Muhammad Yakoob Ahmedani

Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan.

AIMS The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity were estimated in Punjab, Pakistan by a population-based survey done in 1998. METHODS Oral glucose tolerance tests were performed in a stratified random sample of 1852 adults aged >or=25 years. The diagnosis of diabetes and IGT were made on the basis of WHO criteria. RESULTS The prevalence of diabetes was 12.14% in males and 9.83% in females. Overall total glucose intolerance (diabetes and IGT) was present in 16.68% males and 19.37% females. Central obesity, hypertension and positive family history were strongly associated with diabetes. CONCLUSIONS These results indicate that the prevalence of glucose intolerance is high in the studied population and comparable with the published data from the other three provinces of Pakistan i.e. Sindh, Baluchistan and North West Frontier Province, studied by the same group.

Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan

BackgroundTo observe the outcome of implementation of Ramadan-specific diabetes management recommendations in fasting individuals with diabetes through health care providers.MethodsThis multi-centered prospective study was conducted at nine diabetes specialist centers in four provinces of Pakistan. The study was carried out in two phases; pre-Ramadan recruitment interview (visit A) and post-Ramadan follow up interview (visit B) of the same patients. Pre-Ramadan individual counseling was given and educational material provided to each patient by health care providers during visit A.ResultsOut of 388 patients with diabetes, blood glucose level was checked by all patients with type 1 and 71.43% patients with type 2 diabetes when they developed hypoglycemic symptoms during Ramadan. Of patients with type 1 and type 2 diabetes, 33.33% and 48% discontinued their fast when they felt hypoglycemic symptoms, respectively. None of the patient with type 1, while 18.87% patients with type 2 diabetes discontinued fast on the development of hyperglycemic symptoms. Drug dosage and timing were altered in 80% patients with type 1 and 90.5% patients with type 2 diabetes during Ramadan. Majority of the patients with type 2 diabetes changed from moderate/severe levels of physical activity before Ramadan to light physical activity during Ramadan (p<0.000). None of the patients required hospitalization when they developed symptomatic hypoglycemia or hyperglycemia and none developed diabetic ketoacidosis and hyperglycemic hyperosmolar state during Ramadan.ConclusionWe observed that it is practicable to implement Ramadan-specific diabetes management recommendations through health care providers.

Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan

AIMS To observe temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan province of Pakistan according to American Diabetes Association criteria by comparing the two surveys done in 2002 and 2009. METHODOLOGY This community based survey of 1264 subjects aged 25 years and above was conducted from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed in comparison with a similar survey conducted seven years previously. Data from 2002 survey was also re-analyzed according to the latest ADA criteria. RESULTS A two-fold increase in the prevalence of diabetes (from 7.2% to 14.2%) was seen in 2009 survey and the prevalence of impaired fasting glucose also increased significantly (6.5-11.0%). An important finding was the number of hypertensives and subjects with positive family history of diabetes also increased significantly (p<0.000) from the previous survey. CONCLUSION Coordinated National Programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Further large scale studies with proper risk factor assessment are needed to ascertain the reasons of rising prevalence of glucose intolerance.

Dietary Patterns and Glycemic Control and Compliance to Dietary Advice Among Fasting Patients With Diabetes During Ramadan

Modified eating habits during the month of Ramadan and the significant increase in food intake after breaking the fast can unbalance the metabolism of patients with diabetes (1–3). Evidence-based guidelines for food intake during Ramadan do not exist. A study was planned to observe the association between different dietary patterns and glycemic control and compliance to dietary advice among fasting patients with diabetes. Observational data were obtained as part of a study conducted at the outpatient department of Baqai Institute of Diabetology and Endocrinology during Ramadan of 2009 (4). An educational session was given to each patient by a dietitian on a one-to-one basis. All patients were advised to keep a record of food intake and blood glucose readings. Individual counseling was provided to encourage 1 ) adequate intake of energy, 2 ) consumption of balanced meals, and 3 ) distribution of carbohydrate intake over various meals …

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 (

Detecting Insulin Resistance in Pakistani Subjects by Fasting Blood Samples

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.

Comparison of Ramadan-specific education level in patients with diabetes seen at a Primary and a Tertiary care center of Karachi-Pakistan.

Background: Insulin Resistance has been identified as an independent risk factor for a number of chronic diseases such as diabetes and cardiovascular diseases. Thus identifying insulin resistant cases would help to better prevent the progression of these diseases in such individuals. Objective: To identify a simple indirect method for detecting insulin resistance in our population by using fasting blood samples. Methods: Geographical Imaging Systems was used for randomly selecting the subjects during an epidemiological survey done. For visiting the 532 households selected by geographical imaging systems, nine field teams were developed. A total of 871 subjects older than 25 years were approached by these teams out of which 867 agreed to participate in the survey. Insulin resistance was assessed in 227 normal subjects by fasting insulin, Homeostasis model assessment for insulin resistance (HOMA-IR), Quantitative insulin-sensitivity check index (QUICKI) and McAuley Index. Results: Insulin Resistance was defined at 75 th percentile cut off of insulin levels (9.25 U/mL) and at 75 th percentile of HOMA-IR (1.82). The 25 th percentile cut off was used for defining insulin resistance in QUICKI (0.347) and McAuley Index (6.77). Conclusion: A common approach towards managing subjects with metabolic risk factors will help identify insulin resistance earlier by this fasting method and using insulin resistance reference values identified from simple indirect methods would be of value in such cases. However larger population based studies are needed to further define and validate these cutoff values for insulin resistance to be used for the general population.

Ramadan and diabetes - knowledge, attitude and practices of general practitioners; a cross-sectional study.

AIMS To compare Ramadan-specific education level in fasting patients with diabetes at a Primary and a Tertiary care center. METHODOLOGY An observational study was conducted in the Outpatient departments of a Primary care center and a Tertiary care center in Karachi-Pakistan. Recruitment of patients started at the end of Ramadan 2011 and continued till three months after Ramadan 2011. All patients with diabetes who observed fast during the month of Ramadan 2011 were included in the study. In Primary care center, patients were attended by physicians only, while at Tertiary care center patients were seen by physicians, diabetes educator and dietician. For data collection, standardized questionnaire based interview was conducted on one to one basis by trained healthcare professionals. Same questionnaire was used at both the centers. RESULTS A total of 392 and 199 patients with diabetes recruited at Primary and Tertiary care centers, respectively. Ramadan-specific diabetes education received by 213 (55%) and 123 (61.80%) patients with diabetes at Primary and Tertiary care centers, respectively. Compared to Primary care center, patients at Tertiary care centers were more aware about components of Ramadan-specific diabetes education such as signs and symptoms of hypoglycemia and hyperglycemia, dose of medicines/insulin during Ramadan fasting, dose of medicines/insulin when not fasting, self-monitoring of blood glucose, dietary modifications, physical activity, adequate nutrition and adequate hydration during Ramadan (p<0.05). CONCLUSION It was observed that Ramadan-specific education level of patients at Tertiary care center was significantly better compared to patients at Primary care center.

Role of Ramadan specific diabetes education (RSDE); A prospective study

Background and aims: Fasting during Ramadan is obligatory for all Muslims across the world. Through literature review, it has been found out that there are various articles published for the awareness of patients and general population regarding safe fasting during Ramadan. But very few studies highlight the Ramadan specific knowledge of general practitioners engaged in providing care to people with diabetes. This study aims to describe the practice, knowledge and attitude of general practitioners regarding treatment and dietary modifications for people with diabetes during Ramadan across Pakistan. Methods: A cross-sectional descriptive study was undertaken among a sample of 274 general practitioners. Data was collected by means of a questionnaire that consisted of 25 questions that were structured according to three categories i-e. Ramadan specific knowledge, diet and physical activity and treatment modification related knowledge and practices of GPs. Results: Out of the total population of GPs surveyed, 70% responded correctly to the questions while 30% responded incorrectly. 1/4th of GPs incorrectly responded to questions regarding basic concepts of diabetes and Ramadan. 1/3rd of GPs responded incorrectly regarding questions on diet. Almost 40% of the GPs responded incorrectly to the questions regarding drug dosage adjustment in people with diabetes during Ramadan. However, more than 80% responded in agreement regarding alteration in medication timings. Conclusion: Almost one third of the studied populations of general practitioners across Pakistan lack the knowledge of basic principles that are important to be employed in the management of diabetes during Ramadan. Hence there is need to promote educational programmes and CMEs to improve the knowledge of our GPs that should be reflected by their sound clinical practices in the field of diabetes.

Blood glucose meters and test strips: global market and challenges to access in low-resource settings

Objective: To observe the role of Ramadan Specific Diabetes Education (RSDE) in the management of fasting patients with diabetes. Methods: This prospective study was carried out at out-patients department (OPD) of Baqai Institute of Diabetology & Endocrinology (BIDE), in 2012. Recruitment of patients started a month prior to Ramadan. Muslim patients with diabetes whether had their first or on follow up visit to the OPD and showed intention to hold fast in the month of Ramadan, were included. A printed broacher focused on six cardinal areas of fasting and diabetes identified in Ramadan specific guidelines was given to all participants. All patients had their first visit to the OPD (n=32) were also given RSDE on one-to-one basis (Group A). Whereas patients had follow up visit were advised to attend a group session on RSDE. Those attended (n= 25) and those did not opt (n=45) the group session were included in Group B and Group C respectively. All participants were instructed to visit the OPD after Ramadan. Group D was constituted after Ramadan. It included patients who had not visited the OPD during induction period thus did not receive RSDE (n=76) they however hold fast in the month of Ramadan. Data regarding compliance to structured education through different modes was collected during post Ramadan visit. Results: Comparisons among groups who received education(A with B with C) revealed non-significant difference in self-monitoring of blood glucose, alteration of drug dosage and timing, appreciation of hypoglycemia and action taken on development of hypoglycemic symptoms. However, significant differences were noted when group who received education was compared individually with group who did not receive education. Conclusion: Patients who receive Pre-Ramadan diabetes education were found to be significantly better in following Ramadan specific diabetes management recommendations compared to patients who did not receive education. Further large scale studies are needed to validate our findings.