Prevalence of diabetes, pre-diabetes and associated risk factors: second National Diabetes Survey of Pakistan (NDSP), 2016-2017.

OBJECTIVE: The second National Diabetes Survey of Pakistan (second NDSP) was planned to ascertain the updated prevalence of diabetes, pre-diabetes and associated risk factors at the national and provincial levels. RESEARCH DESIGN AND METHODS: The survey was conducted by using multistage clustering technique in all four provinces of Pakistan from February 2016 to August 2017. An estimated sample size of 10 800 was calculated using probability sampling and multistage stratified sampling technique. Twenty-seven clusters were selected out of total 213 clusters from all four provinces (strata) of Pakistan. A total of 46 subclusters were selected by using the 'Rule of thumb'. Out of 12 486 targeted individuals, 10 834 study subjects finally participated in the study (87% response rate). Seventeen trained teams collected data using the structured questionnaire. The clinical and anthropometric measurements included height, weight, blood pressure, waist circumference and waist-to-hip ratio while the blood tests included Oral Glucose Tolerance Test (OGTT), haemoglobin A1c and fasting lipid profiles. WHO criteria were used for the diagnosis of diabetes and pre-diabetes. RESULTS: Overall weighted prevalence of diabetes was 26.3%, of which 19.2% had known diabetes, and 7.1% were newly diagnosed people with diabetes. Prevalence of diabetes in urban and rural areas was 28.3% and 25.3%, respectively. Prevalence of pre-diabetes was 14.4% (15.5% in urban areas and 13.9% in rural areas). Age greater than or equal to 43 years, family history of diabetes, hypertension, obesity and dyslipidaemia were significant associated risk factors for diabetes. CONCLUSION: The findings of the 2nd NDSP imply that diabetes has reached epidemic proportion and urgently need national strategies for early diagnosis and effective management as well as cost-effective diabetes primary prevention programme in Pakistan.

An FTO variant is associated with Type 2 diabetes in South Asian populations after accounting for body mass index and waist circumference.

AIMS: A common variant, rs9939609, in the FTO (fat mass and obesity) gene is associated with adiposity in Europeans, explaining its relationship with diabetes. However, data are inconsistent in South Asians. Our aim was to investigate the association of the FTO rs9939609 variant with obesity, obesity-related traits and Type 2 diabetes in South Asian individuals, and to use meta-analyses to attempt to clarify to what extent BMI influences the association of FTO variants with diabetes in South Asians. METHODS: We analysed rs9939609 in two studies of Pakistani individuals: 1666 adults aged ≥40 years from the Karachi population-based Control of Blood Pressure and Risk Attenuation (COBRA) study and 2745 individuals of Punjabi ancestry who were part of a Type 2 diabetes case-control study (UK Asian Diabetes Study/Diabetes Genetics in Pakistan; UKADS/DGP). The main outcomes were BMI, waist circumference and diabetes. Regression analyses were performed to determine associations between FTO alleles and outcomes. Summary estimates were combined in a meta-analysis of 8091 South Asian individuals (3919 patients with Type 2 diabetes and 4172 control subjects), including those from two previous studies. RESULTS: In the 4411 Pakistani individuals from this study, the age-, sex- and diabetes-adjusted association of FTO variant rs9939609 with BMI was 0.45 (95%CI 0.24-0.67) kg/m(2) per A-allele (P=3.0 × 10(-5) ) and with waist circumference was 0.88 (95% CI 0.36-1.41) cm per A-allele (P=0.001). The A-allele (30% frequency) was also significantly associated with Type 2 diabetes [per A-allele odds ratio (95%CI) 1.18 (1.07-1.30); P=0.0009]. A meta-analysis of four South Asian studies with 8091 subjects showed that the FTO A-allele predisposes to Type 2 diabetes [1.22 (95%CI 1.14-1.31); P=1.07 × 10(-8) ] even after adjusting for BMI [1.18 (95%CI 1.10-1.27); P=1.02 × 10(-5) ] or waist circumference [1.18 (95%CI 1.10-1.27); P=3.97 × 10(-5) ]. CONCLUSIONS: The strong association between FTO genotype and BMI and waist circumference in South Asians is similar to that observed in Europeans. In contrast, the strong association of FTO genotype with diabetes is only partly accounted for by BMI.

Replication of 13 genome-wide association (GWA)-validated risk variants for type 2 diabetes in Pakistani populations.

AIMS/HYPOTHESIS: Recent genome-wide association (GWA) studies and subsequent replication studies have greatly increased the number of validated type 2 diabetes susceptibility variants, but most of these have been conducted in European populations. Despite the high prevalence of the disease in South Asians, studies investigating GWA-validated type 2 diabetes risk variants in this ethnic group are limited. We investigated 30 single nucleotide polymorphisms (SNPs), predominantly derived from recent GWA studies, to determine if and to what extent these variants affect type 2 diabetes risk in two Punjabi populations, originating predominantly from the District of Mirpur, Pakistan. METHODS: Thirty SNPs were genotyped in 1,678 participants with type 2 diabetes and 1,584 normoglycaemic control participants from two populations; one resident in the UK and one indigenous to the District of Mirpur. RESULTS: SNPs in or near PPARG, TCF7L2, FTO, CDKN2A/2B, HHEX/IDE, IGF2BP2, SLC30A8, KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 displayed significant (p < 0.05) associations with type 2 diabetes, with similar effect sizes to those seen in European populations. A constructed genetic risk score was associated with type 2 diabetes (p = 5.46 × 10(-12)), BMI (p = 2.25 × 10(-4)) and age at onset of diabetes (p = 0.002). CONCLUSIONS/INTERPRETATION: We have demonstrated that 13 variants confer an increased risk of type 2 diabetes in our Pakistani populations; to our knowledge this is the first time that SNPs in or near KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 have been significantly associated with the disease in South Asians. Large-scale studies and meta-analyses of South Asian populations are needed to further confirm the effect of these variants in this ethnic group.

Prevalence of diabetes in Pakistan.

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.

Prevalence of chronic complications and associated factors in type 2 diabetes.

OBJECTIVE: To determine the prevalence of chronic complications and associated factors in type 2 diabetes in 500 diabetic patients, age > or = 25 years, attending the clinic of Diabetic Association of Pakistan (DAP), Karachi. METHODS: Every 5th registered diabetic patient > or = 25 years age, was examined for the presence/absence of micro and macro vascular complications and associated factors. Blood samples were collected for HbA1c, lipid profile and serum creatinine. Urine was examined for albumin and microalbumin. RESULTS: Of the 500 diabetic patients examined (160 males, 340 females, mean age 55.2 10.6 years), retinopathy was seen in 43%, neuropathy in 39.6% and foot ulcers in 4%. Nephropathy was found in 20.2%, and was significantly associated with hypertension. The prevalence of microvascular complications was higher in the group of patients with HbA1c > 8% and was significantly related to duration of diabetes, hypertension and obesity. Hypertension was manifest in 64.6% patients, 61% had raised Body Mass Index and Waist Hip Ratio was more than normal in 88% subjects. Macrovascular complications were encountered in 102 diabetic patients, with angina in 85 (17%), heart attack in 25 (5%) and stroke in 13 (2.6%). CONCLUSION: The prevalence of diabetic microvascular complications was higher in people with poor glycaemic control, longer duration of diabetes and associated hypertension and obesity.

Diabetes related knowledge, attitude and practices of family physicians in Pakistan.

OBJECTIVE: To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physicians (FPs) working in urban and rural areas of Pakistan. METHODOLOGY: A cross-sectional survey was conducted on FPs through an interview by a trained person and filling up a questionnaire focused on diagnosis, treatment and complications of diabetes. The answers were scored by assigning marks and conversion to percentages. The computer package SPSS version 10 was used for statistical analysis. RESULTS: A total of 767 FPs (756 males, 11 females, average age 42.18 years) with a mean clinical practice duration of 13.41 years, with 681 practicing in urban areas and 86 in rural areas, participated in the study. Each FP saw on an average 58 patients daily, spending a mean of 8.5 minutes with each case. More than 90% FPs treated diabetics and 107 (14%) of the doctors were diabetic themselves. Overall 62% answers were correct, with the FPs from Sindh having the highest score of 66% and the Federal Capital Area with the lowest 54%. The questions answered correctly by less than 50% of FPs pertained to diagnostic blood values of glucose, treatment of children with diabetes, pregnant diabetics, monitoring of diabetics and technique of insulin injection. The questions answered correctly by more than 50% of FPs were related to diagnosis of Impaired Glucose Tolerance (IGT), insulin in pregnancy, importance of education in diabetics and diabetes complications, screening and management. CONCLUSION: This study has explored several aspects of diabetes related KAP of Family Physicians and identified the need for improvement in their practices for treating and educating diabetics. Awareness and education programmes are recommended to update the FPs on early detection and management of diabetes.

Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Baluchistan province.

The prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) and their relationship to age and obesity was estimated in a population-based survey in urban and rural areas in Baluchistan province, Pakistan. Cluster sampling of 834 adults (260 men, 574 women) in the urban and 570 adults (175 men, 395 women) in the rural areas was carried out. Oral glucose tolerance tests were performed in adults aged 25 years and above. Diagnosis of diabetes and IGT was according to the World Health Organization (WHO) criteria. The overall prevalence of diabetes and IGT in both sexes was 10.8 and 11.9% (urban) versus 6.5 and 11.2% (rural), respectively. The crude prevalence of diabetes in the urban versus rural area was 11.1% in men and 10.6% in women versus 10.3% in men and 4.8% in women. As against this IGT was found in 6.5% of men and 14.3% of women in the urban area and 7.4% of men and 13.0% of women in the rural setting. The major risk factors associated with diabetes were age, positive family history (F/H) of diabetes and obesity. Central obesity was more strongly associated with diabetes in women than men.

Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province (NWFP) of Pakistan.

AIM: To estimate the prevalence of non-insulin dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) and their relationship with age and obesity in a population based survey in the rural areas of NWFP, Pakistan. SETTING: Three villages, Pawakai, Reghi and Jhagra in NWFP were the target areas. METHODS: Cluster sampling of 1035 adults aged 25 years and above (207 men, 828 women) was done. Oral glucose tolerance tests were performed and the diagnosis of diabetes and IGT was made according to WHO criteria. Height, weight and waist hip ratio of the study population were recorded. The Chi Square test was used to measure the association among the different variables. Basic demographic information from the subjects was collected by a physician using a standard questionnaire. RESULTS: The overall prevalence of NIDDM and IGT in both sexes was 11.1% and 9.4%. The sex-specific prevalence of diabetes was 9.2% in men and 11.6% in women. Advanced age, positive family history of diabetes and obesity were associated with higher rates of diabetes. In both sexes high Waist Hip Ratio (WHR) was more closely associated with diabetes than was high Body Mass Index (BMI). CONCLUSION: The prevalence of diabetes mellitus in rural areas of NWFP is high and almost similar to that of Sindh and Baluchistan.

Gestational diabetes mellitus--screening in a developing country.

All gravid women attending the antenatal clinic of the department of Gynaecology Unit-II, Civil Hospital Karachi and unbooked cases presenting in labour from October, 1986 to December, 1993, were included in the study. On the basis of risk factors for diabetes mellitus (DM), they were divided into 3 groups. Women in Group-I had family history of DM, bad obstetric history, congenitally malformed babies, polyhydramnios, obesity and macrosomia. Group-II included women with pregnancy induced hypertension (PIH) abruptio placentae, age > 30 years and multiple pregnancy. Group-III comprised of the pregnant women with no risk factors for DM. Screening of 4497 subjects from the antenatal clinic was performed and DM was diagnosed in 211 (12%) in Group-I, 11 (3%) in Group-II and 13 (0.6%) in Group III. Chi-square analysis demonstrated that frequency of DM was significantly higher (P < 0.001) in Group I and Group II as compared to Group III. Non-booked admissions numbered 7600, of these, DM was detected in 166 (20%) belonging to Groups-I and II, whereas, 38 (0.6%) were from Group-III. Screening was done by the O'Sullivan criteria. It was concluded that all pregnant women should be screened for DM. However, if financial constraints prevail, then women with high risk factors only should be subjected to screening.

Pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province.

The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity was estimated in the rural town of Shikarpur in Sindh Province, Pakistan by a population-based survey in 1994. Oral glucose tolerance tests were performed in a stratified random sample of 967 adults (387 men, 580 women) aged 25 years and above. The diagnoses of diabetes and IGT were made on the basis of WHO criteria. The response rate was 71% for men and 80% for women. The prevalence of diabetes was 16.2% (9.0% known, 7.2% newly diagnosed) in men, and 11.7% (6.3% known, 5.3% newly diagnosed) in women. The prevalence rose with age to a peak of 30% and 21% in 65-74 year-old men and women respectively. IGT was detected in 8.2% of men and 14.3% of women. Thus, total glucose intolerance (diabetes and IGT combined) was present in 25% of subjects examined. These results indicate that glucose intolerance in South Asians can no longer be regarded as a problem confined to migrant communities. Of the 72 subjects previously known to have diabetes, none was using insulin treatment, but 57 (79%) took oral hypoglycaemic agents. Central obesity and positive family history were strongly associated with diabetes, as was prevalence of hypertension. The association with central obesity was greater for women than for men, and suggests important, modifiable risk factor(s) related to lifestyle.

Glucose intolerance in pulmonary tuberculosis.

The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis attending Nazimabad Chest Clinic. Diagnosis was based on X-ray and a positive sputum smear. An oral glucose tolerance test (OGTT) was performed and evaluated according to the WHO criteria. Glucose intolerance was detected in 52 (49%) patients, 31 Impaired Glucose Tolerance (IGT), 21 Diabetes Mellitus (DM). After adequate antitubercular therapy and sputum conversion, the OGTT was repeated in 23 cases. Of these 13 (56.5%) patients had a normal glucose tolerance indicating that glucose intolerance observed during active pulmonary tuberculosis improves or normalizes after adequate therapy.

Changes in glycosylated proteins in long-term complications of diabetes mellitus.

Increased glycosylation of various proteins in diabetic patients has been reported by many authors. In the present study, the extent of non-enzymatic glycosylation in diabetic patients with or without chronic complications was investigated. Eighty-five diabetic patients were studied, 20 were without any clinical evidence of chronic complications while the remainder were suffering from cataract (n = 18), retinopathy (n = 16), peripheral neuropathy (n = 16) and cardiovascular complications like angina pectoris, myocardial infarction and hypertension (n = 15). All patients were selected on clinical grounds. Fifteen apparently healthy subjects of similar age and weight were studied as control subjects. Fasting plasma glucose was increased in all diabetic patients and correlated significantly with glycosylated hemoglobin, glycosylated plasma protein and serum fructosamine concentrations. There was no significant difference between diabetic patients with or without chronic complications in the levels of fasting plasma glucose, glycosylated plasma proteins, glycosylated hemoglobin, serum fructosamine, mucoprotein, hexosamine, sialic acid and fucose. Alpha-2 globulin fraction was increased in both uncomplicated and complicated diabetic patients and albumin was found to be decreased in patients with cataract, peripheral neuropathy and cardiovascular diseases. Alpha-1 and beta globulins were significantly decreased in patients with cardiovascular diseases and retinopathy respectively while gamma globulin was increased in retinopathy patients. In uncomplicated diabetic patients alpha-1 glycoprotein was decreased and gamma glycoprotein was increased. In diabetic patients with retinopathy, alpha-1 glycoprotein was elevated significantly while beta glycoprotein was decreased.