In the Name of ALLAH, Ever Beneficent, Infinitely Merciful Current Status of Diabetes Care in Pakistan
MMDA International Symposium on Diabetes “ 2017 Updates” (F.R.C.P) Yangon, Myanmar Prof. Abdul Basit Professor of Medicine th 11 June, 2017 Director Baqai Institute of Diabetology & Endocrinology(BIDE) Karachi, Pakistan Prof. Abdul Basit (FRCP)
• Chair- elect IDF MENA Region • Director, Baqai Institute of Diabetology and Endocrinology (BIDE) • Joint Secretary , Diabetic Association of Pakistan (DAP) • Founder, National Association of Diabetes Educators of Pakistan (NADEP) • Chairman, Pakistan Working Group on Diabetic Foot (PWGDF) • Founder member , Diabetes in Asia Study Group (DASG) Current Status of Diabetes Care in Pakistan Screening and Prevalence Prioritization Strategies Capacity Building Management updates Future Directions Screening and Prevalence Still the gold standard diagnostic and screening test in Asians is Modified GTT Screening and Prevalence
International bodies are now recommending HbA1c as diagnostic criteria but regional/national studies are required before it can be included in national guidelines
Reference: American Diabetes Association, European Association for the Study of Diabetes, International Federation of Clinical Chemistry and Laboratory Medicine, International Diabetes Federation. Consensus statement on the worldwide standardization of the HbA1c measurement. Diabetologia 2007; 50: 2042-2043 Nature Reviews Endocrinology 6, 589-593 (October 2010) National Diabetes Survey – Pakistan 2016-17
Parameters being assessed • Fasting blood glucose • Random post 75 gms. Glucose load • HbA1c • Fasting lipid profiles • Blood pressure • Obesity measurements
Approved by National Bioethics Committee (NBC) - Pakistan
Collaborators DROP 2 Sampling progress Required Done Punjab 5800 4401 (76%)
Sindh 2630 1730 (66%)
KPK 1695 1513 (89%)
Baluchistan 555 528 (95%)
Islamabad 120 117 (97 %)
Overall 10800 8289 (77%)
DROP 2 Current Status of Diabetes Care in Pakistan Screening and Prevalence Prioritization Strategies Capacity Building Management updates Future Directions Prioritization Strategies IDF Consultative Sections
Diabetes education 3 top most Diabetic foot priority sections Diabetes and children BIDE in Diabetes EducationPrioritization Strategies
University based One year diploma in Diabetes Education
148 Educators trained International recognition Prioritization Strategies
WDC, Montreal 2009
Eight centers designated as IDF Centers of Education 2009-2013
WDC, Melbourne in 2013
Renewal till 2015 done 115 diabetic foot clinics
Sehwan Mirpur Khas Quetta Lahore
Diabetic 14
12
foot clinics 10 Amputation rate 8
6
4 halved 2 Percentage of Patients Percentage 0 2008 2009 2010
A.Basit and A.Nawaz. Preventing diabetes related amputations in a developing country – steps in the right direction. Diabetes Voice 2013;58:36-39 Second Decade of Diabetic Foot Care International Diabetic Foot Guidelines Prioritization Strategies Noordwijkerhout, Netherlands 2007 Noordwijkerhout, Netherlands 2011 The Hague,Netherlands2015
ISDF Advisory Board Member The Hague, Netherlands IWGDF Prioritization Strategies th 8 International Symposium on the Diabetic Foot in 2019
May 22-25, 2019 World Forum - The Hague - Netherlands
Invited as a member of the International Scientific Advisory Board Prioritization Strategies ABCD
Advisory Board for the Care of Diabetes Prioritization Prof. Abdul Basit Assoc. Prof .Qazi Masroor Chairman ABCD in Pakistan Bahawal Victoria Hospital Strategies Director Baqai Institute of Quaid-e-Azam Medical College Diabetes & Endocrinology Bahawalpur Professor of Medicine – Karachi
Assoc. Prof. Bilal Bin Younus Asst. Prof. Abdul Waheed Iqbal SIDER (Sakeena Institute of Tehseel Head Quarter Hospital Dadyal Diabetes & Endocrine Benazeer Bhutto Medical College Research) – Lahore District – Mirpur Azad Kasmir
Prof. Jamal Zafar Asst. Prof. Salma Tanweer Pakistan Institute of Medical Nishter Hospital & Medical Sciences – Islamabad College – Multan
Prof. Zaman Shaikh Asst. Prof. Sobia Sabir Liaqat University of Medical Lady Reading Hospital – and Health Sciences – Peshawar ABCD Hyderabad
Assoc. Prof. Jehangir Khan Assoc. Prof. Irshad Khoso Ayub Medical College – Bolan Medical Complex Abbottabad Hospital – Quetta Strategies Prioritization AdvisoryMeeting Board every Wednesday9am ABCD National DiabeticFoot 7 December7 2016 7 December7 2016 Islamabad Multan IDF, DF MENA Group, 2015 Prioritization Strategies Insulin my life Centers established
34 Teachers sensitized Type 1 diabetes model clinics Subjects registered
DAP- BIDE- WDF Free insulin vials distributed International recognition
L I F E FOR A CHILD IML Guest Visit 2016 Awareness Walk - IML Patient Participation Resulting National Life for a child acceptance impact 500 children FREE insulin
Pakistan Sudan Bangladesh Azerbaijan Mali Genetic studies
HbA1c machines
NICH
Punjab chapter of IML
Diabetes Registry of Pakistan (DROP)
DROP-1
DROP-F DROP-2 DROP
DROP-R DROP-G Dr. Nazeer Soomro Prof. Jamal Zafar Prof. Yakoob Ahmedani Dr. Asif Brohi Dr. Veru Mal
Dr. Pawan Kumar Dr. Bilal Bin Younus Prof. Abdul Basit Dr. Fareed Uddin Dr. Zahoor Shaikh
Dr. Riasat Dr. Abdul Waheed Iqbal Dr. Asher Fawwad Dr. Farhan Baloch Dr. Muhammad Irfan
Dr. Riaz Ahmed Dr. Salma Tanweer Dr. Zahid Miyan Dr. Fateh Dero Dr. Imtiaz Hasan
Dr. Saif Ul Haque Dr. Sobia Sabir Dr. Asim bin Zafar Dr. Irshad Ahmed Dr. Ali Jawa
Dr. Sanober Prof. Irshad Khoso Dr. Farhatullah Khan Dr. Kashif Dr. Jehangir Khan
Dr. Shahid Prof. Abrar Shaikh Dr. Abdul Rasheed Joyo Dr. Merajuddin Nizami Dr. Qazi Masroor
Dr. Shahjahan Mangi Prof. Jamal Raza Dr. Abdullah Memon Dr. Najma Samejo Dr. Ahsan Siddiqui
Dr, Umeet Kumar Prof. Zaman Shaikh Dr. Aejaz Solangi Dr. Nazeer Khokar Dr. Ameer Memon
Dr. Khurshid Khan Dr. A.H. Amir Dr. Abbas Raza Dr. Osama Ishtiaq Registry form Website
Online Registry Portal
DROP 1 Current Status of Diabetes Care in Pakistan Screening and Prevalence Prioritization Strategies Capacity Building Management updates Future Directions Diploma in Diabetology for Family Physicians Capacity Building
Batches completed
Diploma holders 17 417
Online Capacity Building Aga Khan University hospital
Baqai Institute of Diabetology & Endocrinology
Specialists Jinnah Postgraduate Medical Centre Training Jinnah-Allama Iqbal Institute Of Diabetes & Endocrinology
Diabetes Setup at Hyattabad Med Complex
Diabetes Unit at PIMS Capacity Building Family Physio physicians Therapists
Consulatnt Diabetes Diabetologist and care Endocrinologist People nurses with
Diabetes Diabetes Educators Dieticians
Phamacist Associate Foot Care Diabetologists Assistants Family Physio Gynaecologist physicians Therapists Ophthalmologist
Consulatnt Dermatologist Diabetes Diabetologist care Cardiologist and Endocrinologist People nurses
with Pshycologist
Surgical Diabetes Diabetes colleagues Educators Dieticians Clinical Nutrionist
Nephrologist Phamacist Associate Foot Care Diabetologists You name Assistants it and it ought to be Capacity Building here Capacity Building Public Health Depts Politicians Public forums NADEP etc.
Role of Physician multiple Associations stakeholders Media Teaching Faculties
Donors Pharmaceutical Philantropy industry Diabetes Leadership Forum Capacity Building Policy Makers Advocacy Board Meeting 1st and 2nd March, 2014, Islamabad What needs to be done? M.Sc NCDs Who Can Apply
MBBS, MD, BDS or Objective equivalent qualification
Develop professional skills Master’s degree in to analyze the underlying Sciences, Social Sciences determinants of NCDs and Any equivalent degree to formulate and implement recognized by PMDC, PNC preventive strategies. or HEC Current Status of Diabetes Care in Pakistan Screening and PrevalencePrioritization Strategies Capacity Building Management updates Future Directions Management updates
Low-cost and effective strategies
Basit A, et al,. BRIGHT Guidelines on self monitoring of blood glucose. PJMS 2014; 30:1150-1155 Management updates Self Monitoring of Blood Glucose (SMBG)
39 Management updates
40 Management updates EDITORS
Prof. A Samad SheraProf. Abdul Basit Advisory Board for the Care of Diabetes (ABCD) PROMPT Core Team
Prof. Bilal Bin Prof. Jamal Prof. Qazi Dr. Sobia Sabir Prof. Zaman Younus Zafar Masroor Shaikh Karachi Peshawar Lahore Islamabad Bahawalpur Dr. Zahid Miyan Dr. Dr. Asima KhanDr. Riasat Ali Khan Musarrat Co ContributorsRiaz
Dr. Salam Prof. Irshad Dr. Jehangir Tanveer Khoso Khan Prof. Waheed Iqbal Multan Quetta Abbottabad
Dr. Asher Prof. Rubina Dr. A. B. Fawwad Hakeem Zafar TABLE OF CONTENTS
01 Introduction 02 Factsheet
Referral Criteria for Non Pharmacological 03 different levels of care 04 Management
Pharmacological Acute emergencies 05 Management 06 Macrovascular Microvascular Complications 07 Complications of diabetes 08 09 Diabetic Foot 10 Obesity
PROMPT 43 Future Plan
MENA Regional Council Meeting 20th August, 2016 Karachi- Pakistan Future Plan
The PROMPT document MENA has been approved Regional Council by the MENA RC in Khartoum in Dec 2016 Meeting It will be finalized 20th August, 2016 and submitted Karachi- Pakistan in Alexandria in May 2017 The IDF Middle East and North Africa (MENA) Region covers a wide area in North Africa and West-Asia, extending from Pakistan in the east to Morocco in the west.
Committee Members FACILITATOR Prof. A. Samad Shera Prof. Kamel Salameh Prof. Abdul Basit Prof. Hessa Al-Kandari Prof. Inass Shaltout COORDINATOR Dr. Muhammed Hassanein Dr. Asher Fawwad Prof. Mesbah Kamel MENA Guidelines Chapter Diabetes in MENA Region Chapter Chapter Factsheet Referral Criteria for 01 Different Levels of 02 03 Care
Chapter Non Pharmacological Management Chapter 04 Pharmacological Chapter Management of Diabetes in Elderly Diabetes 05 06 Chapter Acute Complications of diabetes Chapter 07 Microvascular Chapter Complications of diabetes Macrovascular 08 09 Complications
Chapter Diabetic Foot Chapter 10 Obesity and Chapter Annexure Diabetes 11 12
MENA Guidelines Current Status of Diabetes Care in Pakistan Screening and Prevalence Prioritization Strategies Capacity Building Management updates Future Directions Future Directions International Faculty IDEC - 2016 Prof. Adel El Sayed Dr. Maria Al Mahdi Prof. Akhtar Hussain Prof. Morsi Arab Egypt Kuwait Norway Egypt
Prof. Chandrika N. Dr. Misbah Syed Kamel Wijeyeratne Dr. Wasim Hanif Prof. Paul Thornalley Dr. Naila Rabbani Prof. Graham Hitman Ms. Susan Clever Dr. Kristien Van Acker Dr. Zulfiqar G. Abbas Srilanka Egypt United Kingdom United Kingdom United Kingdom United Kingdom Germany Belgium Tanzania
Mr. Lucas Fogarty Dr. Mohsen NematyDr. Mahfuzy Mohammad Mr. Piero Galasso Prof. Mandika Dr. Mohammaed Sandid Dr. Aamir Kamran Ms. Barbara Eichorst Prof. A.K. Azad Khan Malaysia Italy Wijeyeratne Lebanon USA Iran Srilanka Iran United States of America Bangladesh Future Directions International Faculty
IDEC - 2016 Prof. Liaquat Ali Dr. Hamed Farooqi Prof. Ashma Rana Prof. Fathy Elsewy Bangladesh UAE Nepal Egypt
Dr. Abdul Jabbar Dr. George Majaj Dr. Graham Ogle Prof. Suliman Dr. Mohamed Eltom Dr. A. Hakim Aziz Miss. Erin Little Dr. Hana Alghanem Dr. Firdaus Jahan UAE Palestine Australia Abusrewil libya Sudan Afghanistan USA Syria Oman
Dr. Uzma Khan USA Dr. Abdullah Al Hamaq Dr. Michele Abi Saad Dr. Abdulameer Jasim Dr. Ibtisam Hadeed Mr. Bent Qatar Lebanon Jawad Al-Gbur - Iraq Saudi Arabia Denmark Future Directions National Faculty
IDEC - 2016 Prof. Zaman Prof. Bilal Bin Dr. A. H. Aamir Dr. Aisha Shaikh Dr. Ali Jawa Shaikh -Karachi Younis - Lahore Peshawar Karachi Karachi
Dr. Syed Abbas Prof. Tasneem Dr. Saeed A. Dr. Romaina Dr. Robina Ms. Saima Rasheed Prof. Shabeen Dr. Musarrat Raza Ahsan Mahar Iqbal Sohail Karachi Naz Masood Riaz - Karachi Karachi
Dr. Ayesha Prof. Jamal Zafar Prof. Qazi Masroor Prof. M. Yakoob Dr. Shabana Dr. Col. Shahid Ahmed Dr. Sobia Sabir Prof. A. Samad Shera Habib - Karachi Islamabad Ahmedani - Karachi Saeed Karachi Peshawar Karachi Future Directions National Faculty
IDEC - 2016 Prof. Nazli Hossain Prof. Nazeer Khan Dr. Nilofer Fatimi Dr. Osama Ishtiaq Dr. Qamar Masood Karachi Karachi Safdar - Karachi Islamabad Karachi
Dr. M. Saif Ul Haq Dr. Zahid Miya Prof. Jamil Ahmed Dr. Khadija Nuzhat Dr. Asmat Nawaz Prof. Irshad Khoso Dr. Rabia Saqib Dr. Jehangir Khan Prof. Najmul Islam Karachi Karachi Karachi Karachi Karachi Quetta Karachi Karachi
Ms. Fayza Khan Prof. Sadaqat Jabeen Dr. Salam Tanveer Prof. Rubina Hakeem Dr. Zafar Abbasi Dr. Mahjabeen Khan Karachi Peshawar Multan Karachi Karachi Karachi Footwear For Every Diabetic (FED) group 2016-2019
• Establishment of 10 risk assessment clinics
• Low cost and durable footwear A joint Project of WDF – BIDE (BMU), Karachi, Pakistan manufacturing technique
• 10 foot care assistants and 10 cobblers from BIDE to be trained • 1 foot care assistant and 1 cobbler from each of the 10 project centres will be trained Train the Trainer Course :19 – 21st August, 2016
Footwear For Every Diabetic (FED) group - 2016 to 2019 A joint Project of WDF – BIDE (BMU), Karachi, Pakistan Footwear For Every Diabetic (FED) group – 2016 to 2019
A joint Project of WDF – BIDE (BMU), Karachi, Pakistan Insoles Development Machines Footwear For Every Diabetic (FED) group - 2016 to 2019
A joint Project of WDF – BIDE (BMU), Karachi, Pakistan Future Directions RAMADAN AND DIABETES
Lead : Prof. M. Yakoob Ahmedani
Deputy : Dr. Farhat Ullah RAMADAN AND DIABETES Future Directions S# Two Years Five Years Ten Years
To extend the activities of RSG at tertiary care level. To extend the activities of RSG at secondary To extend the activities of RSG at 1 care level. primary care level.
To train around 3,000 doctors through Around 10,000 doctors will be Around 30,000 doctors will 2 workshops and short courses. trained through workshops and short be trained. courses. Awareness about safe fasting in people with diabetes Including secondary care centers for The message will be spread through will be disseminated through tertiary care centers dissemination of information with primary care centers with the aim with the aim that 20 to 30% people with the aim that 50% people with that 90 % people with diabetes 3 diabetes in the community should be able to observe in the community should be safe fasting. diabetes in the community should be able to observe safe fasting. able to observe safe fasting.
Customization of the available IDF and DAR To enhance scientific evidence at the To enhance scientific International guidelines for national adaptation local level through conducting research evidence at the International level and dissemination. 4 activities. through conducting multi- national and multi- centered studies. Future Directions
Diabetes and Ramadan Conferences Diabetes and Ramadan Workshops Awareness Programs Educational material for patients Ramadan Study Group Website Ramadan Study Group Publications
• Since 2008 Ramadan Study Group has done 12 studies which were published in international and national indexed journals and 2 has been accepted for publication. DAR International Alliance 3rd Forum, DUBAI, April 17 2015
The forum was attended by International Faculty including: • Sir Michael Hirst, IDF President • Dr Shaukat Sadikot, IDF President Elect • Dr Adel El-Sayed, IDF-MENA Region Chair • Dr Evariste Bouenizabila, IDF- Africa Chair • Dr Line Kleinbreil, DESG Chair • Dr Abdelrazzq Al-Madani, President of EDS • And many other experts in the field
Future Directions Diabetes and Ramadan: Practical guidelines
Mohamed Hassanein et al,Diabetes and Research Clinical Practice 126(2017)303-316 Prioritization Strategies Other community issues addressed
BIDE 2009 DAP UIO Maternal Child Health
BIDE WDF Gestational Diabetes Project 2013 SOGP with SOGP (Society of Obstetrics and Gynecologists of Pakistan) FANS
2011- EU Genomic and lifestyle predictors of foetal outcome relevant to diabetes and 17 obesity and their relevance to prevention strategies in South Asian peoples 2017 centers (GIFTS). Prioritization Strategies
Prof. Zahida Baqai
Prof. Noorjahan Samad
Prof. Abdul Basit
Prof. Shabeen Naz Masood
Dr. Musarrat Riaz
Dr. Asmat Nawaz
Dr. Shehla Naqvi
Mr. Shokat Ali Javed MATERNAL AND CHILD HEALTH S# Two Years Five Years Ten Years
To coordinate and liaise with the health care To form National Registry regarding To include GDM prevention and 1 organizations by already constituted GDM GDM in Pakistan and link GDM management care in the national health Advocacy Board. with MCH programs. programs. To intensify and expand at national level, the training To develop National GDM guidelines To develop and promote uniform of health care professionals in prevention, screening, criteria for diagnosis of GDM, and GDM reference manual for diagnosis and management of GDM. across Pakistan. 2 Pakistani population taking into consideration our local socio-cultural parameters. To establish a model network of three GDM centers To establish GDM model clinics in all the To establish GDM clinics network 3 and thirty GDM clinics, initially in the province of major cities of Pakistan. nationwide. Sindh.
To institutionalize universal screening programs for To carry out universal screening To carry out universal screening GDM at least in all teaching hospitals across Pakistan. 4 programs for GDM in all secondary care programs for GDM in all primary care facilities across Pakistan. facilities across Pakistan. To organize across the country, awareness activities To incorporate material regarding balanced To include a section on GDM in related to diagnosis and management of GDM. Also diet, physical activity and prevention of the syllabi of medical 5 optimize the use of print and electronic media childhood obesity in the school syllabi for for dissemination of knowledge regarding GDM. primary prevention. schools in Pakistan.
Gestational Diabetes Mellitus Prevention and Control Program - Pakistan
3 GDM centers and 20 GDM clinics established
Joint project of World Diabetes Foundation & Baqai Institute of Diabetology & Endocrinology Training of Health care professionals
• Number of doctors trained: 568
• Training of Allied HCPs and Nurses 878
Awareness Camps Number of participants: 5229 women •
Number of Women screened for GDM
• No. of women to be screened 25000
• No. of women screened 12473
• Frequency of GDM (approx.) 12 % Future Directions Age Less than 40 years 0 Between 40 to 50 years 1 Risk assessment Greater than 50 years 3 Waist circumference - Males of Pakistani Less than 90 cm (35.5 inches) 0 individuals 90 cm (35.5 inches) or greater 2 Waist circumference - Females for diabetes Less than 80 cm (31.5 inches) 0 80 cm (31.5 inches) or greater 2 (RAPID) Family history of diabetes No family history of diabetes 0 Any parent and/or siblings 1 A score of 4 or more predicts high risk of developing Type 2 diabetes
Riaz M, Basit A, et al,. Risk assessment of Pakistani individuals for diabetes (RAPID). Prim Care Diabetes. 2012, 6; 297-302 Future Directions
• Diabetes Education • Diabetic Foot • Diabetes Registry • Gestational Diabetes • Diabetes Guidelines • Diabetes and Ramadan • Primary Prevention Program Future Directions
Diabetes and University of Ramadan - DAR University of Oslo M.V Hospital Birmingham for Diabetes – India Foundation of European nurses for diabetes PAD registry XLPAD GIFTS EU collaboration International associations and IDF Regional Council IDF centres of MENA Region collaborations education D-Net
Diabetes in Asia Diabetes Study Group Specialist Center DASG India University of International Bangladesh Life for a Child Manchester working group on University of Diabetic Foot Qatar Diabetes Health Sciences IWGDF Association Future Directions Diabetic Pakistan Association Nursing of Pakistan Council DAP PNC
Pakistan Cardiac PMDC Society National CPSP PCS HEC associations Acknowledgements and Pakistan collaborations Pakistan Hyperten Endocrine League Society PHL PES Pakistan Society of Pakistan Health Pakistan Working Systems Nutrition group on Pharmacist and Dietetics diabetic foot PWGDF PSHSP Society PNDS Consultant Diabetologist Research Diabetic Foot Administration Prof. Yakoob Ahmedani Dr. Asher Fawwad Dr. Farhat Ullah Mr. Abdul Rehman Dr. Zahid Miyan Dr. Faraz Alvi Dr. Adil Mr. Osama Ul Haq Dr. Asim Bin Zafar Ms. Fariha Shaheen Mr. Salman Junior Doctors Dr. Musarrat Riaz Mr. Bilal Tahir Mr. Sabir hussain Dr. Majid Dr. M. Saif Ul Haque Mr. Hassan Moin Mr. Kashif Ali Dr. Anam Butt Ms. Raheela Naseem Mr. Arsalan Saeed Dr. Lal Chand Dietician Educationist Ms. Huma Khan Dr. Zaryab Ms. Tahmina Rashid Mrs. Rabia A. Rahman Mr. Arshad Akhter Dr. Naveed Ms. Sara Jaffri Ms. Erum Ghafoor Mr. Furqan Uddin AcknowledgementDr. Shahzaib Ms. Sanober Aijaz Ms. Sadaf Mateen Mr. Rameez Mr. Farrukh Ahmed Ms. Aneela I.T Department GDM Mr. Qutub Uddin Dr. Asmat Nawaz Mr. Naimat Rehman Mr. Mansoor Siddiqui Mrs. Saira Shahid Institutional Coordinator Insulin My life Mr. Kamran Adam Ms. Hina Naz Mr. Iqbal Hussain Mr. Anwar ul Haq Dr. Zafar Iqbal Abbasi Ms. Zainab Akber Mr. Rizwan Alam Mr. Faizan Mahmood Ms. Amna Khatoon Mr. Sufran Ahmed Thank You…