Epidemiological study of diabetes mellitus dm among different ethnic segments of population in pakistan a nationwide ethnographapical study

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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 Rizvi1
, Sidra Tanwir1
, *Atta Abbas1,2
, Arif Sabah1
, Zeb-un-Nisa1
, Imran
Mushtaq1
, Muhammad Ahmed1
, Kalb- e- Ali Zaidi1
, Muhammad Nabeel1
, Sumaira
Shakeel Siddiqui1
, Faiza Hussain1
and Anam Qureshi1
.
1
Faculty of Pharmacy, Ziauddin University, Karachi, Sindh, Pakistan.
2
Department 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

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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.

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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

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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 type
1
Male with DM type
2
Female with DM
type 1
Female with DM
type 2
Cross tabulation of gender with phenotype of DM
Observed Count Expected Count

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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.
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