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My last post about Pakistan becoming number #1 in diabetes prevalence raised quite a bit of interest, surprise, concern, and disbelief. I also mentioned that obesity in our population is much lower than many other countries, so there would be other probable reasons for such high prevalence.
I am taking from two published research articles and a news report for the German publication DW.
Research article titled ‘Type 2 diabetes prevalence in Pakistan: what is driving this? Clues from subgroup analysis of normal weight individuals in diabetes prevalence survey of Pakistan’ was published in June 2020, and is available on PubMed Central. There are ten authors from Peshawar, Islamabad, Lahore, Karachi, and the UK. This was a cross-sectional, community-based survey of people aged twenty years and above. The participants were subjected to HbA1C testing which is a routine blood test which gives a snapshot of glucose profile over the last three months. The results of HbA1C may be read as follows:
- Below 5.7% is Normal
- 5.7% to 6.4% is pre-diabetic
- 6.5% and above is diabetics
The entire study was conducted on 18,856 individuals which included some known diabetics. Diabetes prevalence was determined across BMI categories, age groups, gender, rural/urban residence, and education level.
Of the 6,824 normal BMI individuals, there was a high prevalence of T2DM 14.92%, and in underweight at 10.14%. Corresponding rates for prediabetes for normal BMI category 9.79%, and underweight 8.99%.
Pre-diabetes is a condition in which the patient does not exhibit symptoms of diabetes, but glucose readings may be deranged at times; HbA1C is the main indicator which shows that the person is pre-diabetic. Pre-diabetics are highly prone to become diabetic if they do not take precautionary measures with diet and lifestyle.
In this study, the risk of T2DM was greatly increased by prior family history and by age, but not by urban vs rural living environment. The factors that underlie very high prevalence of T2Dm in Pakistan even in rural areas are not clear and need in-depth studies. It is possible that specific strains of wheat or the way the bread in made may influence glucose profile. It has also been proposed that arsenic and pesticides applied to crops and in the soil may contribute to causing diabetes. Yet another possibility is environmental agents that may directly damage pancreatic beta cell which produce insulin.
Education also came up as an important factor. In normal BMI individuals, there was a significant increase in T2DM prevalence with decreasing level of formal education.
The second study titled ‘The increasing rate of diabetes in Pakistan: A silent killer’ has been authored by two researchers from Lahore and one from Karachi and was published in June 2022.
Diabetes prevalence has been steadily rising through the years.
- 2016 11.77%
- 2018 16.98%
- 2019 17.1%
- 2021 26.7% About 33 million people
- 2023 30.8%
This study was based on data review and did not involve patients. The reasons for diabetes include diet, lifestyle, use of processed foods, and increased consumption of sweets.
The third resource is the article by S. Khan for DW which reiterates the findings as mentioned above. In addition, it says that the cost of antidiabetic drugs is out of reach of many people and that the government spending on health is so small, it does not cover anything adequately.
When I joined Pharma industry in 1975, the company had an oral antidiabetic drug which was top selling in the market. We were taught about diabetes, its causes and management in detail. My interest in diabetes has been there since then, and I have huge number of personal observations on diabetes in our society. I would not go for the standard reasons which are given in literature but mention the unreported ones. These factors become a serious hinderance in diagnosis and management of diabetes.
Stigma – diabetes has been associated with social stigma. Even highly educated patients do not declare themselves as diabetic publicly because they think their status goes down somehow if they do so. Therefore, they would consume all prohibited foods publicly to show that they are completely normal. Some people take the denial to the extent where they do not even reveal it to their own family, wife, and children. Obviously, they never take any treatment and are finally caught when their kidneys fail, or eyesight fails, or they have a heart attack. The family comes to know at that time and then it is too late.
Superstitions – though we claim to be devout Muslims, yet the amount of superstitions is staggering. Diabetes is not a disease, but the effect of ‘something’, just like mental illnesses. The treatment must be to ward off the evil spirits and this job shall be done by some expert who himself may be severely diabetic, obese, and suffering from complications. These patients never go to doctor and never seek any treatment. In their view, complications are also due to the same thing.
Cure of diabetes – too many diabetic patients, even the educated ones, still believe that diabetes can be cured forever. Advertisements about complete cure of diabetes in a few days or weeks have been appearing in print media for years; now these have even greater reach through social media. The media is complicit in this crime because they would like to receive money no matter how and from where it comes. Quacks, self-proclaimed hakeems and homeopaths regularly advertise about rooting out diabetes from the body. The lure of cure in few weeks is so big in comparison to lifelong treatment and restrictions that people fall for it. The cure never comes, rather the pain of blindness, dialysis, amputations, and debility comes sooner or later.
Alternative Treatments – these do not claim to cure outrightly but promise to manage diabetes without drugs, while subtly implying that the disease may leave altogether at some point in time. The most popular are ‘ta’aweez’ which are issued by some spiritual person, with the instruction to put in a bottle of water and refill when needed. There are strict orders to drink only the ta’aweez water and no other water at all, otherwise the effect will be lost. I know of one gentleman who lost life at a rather young age after drinking ta’aweez water for a few years.
The second popular treatment is ‘some special water coming from some special spring somewhere up in the mountains’. Several of these are located at various difficult locations. Instructions are the same; drink only spring water, no drugs, and eat any food you like. Results are the same which are expected from these practices.
Fear of Insulin – Our people have insulin phobia, ostensibly because many believe that insulin means the last stage of disease. They will do their utmost to avoid shifting to insulin and may keep increasing the number of tablet without much benefit. These people go into complications soon because their diabetes is uncontrolled.
How can we tackle these issues? Education and awareness at mass level, consistently and persistently is essential. This is not possible without government support which must come. Government should also take legal measures to stop the advertisements about the cure of diabetes.
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