Authored by Abdul Kader Mohiuddin*
Abstract
With the increasing burden of non-communicable diseases in low-income and middle-income countries (LMICs), biological risk factors, such as hyperglycemia, are a major public health concern in Bangladesh. Optimization of diabetes management by positive lifestyle changes is urgently required for prevention of comorbidities and complications, which in turn will reduce the cost. Diabetes had 2 times more days of inpatient treatment, 1.3 times more outpatient visits, and nearly 10 times more medications than non- diabetes patients, as reported by British Medical Journal. And surprisingly, 80% of people with this so called “Rich Man’s Disease” live in low- and middle-income countries. According to a recent study of American Medical Association, China and India collectively are home of nearly 110 million diabetic patients. The prevalence of diabetes in this region is projected to increase by 71% by 2035. Bangladesh was ranked as the 8th highest diabetic populous country in the time period of 2010-2011. In Bangladesh, the estimated prevalence of diabetes among adults was 9.7% in 2011 and the number is projected to be 13.7 million by 2045. The cost of diabetes care is considerably high in Bangladesh, and it is primarily driven by the medicine and hospitalization costs. According to Bangladesh Bureau of Statistics, in 2017 the annual average cost per T2DM was $864.7, which is 52% of per capita GDP of Bangladesh and 9.8 times higher than the general health care cost. Medicine is the highest source of direct cost (around 85%) for patients without hospitalization. The private and public financing of diabetes treatment will be severely constrained in near future, representing a health threat for the Bangladeshi population..
Keywords: Blood sugar screening; Compliance; Overweight; Lifestyle; Regular health checkup; Ramadan fasting; Climate issue of diabetes
Abbreviations: LMICs: Low-And Middle-Income Countries; IDF: International Diabetes Federation; NEHEP: National Eye Health Education Program; BDHS: Bangladesh Demographic and Health Survey; BIRDEM: Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders; IPH: Institute of Public Health
Introduction
Bangladesh is among the top 10 countries with the highest rates of projected age-standardized mortality among selected LMICs due to chronic diseases, particularly for CVDs and diabetes [1]. The age adjusted death rate 40 per 100,000 of population ranks Bangladesh 57 in the world, says WHO [2]. Diabetes is one of the four major types of non-communicable diseases that make the largest contribution to morbidity and mortality worldwide. The International Diabetes Federation (IDF) estimated that, worldwide, approximately 425 million people had diabetes in 2017, projected to be 629 million by 2045. Again, worldwide $727 billion was spent in 2017 for treating and preventing diabetes, projected to be US$776 billion by 2045 [2]. In Bangladesh, specifically, the IDF projects the prevalence of diabetes will increase to more than 50% in the next 15 years [4]. About 129,000 deaths were attributed to diabetes in Bangladesh in 2015, as reported by leading research organization ICDDR, B [5]. According to the WHO-Diabetes country profile of Bangladesh in 2016, the physical inactivity was prevailing among 25.1% of population [6]. Around 85% population of age group 25-65 never checks for diabetes [7]. A recent study by British Medical Journal says, 1 in 10 Bangladeshi adults aged ≥18 years have hyperglycemia (among urban residents) [4]. Even in rural Bangladeshi community, undiagnosed diabetes was high, 7.2% found in a 2016 [8] and 10% in 2019. Roughly 20%–30% of adults in rural areas of Bangladesh have abnormal fasting glucose or impaired glucose tolerance, with the prevalence of diabetes (mostly type 2 diabetes) expected to reach 24%–34% by 2030 [9]. And IDF says, there are 7.1 million people with undetected diabetes in Bangladesh and this number will be double by 2025 [10]. Das et.al, 2019 reported prevalence of dyslipidemia was over 70% to both male and female subjects, which indicates the urgency of lifestyle intervention strategies to prevent and manage this important health problem and risk factor [11]. Among 8400 stroke patients from different hospitals in Bangladesh over a period of sixteen years, diabetic patients were nearly 25% [12]. Prevention strategies should focus on increasing physical activity, weight loss, smoking cessation, and stricter control of hypertension and glycemic level [13] (Figure 1).
Material and Methods
The TRACK Concept
National Eye Health Education Program (NEHEP) developed a tool using the word “TRACK” to help you remember how to stay on track with diabetes. To keep blood sugar level on target and avoid problems with eyes, kidneys, heart and feet, patients should eat right and be active, and may need to take medication. This helps them make choices in eating and being active so body can perform at its best. By regularly monitoring, patients get it on track and prevent long-term health problems [14,15]. TRACK was developed for diabetic retinopathy prevention but in real life it prevents all other diabetic complication by disease progression. The criteria, in short are regular health checkup and compliance of treatment guidelines along with some lifestyle modifications.
Methodology
Research conducted a year-round comprehensive literature search, which included technical newsletters, newspapers journals, and many other sources. The present study was started at the beginning of 2019. PubMed, ALTAVISTA, Embase, Scopus, Web of Science, and the Cochrane Central Register were thoroughly searched. The keywords were used to search for different publishers’ journals such as Elsevier, Springer, Willey Online Library, and Wolters Kluwer which were extensively followed. Medicine and technical experts, pharmaceutical company representatives, hospital nurses, and journalists were given their valuable suggestions. Projections were based on TRACK criteria of regular health checkup by diabetic and non-diabetic Bangladeshi population. There are many studies regarding diabetes in Bangladeshi population. This is the first study so far, where TRACK criteria (suggested by NEHEP of National Institute of Health, England) fulfillment is studied in Bangladesh.
Results and Discussion
TRACK Vs Bangladesh: Perplexity of the Present Situation
Compliance issue
Poor adherence is a well-documented obstacle in therapeutic control of diabetes. For an effective control and prevention of diabetes, 87% of Bangladeshis were noncompliant, compared to 71% of Indians and 52% Europeans [16]. Out-of-pocket expenditure, emotional status, frequency of counseling, patient’s family priorities, availability of medication (mainly insulin) are the factors greatly influence patient compliance to treatment guidelines. In 2016, the median monthly cost of diabetes maintenance was close to $10, approximately 10% of the median monthly income [17]. According to a 2018 BBC record, insulin availability found supplies were low in six countries - Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka [18]. Also, huge gap between the number of diabetic patients and doctors are well-known. The Diabetic Association of Bangladesh (DAB) record shows, except Dhaka and Chittagong, there are no tertiary facilities in Bangladesh to preventing blindness due to diabetic retinopathy [19]. Children with diabetes are still managed by adult physicians or occasionally by adult diabetologists, except in institutions like BIRDEM, and Dhaka Shishu Hospital. Children and adolescents have special needs at different stages e.g., nutrition, schooling, growth, puberty etc. Improving detection, awareness, and treatment strategies is urgently needed to prevent the growing burden associated with diabetes [20].
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