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Prevention of diabetes mellitus is cost effective in high risk group - Prof. Hajera Mehtab.

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On second day of the SAFES-II Summit held at Dhaka Bangladesh from April 24-26. 2015, Prof. Liaquat Ali, Vice Chancellor of Bangladesh University of Health Sciences chaired the first session. Dr. Noel Somasunderam from Sri Lanka was the first speaker who talked about Epidemiology of Diabetes in South Asia. He pointed out that 25% of all people with diabetes live in South Asia. IHD and Infectious diseases are also on top in these areas. Diabetes prevalence in Pakistan is reported to be 8% in rural areas and 5% in urban areas. India, Sri Lanka and Bangladesh have high prevalence of diabetes. In China the prevalence of diabetes is 18.6% in people above twenty years of age which is going to increase to 24.7% in the next ten years. Sri Lanka has an overall diabetes prevalence of 26.9% and if we combine the diabetic and pre diabetic prevalence the figure comes to 59.26%.

Another study showed the prevalence of hypertension to be 39%, Dyslipidemia 42%, smoking 8% which are all important metabolic risk factors. We also have to be mindful of diabetic complications. India has almost forty million people with diabetes which are out of control. His conclusions were that diabetes is increasing at an alarming pace hence there is an urgent call for action. Some of the SNIP, it was stated, increases the risk of diabetes mellitus by 30%.

In another session which was chaired by Prof. A.R.Khan, Prof. Hajera Mehtab from Bangladesh spoke about primary prevention of type 2 DM highlighting the achievements of primary prevention programme of diabetes mellitus in Bangladesh. Diabetes, she said, is increasing fast in developing countries due to changing life style, fast food, obesity and sedentary life style. Population is also increasing. We are seeing rapid urbanization. In Bangladesh the prevalence of diabetes mellitus in 2010 was 8.4 million which is expected to be 16.8 million by the Year 2030. It has tremendous impact on health and economy of the country. She laid emphasis on timely prevention, increased physical activity, identify and focus people with high risk group. Prevention, she opined, is cost effective in high risk group.

Continuing Prof. Hajera Mehtab recalled that in 1956, there were only 39 registered patients suffering from diabetes in Bangladesh. Now we have more than five lac registered patients. Diabetic Associaton of Bangladesh currently takes care of 25% of patients with diabetes and hopes to look after 50% in a year's time. She called for identifying cost effective strategies for prevention of diabetes mellitus involving folk singers, religious leaders, community leaders, using diabetic patients, short films, leaflets, provision of insulin and oral anti diabetes drugs. Screening programme in schools will be very effective. Songs in films, education and training doctors, and other healthcare professionals could also prove useful. She also talked about the national policy for prevention of diabetes and different intervention strategies. A national programme for prevention, she emphasized, was essential.

This was followed by Prof. Abdul Basit from BIDE Pakistan who gave details of the Diabetic Foot Care Model which they have developed at Baqai Institute of Diabetes and Endocrinology. Tracing the history he said in 1996 there was no diabetic foot clinic in Pakistan. We have 7.1 million people suffering from diabetes mellitus. We started training Diabetic Foot Care Assistants in a six weeks course. They helped in achieving good glycaemic control, providing low cost dressings. Number of dressings was increased; antimicrobial agents were used in high dose and for a longer duration.

We also introduced low cost off loading devices. We also started training physicians in foot surgery curtailing cost of surgery. It resulted in 50% reduction in amputations in ten years time. We have formed the Pakistan Working Group on Diabetic Foot. From 2006 onward, the diabetic foot care programme has entered in the second decade. So far we have trained 199 teams. Advance care programme was introduced for the earlier participants who included one hundred three Diabetic Foot Care Assistants. We still use Pyodine to debride the wound despite increasing cost of diabetic foot care, he remarked.

BIDE then established the National Associaton of Diabetic Educators of Pakistan (NADEP). We hold Cardio Metabolic Clinic at the NICVD, we have also started PAD clinic preparing Pedograph. Now our aim is to prevent ulcer, treating ulcer was the story in the past. We give Foot Care advice to the patients from Day One. The result is almost 75% reduction in amputation rates. Now we have established 115 Diabetic Foot Care Clinics all over the country. In the third phase, we aim to start corrective surgery. Since there is no money in it, surgeons are least interested. Hence, we are training our physicians in this type of surgery. We are planning to start MSc programme in Podiatry and hope to offer customized foot care. We are also developing local footwear for the patients with diabetes using local material using Insole development machines. It is cost effective and hopes to accomplish it by the Year 2020. Pakistan needs 1700 Foot Care Clinics. This year we are training six hundred teams.

We have formed an Advisory Board for Care of Diabetes at ten diabetic units all over Pakistan. We have developed National Guidelines and are working on many other projects as well, Prof. Basit concluded.

Yan CAI from Novo Nordisk discussed innovations in Diabetes Care: Changing Diabetes for 90 Years. She commended the contributions of BIRDEM in diabetes care saying that it was one of the best centers in the word. She also highlighted the future activities of Novo Nordisk in the field of diabetes. At present she said only 6% of people with diabetes achieve desired treatment outcome. Just one percent reduction of HbA1c will reduce death and complications. It was in 1922 that insulin was discovered and in 1923 first Insulin was launched by NOVO. In 1946 we introduced NPH while in 1982 human insulin was made available. We provide continuous innovation in treatment and also educate the healthcare providers. In 1985 Novo Pen was introduced and in 1990 Biphasic insulin was made available followed by Basal Insulin-Rapid acting insulin which was followed by Ideg/Ideg Asp combination. We have a large team involved in Research and Development and have been conducting clinical trials in fifty countries.

In future we expect to make available oral insulin and once weekly injections, she added.

In the session devoted to Obesity and Metabolic Syndrome, Prof. Zaman Sheikh from Pakistan spoke about childhood obesity to prevent T2DM. He pointed out that at present there are over six million children in the world who are overweight, 20% are obese and about 40% of them will have obesity in their adulthood. Diet, decrease in activity, genetics, lack of safe and secure areas for physical activity were all contributing to increase in obesity. He suggested decrease in energy intake and increase in energy expenditures. Diet, he opined, was the cornerstone of therapy. Avoid sitting in front of TV for too long. Diabetologists, he suggested, should interact with the food industry to produce healthy foods for children. Children should also be encouraged to have increased physical activity. He concluded his presentation by stating that weight control was a journey and not a destination.

Prof. Liaquat Ali VC Bangladesh University of Health Sciences spoke about genetics and biochemical characteristics of diabetes mellitus. Insulin tolerance test, he said, was not easy to do. There are some basic defects in GDM as our policies are different from the West. Dr. Manoj Chadha talked about surgical management of obesity and indications for bariatric surgery. He discussed at length types of surgery, post operative care and long time outcome. Obesity, he said, starts early in life. It has severe morbidity and mortality. Management of obesity has not been good by physicians but it has been rather disappointing. Patients selected for bariatric surgery should have BMI of over forty; they should be between 20-60 years of age, BMI more than 35 with co-morbidity and those who have failed having used other forms of therapy.

It is contra indicated in those who are suffering from psychiatric disease or celiac disease. Speaking about the types of bariatric surgery procedures he pointed out that banding has gone into disrepute in India. Restrictive and malabsorptive procedures, gastric bypass are currently more popular. Steve gastrectomy was more popular in our center, he added. Every centre, he said, has its own learning curve. After surgery, the patient should have minimal nutrition complications, 75% remissions have been observed in T2DM, some patients have gone on off insulin therapy. Feeling of well being is there. There is reduction in sleep apnea and weight loss besides mortality reduction. Obesity Society of India says that it is a metabolic surgery which should be offered to selected patients. COSMID study showed that all patients were of lipids and off diabetic medications. In selected cases, it offers practical cure of diabetes.

After bariatric surgery, diabetes, hypertension, dyslipidemia all show significant improvement. However, risks of nutritional deficiencies have to be looked into. To ensure that a Dietetician should be a part of the medical team managing these patients. Hepatic failure, excessive weight loss, short bowl, abdominal pain could be some of the problems encountered in these patients hence involvement of a good psychiatrist, psychologist was important. He concluded his presentation by stating that surgery is the last option. First diet therapy should be tried followed by medical treatment and if nothing works, only then surgery was advisable. Responding to a question as regards patient selection for bariatric surgery, he said that it is the team who decided otherwise surgeon would like to operate on every patient. Prof. Liaquat Ali suggested that we should generate our own data and then produce local guidelines on management of these disorders.
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Publication:Pulse International
Date:Aug 15, 2015
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