www.ijrpp.com

~ 40~

ISSN Print: 2278 – 2648 IJRPP |Vol 3 | Issue 1 | Jan-Mar-2014

ISSN Online: 2278_ 2656 Journal Home page: www.ijrpp.com

Research article Open Access

Epidemiological study of diabetes mellitus DM among different

ethnic segments of population in Pakistan: A nationwide

ethnographapical study Mehwish Rizvi

1, Sidra Tanwir

1, *Atta Abbas

1,2, Arif Sabah

1, Zeb-un-Nisa

1, Imran

Mushtaq1, Muhammad Ahmed

1, Kalb- e- Ali Zaidi

1, Muhammad Nabeel

1, Sumaira

Shakeel Siddiqui1, Faiza Hussain

1 and Anam Qureshi

1.

1Faculty of Pharmacy, Ziauddin University, Karachi, Sindh, Pakistan.

2Department of Pharmacy, Health and Well Being, University of Sunderland, England,

United Kingdom.

* Corresponding author: Atta Abbas

E-mail id: bg33bd@student.sunderland.ac.uk

Abstract

Introduction

Diabetes mellitus is one of the leading causes of morbidity and mortality worldwide. It has been estimated that the

number of people with diabetes mellitus will greatly increase in the upcoming years. This prevalence has been

projected to be greatest in the region of South Asia although several developing countries have reported a rise in the

patients suffering from this disease as well.

Methods

A cross sectional survey was conducted in health care settings of various cities of Pakistan for 8 months i.e. March

2013 to October 2013. It targeted patients diagnosed with diabetes mellitus with probability sampling technique. The

survey employed descriptive statistics, cross tabulation, chi square test and epidemiological calculations of relative

risks RR and prevalence rate PR.

Results

Prevalence of diabetes mellitus in adult population above 25 years was found to be 0.74 with RR of 1.4938. Type 2

DM was observed at a PR of 0.72 with RR of 1.4444. The Sindhi race of Urdu speaking origin was seen to be

suffering from the disease for most part (28%), followed by Punjabi race (27%) and Sindhi race of Sindhi speakers

(20%). The gender of patient and phenotype of DM were associated. (P value <0.05).

Conclusion

Diabetes Mellitus is emerging as a serious threat in Pakistan. There is an urgent need of establishing preventive and

management programs to counter this rising disease.

Keywords: Epidemiology; Prevalence; Diabetes Mellitus DM; Ethnic; Pakistan.

International Journal of Research in Pharmacology & Pharmacotherapeutics

Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [40-45]

www.ijrpp.com

~ 41~

INTRODUCTION

Diabetes mellitus is a group of metabolic diseases

characterized by hyperglycemia resulting from

defects in insulin secretion, insulin action, or both.

The chronic hyperglycemia of diabetes is associated

with long-term damage, dysfunction, and failure of

various organs, especially the eyes, kidneys, nerves,

heart, and blood vessels.1 A major advance was made

in the late 1960s when insulin-dependent diabetes

mellitus (IDDM, type 1) was distinguished from non-

insulin-dependent diabetes mellitus (NIDDM, type

2). Another milestone was the realization in the

1970s that in most cases IDDM has, presumably, an

autoimmune origin2. This helped in better

understanding of the etiology of diabetes mellitus and

hence educed optimism regarding the prevention

techniques.

Diabetes epidemiology has had a

profound impact on diabetes research, care and

prevention. Diabetes and its complications pose a

major threat to future public resources throughout the

world3.

Surveillance of diabetes is a necessary first step

towards its prevention and control4.While the

prevalence of diabetes can provide information about

the burden of disease in the community, prevalence

rates do not capture individuals' risks of developing

diabetes during a defined period5 whereas the lifetime

risk estimates the length and quality of life with

disease are informative and easily understood

measures of the effect of disease in individuals6.

Studies have shown that in developing countries, the

majority of people with diabetes are in the 45 to 64

year age range7, In contrast, the majority of people

with diabetes in developed countries are >64 years of

age. Assuming that age-specific prevalence remains

constant, the number of people with diabetes in the

world was expected to approximately double between

2000 and 2030, based solely upon demographic

changes8. Increasing evidence of effective

interventions, including changes in diet and physical

activity or pharmacological treatment to reduce

prevalence of diabetes, provides an impetus for wider

introduction of preventive approaches9. Furthermore,

improved survival may contribute to increasing

prevalence of diabetes in the future especially in

developed countries 10

.

Prevalence rates of DM vary considerably amongst

different populations and ethnic groups11

. Several

studies have shown that South Asian migrants and

their offsprings have higher prevalence rates of DM

than the native host populations12

.

According to National Institute of Diabetes and

Endocrinology, with an estimated prevalence of 7.6

per cent at present, it is estimated that by 2030,

Pakistan will have the fourth largest diabetic

population in the world — around 13.8 million

people13

. Despite geographical differences and

cultural diversity amongst the ethnic groups in

Pakistan, all carry a similarly high risk of DM14

. In a

number of studies conducted in Pakistan, marked

association between glucose intolerance and

hypertension was observed with indication of a

gradient from normoglycaemia, through IGT, to

diabetes15

.

This study was carried out to estimate the

epidemiological rate of diabetes in Pakistan in

reference to prevalence and its relationship with

gender, co morbidities and the phenotypes of diabetes

mellitus.

METHODS

A cross sectional survey was conducted in health care

settings of various cities of Pakistan for 8 months i.e.

March 2013 to October 2013. The survey consisted

of research instrument in the form of a questionnaire

which targeted patients diagnosed with diabetes

mellitus DM with probability sampling technique.

The inclusion exclusion criteria included all patients

diagnosed with diabetes mellitus and all other

patients were excluded. Prior to the data collection, a

written consent was obtained from the patient. The

survey employed descriptive statistics, cross

tabulation, chi square test and epidemiological

calculations of relative risks RR and prevalence rate.

A statistical significance of p values <0.05 for chi

square was accepted. The epidemiological results are

expressed as upper and lower limits of 95%

confidence interval. SPSS v20 (Statistical Package

for Social Sciences version 20) and MedCalc® was

used to interpret the data.

Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [40-45]

www.ijrpp.com

~ 42~

Results

Of the total 152 patients screened the prevalence of

diabetes mellitus in adult population above 25 years

was found to be 0.74 (0.6675 to 0.8014 for 95% CI)

with a relative risk of 1.4938 (1.208 to 1.8531 for

95% CI). However in geriatrics was 0.22 (0.2901 to

0.4364 for 95% CI) with a relative risk of 0.4444

(0.3137 to 0.6297 for 95% CI) (SD 0.44). In terms of

phenotype of diabetes mellitus, type 2 DM was

observed at a prevalence rate of 0.72 (0.6464 to

0.7834 for 95% CI) with a relative risk of 1.4444

(1.1615 to 1.7963 for 95% CI). The type 1 DM was

observed at 0.21 (0.1544 to 0.2791 for 95% CI) with

a relative risk of 0.4321 (0.3036 to 0.6149) (SD

0.42). The results are tabulated in table 1.1.

Table 1.1 Epidemiological Findings

Population Prevalence Rate 95% CI Relative Risk 95% CI

Adult 0.74 0.6675 to 0.8014 1.4938 1.208 to 1.8531

Geriatric 0.22 0.2901 to 0.4364 0.4444 0.2901 to 0.4364

Disease Phenotype

Type 1 DM 0.21 0.1544 to 0.2791 0.4321 0.3036 to 0.6149

Type 2 DM 0.72 0.6464 to 0.7834 1.4444 1.1615 to 1.7963

When the ethnicity and disease of DM was cross

tabulated, The Sindhi race of Urdu speaking origin

was seen to be suffering from the disease for most

part (28%), followed by Punjabi race (27%) and

Sindhi race of Sindhi speakers (20%). Similar results

were observed for races of Baloch (10%) and

Pukhtoons (12%) with latter being slightly higher.

and the results being statistically insignificant (P

value >0.05, SD 0.25). Majority of the population

suffering from diabetes mellitus appeared to be

married (92%) with few being unmarried (8%). SD

0.25. Graph 1.1 demonstrates the findings.

Graph 1.1 Ethnographic data of patients

When the gender and type of DM were cross

tabulated, statistical significance was obtained with P

values<0.05). Males with type 1 DM were found to

be N = 11, observed to N = 18, expected. However,

males with type 2 DM were found to be N = 67,

observed to N = 60, expected. The females were seen

as N = 24 observed to N = 17, expected and in case

of type 2 DM, N = 50, observed to N = 57, expected.

Graph 1.2 demonstrates the cross tabulation results of

the findings.

28%

20% 27%

10% 12%

3%

Ethnicity

Ethnograph

Sindh (Urdu Speaking) Sindh (Sindhi Speaking)

Punjab Baloch

Pukhtoons Others

Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [40-45]

www.ijrpp.com

~ 43~

Graph 1.2 Cross tabulation of gender with phenotype of DM

Majority had high blood sugar (81.9%) and a third of

population was seen with co morbidity of

hyperlipidemia (32.1%). A third (31.5%) did modify

their diet due to this reason and almost half (56.8%)

appeared to undergo exercise such as brisk walk, etc.

Discussion

Escalation in rates of diabetes, especially type 2

(NIDDM) diabetes in Pakistan is posing threats to the

economy and quality of life of people due to poor

glycemic control and very high rates of

complications16

. Reports from National diabetes

survey and National health survey differs both in

observations regarding prevalence of diabetes and in

relative burden of diabetes in various provinces and

among males and females17

. Epidemiology and

causes for prevalence of diabetes in Pakistan have a

number of risk factors. Mainly the genetic

predisposition and environmental dynamics are the

major contributors in the high prevalence rate of

diabetes in Pakistan. The complications associated

with diabetes which leads to morbidities and

mortalities are the core causative factors in the

establishment of this disease as a solemn social

burden.

This study was aimed at establishing the

epidemiology and the related determinants of

diabetes in Pakistan. The studies done on prevalence

of diabetes in the migrant South Asian populations

elsewhere have consistently shown a much higher

prevalence of diabetes than the indigenous population

of the Indian subcontinent and the native population

of the host country18

. In the Coventry diabetes study,

Simmons et al. noted diabetes in 11% of Asian men

and 8% of Asian women as compared to 3% in white

men and 4% in white women19

. The higher

prevalence rate thus observed in the population as a

whole is consistent with the higher rates predicted in

the region and role of genetics in predisposition of

South Asians to diabetes20

.

In contrast with other studies in migrant South Asian

communities 21

and the recently conducted studies in

India22

where the prevalence rates of NIDDM and

IGT increased with age in both men and women

whereas a lower prevalence is seen in geriatrics. This

is suggestive of introduction of interventions that

may help prevent primary diabetes in this group.

Ethnic differences have been observed with in the

country, this could be attributed to the role of

lifestyle, genetic or environmental differences which

are observed across Pakistan.

A positive family history ‘of diabetes, obesity and

abdominal fat distribution have been described as

related risk factors in a number of studies 23

. A strong

association was observed with the co morbidities in

the study. Also the high carbohydrate dietary pattern

observed as a traditional paradigm contributes to

oxidative stress and the overall increment in

11

67

24

50

18

60

17

57

0

20

40

60

80

Male with DM type1

Male with DM type2

Female with DMtype 1

Female with DMtype 2

Cross tabulation of gender with phenotype of DM

Observed Count Expected Count

Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [40-45]

www.ijrpp.com

~ 44~

prevalence. It was observed that the females in

Pakistan irrespective of ethnicity were seen to suffer

from Type 1 DM for most part, a possible

explanation to this finding can be attributed to the

fact that females in Pakistan suffering from

polycystic ovarian syndrome PCOS exhibit diabetes

and obesity as a triage of co-morbid conditions.24

The Urdu speaking race of Sindhi ethnicity was

observed to have highest incidence of the disease

which is explicable since studies have shown that

Indian emigrants in Pakistan which settled in the

country after independence which later integrated in

the country and became the inhabitants of Sindh had

this ailment.9,14,18

. In case of the Punjabi race, it was

almost at par with the former however in this the

issue can be attributed to the lack of health awareness

among individuals in the Punjab state and the overall

susceptibility of the IndoPak population to DM since

the both races are descendants of Indian

Subcontinent. Contrastingly, the low incidence

among other ethnicities underscores the theory as the

Balochi and Pukhtoon race are descendants from Iran

and Afghan / Central Asian origin respectively.

Intervention through education is the most effective

method for prevention and management of diabetes.

As indicated by the study diabetes is emerging as a

serious threat in Pakistan, yet the awareness among

the healthcare providers and the general population

remains low.

Conclusion

With rising trend and prevalence of diabetes in

Pakistan and the expected further increase, it is

essential to increase the level of awareness, the

importance of physical activity and improvement in

the availability of the dietetic services to ensure more

components preventive and management of diabetes.

Author’s Contribution

MR conceived the idea with ST and jointly prepared

the introduction, the methods and study design was

formulated by the AA and AS, the data was collected

across Pakistan by IM, MA, KAZ, MN, SSS and FH.

The data was entered in analytical software by AA,

ZN and MR, the discussion and conclusion was done

by ST and AA. The abstract was prepared by AS and

final editing of the manuscript was done by AA and

ST.

Source of funding

None.

Acknowledgements

The authors extend their gratitude to all patients who

participated in the study.

Conflict of Interest

The authors declare no conflict of interests exists.

References

[1] American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. 2009. Diabetes

Care. 32(Supp. 1); S62-S67 P.

[2] Bach JF. Insulin-Dependent Diabetes Mellitus as an Autoimmune Disease. 1994. Endocrine Reviews.

15(4).

[3] Zimmet PZ. Diabetes epidemiology as a tool to trigger diabetes research and care. 1999. Diabetologia.

42(5); 499-518 P.

[4] King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: prevalence, numerical

differences estimates, and projections. 1998. Diabetes Care. 21:1414–1431 P.

[5] Narayan KMV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime Risk for Diabetes

Mellitus in the United States. 2003. JAMA. 290(14);1884-1890 P.

[6] Sasieni PD, Adams J. Standardized lifetime risk. 1999. Am J Epidemiol.149(9); 869-875 P.

[7] King H, Aubert RE, Herman WH: Global burden of diabetes, 1995–2025: prevalence, numerical

estimates, and projections. 1998. Diabetes Care. 21(9); 1414–1431 P.

[8] Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of Diabetes, estimates for the year

2000 and projections for 2030. 2004. Diabetes Care. 27(5); 1047- 1053 P.

Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [40-45]

www.ijrpp.com

~ 45~

[9] Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-

Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2

diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. 2001. N Engl

J Med. 344(18); 1343–1350 P.

[10] Stovring H, Andersen M, Beck-Nielsen H, Green A, Vach W: Rising prevalence of diabetes: evidence

from a Danish pharmaco-epidemiological database. 2003. Lancet. 362(9383); 537–538 P.

[11] King H, Rewers M. Global estimates for prevalence of glucose intolerance. 1993. Diabetes Care.

16(1); 121-125 P.

[12] Swai AB, McLarty DG, Sherrif F, Chuwa LM, Maro E, Lukmanji Z, Kermali W, Makene W, Alberti

KG. Diabetes and impaired glucose tolerance in an Asian community in Tanzania. 1990. Diabetes Res.

Clin. Pract. 8(3); 227-234 P.

[13] The tribune. [homepage on internet]. Pakistan has seventh highest number of diabetics in the world.

[internet]. [newletter]. [updated 2011 May; cited 2014 Jan]. Available from:

http://tribune.com.pk/story/162251/pakistan-has-seventh-highest-number-of-diabetics-in-the-world/

[14] Akhter J. The Burden of Diabetes in Pakistan: The National Diabetes Survey. [internet]. 1999. Journal

of Pakistan Medical Association. [homepage on internet]. 205-206 P. [cited 2014 Jan]. Available

from: http://www.jpma.org.pk/full_article_text.php?article_id=3496

[15] Shera AS, Rafique G, Ahmed KI, Baqai S, Khan IA, King H. Pakistan National Diabetes Survey

Prevalence of Glucose Intolerance and Associated Factors in North West Frontier Province (NWFP) of

Pakistan. 1999. Journal of Pakistan Medical Association. 49(9); 206-211 P.

[16] Moin S, Gondal GM, Bano U. Risk of development of chronic kidney disease in patients with type 2

diabetes having metabolic syndrome. 2008. J Coll Physicians Surg Pak. 18(8); 472-476 P. doi:

08.2008/JCPSP.472476.

[17] Hakeem R, Fawwad A. Diabetes in Pakistan: Epidemiology, Determinants and Prevention. 2010.

Journal of Diabetology. 3(4); 1-13 P.

[18] Mather HM, Keen H. The Southall Diabetes Survey: Prevalence of diabetes in Asians and Europeans.

1985. BMJ. 291(6502); 1081-1084 P.

[19] Simmons D, Williams DRR. Powell MJ. Prevalence of diabetes in a predominantly Asian community:

preliminary findings of the Coventry diabetes study. 1989. BMJ. 298(6665); 16-21 P.

[20] Mathias RA, Deepa M, Deepa R, Wilson AF, Mohan V. Heritability of quantitative traits associated

with type 2 diabetes mellitus in large multiplex families from South India. 2009. Metabolism. 58 (10);

1439-1445 P.

[21] Dowse GK, Gareeboo H, Zimmet PZ, Alberti KG, Tuomilehto J, Fareed D, Brissonnette LG, Finch

CF. High prevalence of NIDDM and impaired glucose tolerance in Indian, Creole and Chinese

Mauritians. 1990. Diabetes. 39(3); 390-396 P.

[22] A. Ramachandran, M.V. Jali, V. Mohan, C. Snehalatha, M. Viswnathan. High prevalence of diabetes

in an urban population in South India. 1988. BMJ. 297(6648); 587-590 P.

[23] Wang SL, Pars WH, Hwu CM, Ho LT, Lo CH, Lin SL, Jong YS. Incidence of NIDDM and the effects

of gender, obesity and hyperinsulinaemia in Taiwan. 1997. Diabetologia. 40(12); 1431 -1438 P.

[24] Mehwish Rizvi, Atta Abbas, Sidra Tanwir, Arif Sabah, Zeenat Mansoor Ali, Mehwish Murad

Sundrani, Sabahat Arif, Afrah Afzal and Hira Atiq Mir. Perception and attitude of patients regarding

polycystic ovarian syndrome (PCOS) in tertiary care hospitals of Pakistan. A survey based study.

2014. Inter J of Pharm & Ther. 5(3); 147-152 P.