Fatema Jawad

South Asian women with diabetes: Psychosocial challenges and management: Consensus statement

Diabetes is the ninth leading cause of death in women globally. In South Asians mortality in women with diabetes stands second highest. There is a marked gender discrimination which is faced by women across South Asia esp in access to services and support for diabetes, resulting in high rates of morbidity and mortality in women with diabetes. The most important risk factor identified for the diabetes epidemic is obesity along with genetic susceptibility. Lack of health care, social and cultural disparity, discrimination at work, disparity in marriage, restricted medical facilities are prevalent. Diabetes and depression are common in women. Increasing age, low level of education, low socioeconomic conditions, difficulties posed in finding partners, frequent divorce and family history of psychiatric illness are significant risk factors for diabetes and depression. Such patients usually have poor metabolic control, higher complication rates, increased healthcare costs, lost productivity, lower quality of life as well as increased risk of death. Preconception counseling should be incorporated in the routine diabetes clinic visit for all women of childbearing potential. Women with diabetes should have information and access to contraception. Proper family planning counseling and psychological support can help stop practices such as female foeticide and multiple pregnancies. Psychological support to patients and their families are needed to break the barrier. There is emerging evidence that women with diabetes are more prone to untoward outcomes as compared to men. Central obesity, metabolic syndrome and the polycystic ovary syndrome show ethnic specific differences in South Asian women. Optimal sexuality is an integral part of holistic health. Shortage of trained female health care professionals, lack of privacy in over-crowded health care facilities, a social taboo attached to such matters, and lack of confidence in patients contribute to the neglect of sexual issues in women attending diabetes clinics across South Asia. Guidelines for counselling in female sexual dysfunction, written in culturally appropriate manner for South Asia, are needed. Diabetes affects women more severely because of their unique biological, cultural and socioeconomic circumstances. Women have limited access to health care facilities because of illiteracy, ignorance and negative social customs. Transcending the gender hierarchy and inequality is a formidable challenge. Sensitising men, empowering women on self care and providing peer support maybe the answer to this challenge. It is essential for health care providers to use appropriate coping mechanism such as building psychological contact with the patient, including family and friends as part of social support and empower patient with complete process of managing diabetes. Increasing awareness through the media, seminars, posters, group discussions and education, regular monitoring and consulting the doctor, support group for women and facilities for aerobic exercises are recommended. The health care systems should consider custom-designed prevention and control programs tailored for women based on local and regional attitudes on health care, cultural beliefs, and available social support systems. Policies that empower adolescent girls and young women to take control of their metabolic management must be encouraged. Provision of gender specific diabetes education with a holistic life-cycle approach is recommended.

Long-term Safety of Living Kidney Donation in an Emerging Economy.

Background Long-term follow-up and management of donors was undertaken in a specialist kidney transplant unit in Pakistan to identify risk and prevent adverse outcomes in living related kidney donors. Methods In an observation cohort study between 1985 and 2012, 3748 donors were offered free medical follow-up and treatment 6 to 12 months after donation and annually thereafter. Each visit included history, physical examination, blood tests for renal, lipid, glucose profiles, and 24-hour urine for proteinuria and creatinine clearance. Preventive intervention was undertaken for new onset clinical conditions. Donor outcomes were compared with 90 nondonor healthy siblings matched for age, sex, and body mass index. Results Of the 3748 donors, 2696 (72%) were in regular yearly follow-up for up to 27 years (median, 5.6; interquartile range, 7.9). Eleven (0.4%) died 4 to 22 years after donation with all-cause mortality of 4.0/10 000 person years. Six (0.2%) developed end-stage renal disease 5 to 17 years after donation, (2.7/10 000 person years). Proteinuria greater than 1000 mg/24 hours developed in 28 patients (1%), hypertension in 371 patients (13.7%), and diabetes in 95 patients (3.6%). Therapeutic intervention-controlled protein was less than 1000 mg/24 hours, blood pressure was below 140/90 mm Hg, and glycemic control in 85% up to 15 years after onset. Creatinine clearance fell from 109.8 ± 22.3 mL/min per 1.73 m2 predonation to 78 ± 17 at 1 year, 84 ± 19 at 5 years, and 70 ± 20 at 25 years. Comparison of 90 nondonor sibling and donor pairs showed significantly higher fasting glucose and hypertension in nondonors. Conclusions Long-term follow-up of donors has demonstrated end-stage renal disease in 0.6% at 25 years. Regular follow-up identified new onset of disease and allowed interventions that may have prevented adverse outcomes.

Challenges in Type 1 diabetes management in South East Asia: Descriptive situational assessment.

Treatment of type 1 diabetes is a challenging issue in South East Asia. Unlike in the developed countries, patients have to procure insulin, glucometer strips and other treatment facilities from their own pockets. Coupled with poor resources are the difficulties with diagnosis, insulin initiation, insulin storage, marital and emotional challenges. Being a disease affecting only a minority of people, it is largely ignored by the governments and policy makers. Comprehensive diagnostic, treatment and team based educational facilities are available only in the speciality diabetes centers in the private sector whereas majority of the subjects with type 1 diabetes are from a poor socio-economic background. Unlike in the Western world, being known as a diabetes patient is a social sigma and poses huge emotional burden living with the disease and getting married. Even with best of the resources, long-term treatment of type 1 diabetes still remains a huge challenge across the globe. In this review, authors from India, Pakistan, Nepal, Sri Lanka, Myanmar and Bangladesh detail the country-specific challenges and discuss the possible solutions.

Perspectives on patient-centered care in diabetology

Much has been written about patient-centered care (PCC) in medical literature. PCC has been praised as the ultimate objective of medicine by some. However, critics have pointed out the obvious: The antonym of PCC is doctor-centered medical care. Is doctor-centered care wrong? And what do we practice if we do not follow PCC? Can physicians transfer all responsibility for decision making to patients, in the name of PCC? Do patients have a right to choose outcomes, and make clinical decisions to achieve those outcomes? Most of the work on PCC has been done in the fields of family medicine and primary care. Minimal publications are available to highlight the role of PCC in endocrinology and diabetology. This brief communication discusses some concepts of PCC, and expands upon this term, to assess its relevance to diabetology.

Letter to the Editor: Comment on Predatory Journals

The wrong and deceptive method of inviting authors to publish research in open-access journals with false metrics and no stability has become a source of income for many publishers all over the world. Such journals are termed ‘predatory’ gold open-access models for profit earning. Jeffrey Beall contributed to the Editing, Writing & Publishing Section of the Journal of Korean Medical Science by sharing his thoughts on how to detect these fake publishers and protect the scientific community from them (1).

High dose steroid regime: a tool for reducing organ rejection

IMMUNOSUPPRESSION is an important aspect of organ transplantation (Tx). In the last three decades many new drugs have been introduced. The three main categories are anti–inflammatory drugs, cytotoxics, and fungal and bacterial derivatives. Despite the change in protocol and the multiple side effects, steroids still are the gold standard and play an important role in graft protection. This retrospective study was conducted on two groups of transplanted patients receiving two different dose regimes of steroids to assess the frequency and type of complications and the frequency of acute rejection episodes.