Study from Pakistan.

In Pakistan, there is limited evidence for the levels and relationship of 25 (OH) Vitamin D (25(OH)D) status in pregnant women and their newborns, while the association between maternal 25(OH)D and newborn anthropometric measurements remains unexplored. Sociodemographic data were collected from 213 pregnant mothers during their visit to a tertiary care hospital at the time of childbirth. Anthropometric measurements were performed on all mothers and their newborns and blood samples collected from both for 25(OH)D levels. Participants were classified into two groups according to their 25(OH)D status: sufficient (25(OH)D ≥50 nmol L-1 ) and deficient (25(OH)D <50 nmol L-1 ). Simple and multiple regression models were used for analysis. Among 213 pregnant women, prevalence of 25(OH)D deficiency was 61.5%, and their newborn was 99.5% (mean 25(OH)D levels: 46.3 [11.3] and 24.9 [5.4] nmol L-1 , respectively). Maternal sociodemographic characteristics were similar between 25(OH)D deficient and sufficient mothers, whereas newborn 25(OH)D levels were significantly lower in the former (22.60 [4.53] vs. 27.67 [3.82] nmol L-1 , respectively, P < 0.001). There was a strong positive association between maternal and newborn 25(OH)D levels (r, 0.66; r2 , 43%, B [SE], 0.3 [0.02]; P < 0.001). Association of maternal 25(OH)D levels with newborn weight, length and head circumference was not significant (all P > 0.05). Our study shows a high prevalence of 25(OH)D deficiency in pregnant women and their newborns and a strong positive association between maternal and newborn 25(OH)D levels. Findings of this study indicate the importance of maintaining sufficient 25(OH)D levels during pregnancy.

Prevalence of stroke in Pakistan: Findings from Khyber Pakhtunkhwa integrated population health survey (KP-IPHS) 2016-17.

OBJECTIVE: To study the prevalence of stroke and associated risk factors in Khyber Pakhtunkhwa (KP) province of Pakistan. METHODS: This study was a part of cross-sectional KP Integrated Population Health Survey 2016-17 conducted on population aging ≥18 years at 24 districts of KP. Primary (n=1061) and secondary sampling units (n=15724) were developed, based on urban/rural and socio-economic status. Each primary-unit comprised of 250-300 households. Sample was selected through a multi-staged stratified systematic cluster sampling technique by taking every 16th household per rural and every 12th household per urban-unit. A validated "Cincinnati Stroke Scale" for identification of stroke patients in community was used along with demographics and potential risk factors. RESULTS: Among the 15724 randomly selected households, 22500 participants (51.4% females; 74.6% rural areas, mean age 42±12.6 years) were interviewed. Stroke was identified in 271 cases (137 males, 134 females; Mean age=43.39±0.85 years) and prevalence of stroke was 1.2% (1200 per 100,000 population). Obesity/overweight (38.8%), hypertension (21.8%), smoking (6.6%) and known diabetes mellitus (5.9%) were the common associated risk factors of stroke. Age groups >60 years (adjusted OR=1.68; 95% CI: 1.05-2.68); urban area (adjusted OR=1.68; 95% CI: 1.29-2.19); unemployment (adjusted OR=3.78; 95% CI: 2.49-5.73) and lower formal (primary) education (adjusted OR 2.18; 95% CI: 1.30-3.64) were significantly associated with stroke (p <0.05). CONCLUSION: Prevalence of stroke is 1.2% in the province of KP. Obesity, hypertension, smoking and Diabetes Mellitus are the common associated risk factors of stroke. Higher age, urban area, unemployment and lower formal education are significantly associated with stroke.

Assessment of the impact of integrated disease surveillance and response system on surveillance management at healthcare facilities in Pakistan.

Background: Disease surveillance is very crucial especially in high vulnerability settings like Pakistan. However, surveillance and outbreak response management are still evolving in the country and research studies are needed to assess the existing system. Aim: To assess the impact of integrated disease surveillance and response system (IDSRS) implemented by the provincial government to strengthen infectious disease surveillance and reporting in 6 districts of Pakistan in 2016. Methods: A baseline cross-sectional assessment of health facilities and the healthcare workforce was conducted in 2016 to identify needs and gaps in public sector health facilities and the health system of 6 selected districts of Khyber Pakhtunkhwa Province, Pakistan. This was followed by a 2018 endline survey of the same facilities using the same variables. Results: Overall, there was improvement in district management and facility level performance (χ2 (1, 314) = 21.19, P < 0.001, V = 0.26). District level management improved significantly in areas with relatively lower Gross Domestic Product (GDP)? χ2(1, 154) = 30.41, P <0.001, V = 0.44). Facilitation domain variables improved in the lower GDP districts (χ2 (1, 74) = 5.76, P = 0.016, V = 0.28) and showed counterintuitive deterioration (χ2 (1, 74) = 4.80, P = 0.028, V = 0.25) in relatively higher GDP areas. Conclusion: IDSRS is effective in improving surveillance and response systems, however, its effectiveness appears to depend on locale-specific economies and can be enhanced by modifying the implementation approach. Better empowerment of the local workforce can contribute to such improvement.

Long-Term Impact of Multiple Micronutrient Supplementation on Micronutrient Status, Hemoglobin Level, and Growth in Children 24 to 59 Months of Age: A Non-Randomized Community-Based Trial from Pakistan.

Cost-effective interventions are needed to address undernutrition, particularly micronutrient deficiencies, which are common in children under the age of five in low- and middle-income countries. A community-based, non-randomized clinical trial was undertaken in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019, to evaluate the effect of locally produced micronutrient powder (local name: Vita-Mixe) on plasma micronutrient status, hemoglobin level, and anthropometric outcomes. Children aged 24-48 months old were recruited and allocated to the intervention and control arm of the study. The enrolled children in the intervention arm received one micronutrient powder (MNP) sachet for consumption on alternate days for 12 months. To assess the impact of the intervention on plasma levels of zinc, vitamin D, vitamin A, and hemoglobin level, blood samples were taken at baseline and after one year following the intervention. The analysis was conducted using Enzyme-Linked Immunosorbent Assay (ELISA), atomic absorption spectrometry, and an automated hematology analyzer. For the impact on growth parameters, the anthropometric assessment was performed using WHO standard guidelines. A 24 h dietary recall interview was used to assess the nutrient intake adequacy. Results showed that in the intervention arm, children had on average a 7.52 ng/mL (95% CI 5.11-9.92, p-value < 0.001) increase in the plasma level of vitamin A, 4.80 ng/mL (95% CI 1.63-7.95, p-value < 0.002) increase in vitamin D levels and 33.85 µg/dL (95% CI 24.40-43.30, p-value < 0.001) increase in the plasma zinc level, as well as a 2.0g/dL (95% CI 1.64-2.40, p-value < 0.001) increase in hemoglobin level. Statistically significant improvement was observed in the weight-for-height z-score (WHZ) (from -1.0 ± 0.88 to -0.40 ± 1.01, p < 0.001) and weight-for-age z-score (WAZ) (from -1.40 ± 0.50 to -1.05 ± 0.49, p < 0.001) in the intervention group compared to the control group. No statistically significant change was observed in the height-for-age z-score (HAZ) in the intervention group (p = 0.93). In conclusion, micronutrient powder supplementation is a cost-effective intervention to improve the micronutrient status, hemoglobin level, and growth parameters in under-five children, which can be scaled up in the existing health system to address the alarming rates of undernutrition in Pakistan and other developing countries.

Effectiveness of locally produced ready to use supplementary food on hemoglobin, anthropometrics, and plasma micronutrients concentrations of 6 to 23 months age children: a non-randomized community-based trial from Pakistan.

Background: Micronutrient deficiencies including vitamin A, vitamin D, and zinc are highly prevalent in children below 5 years of age in low and -middle-income countries. We aimed to evaluate the effectiveness of ready-to-use Lipid-based Nutrient Supplement-Medium Quantity (LNS-MQ) local name "Wawa-mum" on plasma micronutrient status, hemoglobin concentration and anthropometric measurements. Methods: A community-based non-randomized trial was conducted in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019. A total of 110 children aged 6 to 23 months old were recruited and allocated to the intervention and control arm of the study. A total of 57 children in the intervention arm received a daily ration of 50 g of Wawa-mum, for one year. To assess the impact of the intervention on primary outcome measures, i.e., serum vitamin A, D concentration, plasma zinc, and hemoglobin concentration. Blood samples were collected at baseline and after one year following the intervention. The vitamins concentration in serum were assessed using Enzyme-Linked Immunosorbent Assay (ELISA) and plasma zinc by atomic absorption spectrometry. The hemoglobin concentration was measured by an automated hematology analyzer. A 24-h dietary recall interview was used to assess the nutrient intake adequacy. Multivariate Linear regression models were used to analyze the outcomes while controlling for potential confounders. Results: In the intervention arm, children had on average 6.2 µg/dL (95% CI 3.0-9.3, value of p<0.001) increase in the serum vitamin A concentration, 8.1 ng/mL (95% CI 1.3-14.9, value of p 0.02) increase in serum vitamin D concentration and 49.0 µg/dL (95% CI 33.5-64.5, value of p<0.001) increase in the plasma zinc concentration, and 2.7 g/dL (95% CI 2.0-3.3, value of p<0.001) increase in hemoglobin concentration while adjusted for covariates. An addition, length-for-age z-score (LAZ), weight-for-length z-score (WLZ), weight-for-age z-score (WAZ), and prevalence of undernutrition including stunting, wasting, and underweight were calculated as a secondary outcome to investigate the impact of micronutrients on growth parameters, that has been improved significantly after receiving the Wawa-mum. Conclusion: Wawa-mum (LNS-MQ) is an effective intervention to improve the micronutrient status, hemoglobin concentration, and growth parameters in 6 to 23 months children, which can be scaled up in the existing health system to address the alarming rates of under nutrition in Pakistan and other developing countries. Clinical trial registration: https://doi.org/10.1186/ISRCTN94319790, ISRCTN94319790.

Repeated Covid-19 Infection Exists: A Case Series From Pakistan.

BACKGROUND: Protection against SARS-CoV-2 in infected individuals of COVID-19 is lacking. We report a case series of repeated infections of SARS-CoV-2. METHODS: A total of 12 patients were identified with repeated infections for SARS-CoV-2 from 25 April 2020 to 16 March 2021 from Pakistan. Repeated infection was defined as diagnosis of the SARS-CoV-2 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests in the first and second phase of infection after complete recovery from the first phase of infection with a negative RT-PCR. RESULTS: Of the 12 participants, 75% (n=9) were male and mean age of the participants were 40.1±9.7 years. Mean duration between the first and second phase of infection was 184±68.9 days. Patients presenting with mild infection in the first phase largely developed moderate to severe infection in the second phase. None of them were vaccinated. CONCLUSION: The pandemic of COVID-19 is on the rise and repeated infection from SARS-CoV-2 is occurring.

First documented reinfection of SARS-COV-2 in second wave from Pakistan.

Little is known about the pathophysiology and immunology of Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2). It is not yet clear whether SARS-CoV-2 infection produces long-term immune protection, or a short-lived immunity that would fade with the passage of time. We report a first case of SARS-CoV-2 reinfection in second wave from Pakistan. A 41-year-old male, health care worker developed flu-like illness, tested positive on 6th June 2020 and became PCR negative on 19th June 2020 with reactive antibodies. After 4 months and 13 days of negative PCR, he developed symptoms again and tested positive for SARS-CoV-2 with non-reactive antibodies.

Triple Assessment of Breast Lump: Should We Perform Core Biopsy for Every Patient?

Introduction The triple assessment for a lump in the breast is standard practice and the robustness of assessment towards the diagnosis of breast cancer is crucial. The combination of the modalities, physical examination, imaging (mammogram and ultrasound), and fine-needle aspiration cytology (FNAC) is more accurate than any modality alone. Aim To examine the combined and individual predictive values of physical examination (P), mammography (M), ultrasound (U), FNAC (C), with core biopsy (B) - triple assessment in the diagnosis of breast cancer. Methods To obtain the results of physical examination (P), mammography (M), ultrasound (U), FNAC (C), and core biopsy (B), we examined the records of 124 breast cancer patients seen between April 1, 2009, and March 30, 2010. To assess the diagnostic potential of the combination of the modalities (P, U, and M), we considered all cases with a score of 4 (probably malignant) and 5 (malignant) as positive for malignancy. All cases with a score of 3 (equivocal), 2 (benign), and 1 (normal) were considered negative for malignancy. For FNAC, a score of 1 (insufficient sample), 2 (benign), and 3 (atypia/probably benign) were considered. All the patients were diagnosed with breast cancer on excision biopsy. Among 124 patients, 12 were excluded, as they were unfit for intervention. Results The accuracy of physical examination (P) as confirmed by core biopsy (B) is dependent on the experience of the surgeon. It has limitations in younger women and smaller lesions. In our study, P has a positive predictive value (PPV) of 58.9% when compared with surgical biopsy, which is comparable with other studies. Our results showed PPV 66.1% and after an ultrasound scan, the overall radiological grading (M & U) gives a PPV of 81.3%, reflecting the important role of ultrasound scans. Our results showed the sensitivity of FNAC to be 73.2%. Core biopsy was diagnostic in 107 (95.5%) patients, making it a reliable tool. Our results confirmed that a combination of the modalities (P, M, U, R, FNAC) is more accurate than any modality alone. Conclusion When all the three modalities are positive for a diagnosis of malignant breast disease, surgical biopsy confirms the breast cancer diagnosis with a PPV of 100% and a sensitivity of 95.5%.

Type 2 diabetes prevalence in Pakistan: what is driving this? Clues from subgroup analysis of normal weight individuals in diabetes prevalence survey of Pakistan.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a global health tissue. We determined factors relating to the likelihood of developing T2DM in normal BMI individuals. METHODOLOGY: This was a cross-sectional community-based representative survey, of people aged ≥20 years in Pakistan, using HBA1c as the screening tool. The prevalence of T2DM/prediabetes in people having normal BMI together with associated risk factors was estimated. RESULTS: Of 6824 normal BMI individuals, there was still a high prevalence of T2DM 14.92% and in underweight at 10.14% (overall prevalence 16.96%). Corresponding rates for prediabetes for the normal BMI category: 9.79% and underweight 8.99%. Multivariate logistic regression modeling for normal BMI individuals, showed a significantly increased risk of T2DM with increasing age (odds ratio [OR] 2.1, 3.3, 4.5 and 4.8, P < 0.001 for 31-40, 41-50, 51-60 and 61 years and above respectively, compared to age decade 20-30 years). Similarly, there was a significantly high risk of T2DM with lower education level [OR for no vs graduate 2.4, 95% confidence interval (CI) 1.5-3.8]. There was a significantly increased risk of T2DM in individuals having a positive family history [OR 4.3 (95% CI 7.0-11.5)]. Overall the influence of overweight/obese on T2DM occurrence (20% increased risk) was much less than in other regions of the world. CONCLUSION: There are higher than expected rates of T2DM/prediabetes in Pakistani ethnicity normal BMI individuals. Targeted screening of older individuals with historical lack of educational opportunity, with a family history of T2DM even if of normal BMI may result in a significant benefit in the Pakistan population.

Clinical Characteristics, Mortality and Associated risk factors in COVID-19 patients reported in ten major hospitals of Khyber Pakhtunkhwa, Pakistan.

BACKGROUND: COVID-19 is an ongoing public health issue across the world. Several risk factors associated with mortality in COVID-19 have been reported. The present study aims to describe clinical and epidemiological characteristics and predictors of mortality in hospitalized patients from Khyber Pakhtunkhwa, a province in Pakistan with highest COVID-19 associated case fatality rate. METHODS: This multicentre, retrospective study was conducted in hospitalized COVID-19 patients who died or discharged alive until 1st May 2020. Data about sociodemographic characteristics, clinical and laboratory findings, treatment and outcome were obtained from hospital records and compared between survivors and non-survivors. Statistical tests were applied to determine the risk factors associated with mortality in hospitalized patients. RESULTS: Of the total 179 patients from the 10 designated hospitals, 127 (70.9%) were discharged alive while 52 (29.1%) died in the hospital. Overall, 109 (60.9%) patients had an underlying comorbidity with hypertension being the commonest. Multivariate logistics regression analysis showed significantly higher odds of in-hospital death from COVID-19 in patients with multiple morbidities (OR 3.2, 95% CI 1.1, 9.1, p-value=0.03), length of hospital stay (OR 0.8, 95% CI 0.7, 0.9, p-value <0.001), those presenting with dyspnoea (OR 4.0, 95% CI 1.1, 14.0, p-value=0.03) and oxygen saturation below 90 (OR 9.6, 95% CI: 3.1, 29.2, p-value <0.001). CONCLUSION: Comorbidity, oxygen saturation and dyspnoea on arrival and length of stay in hospital (late admission) are associated with COVID-19 mortality. The demographic, clinical and lab characteristics could potentially help clinician and policy makers before potential second wave in the country.

Hospital preparedness for disaster and mass casualty management in Pakistan: A cross-sectional evaluation study.

BACKGROUND: World Health Organization has advocated preemptive readiness of health systems to manage disas-trous events. Pakistan is known to be highly susceptible to disasters on the one hand and significantly lacking in coping ability on the other. Preparedness of health facilities in such locales is especially important, despite which there is little published evidence regarding hospitals' response capacity in Pakistan. METHODS: From 12 most disaster prone districts of the country, a purposive sample of 20 hospitals was assessed us-ing 51 indicators, scored as fully (2), partially (1), or not prepared (0). Two domains, disaster preparedness and mass casualty management, and five subdomains, networking, planning, staff-readiness, materials, and safety, were evalu-ated. Proportions of maximum possible scores achieved by an entity were categorized as acceptable (≥66 percent), par-tial (35-65 percent), or inadequate (<35 percent). RESULTS: Out of the 20 hospitals, 14 (70 percent) were secondary and 3 tertiary level facilities (30 percent). Overall, hospitals were partially prepared with a score of 54.0 percent, 95 percent confidence interval [52.3 percent, 54.7 percent]. Disaster preparedness, 55.2 percent [54.0, 57.0], was significantly better prepared than mass casualty management, 49.2 percent [46.8, 51.6], p < 0.001. Overall, facility safety was the least prepared among the subdomains, 38.3 per-cent [31.8, 44.8], while materials were the best, 75.9 percent [72.6, 79.3]. The least prepared subdomains were staff-readiness in Punjab, 52.1 percent [47.5, 56.8], and facility safety in KP, 29.2 percent [22.1, 36.4]. CONCLUSIONS: Hospitals' preparedness for disaster and mass casualty management is deficient in these most vulner-able districts of Pakistan. Improvement initiatives commensurate with locale vulnerabilities should be instituted.

Diabetes Prevalence Survey of Pakistan (DPS-PAK): prevalence of type 2 diabetes mellitus and prediabetes using HbA1c: a population-based survey from Pakistan.

OBJECTIVES: We conducted a Pakistan-wide community-based survey on the prevalence of type 2 diabetes using glycated haemoglobin (HbA1c) as the screening test. The aim was to estimate diabetes prevalence across different demographic groups as well as all regions of Pakistan. DESIGN, SETTINGS AND PARTICIPANTS: Multistaged stratified cluster sampling was used for the representative selection of people aged ≥20 years, residing in 378 sampled clusters of 16 randomly selected districts, in this cross-sectional study. Eligible participants had blood drawn for HbA1c analyses at field clinics near to their homes. The oral glucose tolerance test (OGTT) was conducted on a subsample of the participants. Overall and stratified prevalence of type 2 diabetes and its association with risk factors were estimated using logistic regression models. MAIN OUTCOME MEASURES: Prevalence of prediabetes and type 2 diabetes. RESULTS: Of 18 856 eligible participants the prevalence of prediabetes was 10.91% (95% CI 10.46 to 11.36, n=2057) and type 2 diabetes was 16.98% (95% CI 16.44 to 17.51, n=3201). Overall, the mean HbA1c level was 5.62% (SD 1.96), and among newly diagnosed was 8.56% (SD 2.08). The prevalence was highest in age 51-60 years (26.03%, p<0.001), no formal education (17.66%, p<0.001), class III obese (35.09%, p<0.001), family history (31.29%, p<0.001) and female (17.80%, p=0.009). On multivariate analysis, there was a significant association between type 2 diabetes and older age, increase in body mass index and central obesity, positive family history, and having hypertension and an inverse relation with education as a categorical variable. On a subsample (n=1027), summary statistics for diagnosis of diabetes on HbA1c showed a sensitivity of 84.7%, specificity of 87.2% and area under the receiver operating characteristic curve 0.86, compared with OGTT. CONCLUSIONS: The prevalence of type 2 diabetes and prediabetes is much higher than previously thought in Pakistan. Comprehensive strategies need to be developed to incorporate screening, prevention and treatment of type 2 diabetes at a community level.