BIDE's Diabetes Desk Book: For Healthcare Professionals

BIDE’s Diabetes Desk Book offers a holistic approach to diabetes management including the most current evidence-based recommendations for diagnosing and treating adults and children with all forms of diabetes, taking into consideration local needs and available resources. It offers guidelines on the management of infections in diabetes, and management of diabetes. The book is based on a successful cost-effective model for countries to utilize at the national level to address important issues such as diabetic foot, gestational diabetes and diabetes education. This is an essential international resource that provides information on primary prevention strategies to encourage diabetes-related research.

• Provides a clear understanding of the etiopathology and diagnosis of diabetes, with its updated classification and epidemiology
• Covers all the glucose levels related to acute complications of diabetes useful to postgraduates
• Includes the latest technological advances of modern-day diabetes management
• Offers guidelines on the management of infections in diabetes and the management of diabetes during Ramadan and disasters, etc.
• Provides useful information microvascular complication of diabetes

• Language: English
• Publisher: Elsevier Science
• Release date: Dec 2, 2023
• ISBN: 9780443221071

Book preview

Chapter 1 Decades of BIDE's journey and experience for LMICs

Abdul Basita,,b; Akhtar Hussainc; Abul Kalam Azad Khand    a Baqai Institute of Diabetology and Endocrinology (BIDE), Baqai Medical University (BMU), Karachi, Pakistan

b Diabetic Association of Pakistan (DAP), Karachi, Pakistan

c NORD University, Bodø, Norway

d Diabetic Association of Bangladesh (BADAS), Dhaka, Bangladesh

Abstract

Baqai Institute of Diabetology and Endocrinology (BIDE) is a constituent unit of Baqai Medical University (BMU), Karachi, Pakistan. It started as a diabetes clinic room in 1996 and now serves as a role model tertiary care institute. The main lesson learned is that capacity building remains the backbone at the primary care level and is used as a successful tool for tackling the burden in many lower middle-income countries (LMICs). National-level programs shall be an essential part of each country’s diabetes care strategy for the utilization of resources pragmatically. In addition, advocacy involved is the primary differentiating factor for success stories, especially at the governmental level. Scaling-up access to affordable insulin and associated delivery and self-monitoring devices is a priority for partners helping governments realize their commitments. Many LMICs successfully run public awareness programs. Research can be initiated with minimal resources but does pay back enormously in the future.

Keywords

Introduction to BIDE; Diabetic care services in LMICs; National-level diabetes care program; BIDE collaborations; Insulin my life; Diabetes-centered networks and research; Delivery of health care; Research activity

Baqai Institute of Diabetology and Endocrinology (BIDE) is a constituent unit of Baqai Medical University (BMU) Karachi, Pakistan. It started with a small single-room diabetes clinic in 1996 at Baqai Medical University Hospital, under the patronage and guidance of (Late) Prof. F.U. Baqai, First Chancellor of BMU, and Prof. Zahida Baqai, Pro Vice-Chancellor of BMU. The vision and determination of the hierarchy of BMU to establish a tertiary diabetes care institution became a reality on January 1, 1999, when BMU established BIDE as a constituent institution of the university [1,2]. BIDE is now serving as a role model tertiary care institute, and hence we share its experience in this chapter.

The three most important questions we have tried to address in this chapter are:

1.Why was the need felt for establishing BIDE in Pakistan?

2.What were the steps in the progression and development of BIDE?

3.How can BIDE experiences help establish diabetes care services, especially in lower middle-income countries (LMICs)?

Why was the need felt to establish BIDE in Pakistan?

Pakistan is a resource-constrained country with disparate socioeconomic groups. It had a population of 127 million in 1996 [3] with an average annual growth rate of 4.8% [4]. Further, 68% of the population lived in rural areas [5], while 31% of the population lived below the poverty line [6], and 40% had no access to even essential health services [7]. Health expenditures accounted for 0.7%–0.8% of GDP and 3.5% of government spending. However, Pakistan spent less than 30% of its health budget on infrastructure. The government offered funding for diabetes mellitus (DM) as part of the overall healthcare budget, but DM received just a small fraction. Funds raised from private and international sources were similarly minimal. Also, there was no infrastructure for DM surveillance and monitoring.

A public-private healthcare collaboration existed, but it lacked the necessary equipment and training to deal with the rising frequency of noncommunicable diseases (NCDs). Under government supervision, almost 0.1 million lady health workers (LHWs) were trained to offer key maternity and child health care, reaching roughly 60% of the population but lacking NCD education. Seventy-five percent of the urban population receives primary health care from general practitioners (GPs). However, general practitioners lacked essential skills to manage and prevent DM and other noncommunicable diseases.

Prof. M Ibrahim started the Diabetic Association of Pakistan (DAP) in 1956 in Dhaka, then East Pakistan. When he moved to Karachi, then West Pakistan, he established a branch of the Diabetic Association of Pakistan there [8]. After the creation of Bangladesh, (Late) Prof. Abdus Samad Shera took over this tremendous responsibility as Secretary-General, DAP. From day 1, DAP has been sharing a substantial burden of people with diabetes (PWD), primarily in the nonaffording low middle-income class. At the same time, Prof. Mahmood Ali Malik and his team played an essential role as counterparts in Lahore, Punjab, the largest province of Pakistan. Endocrinology is a specialty that was well served by professors and colleagues like Prof. Naeem Ul Haq, Prof. Tasnim Ahsan, and (Late) Prof. Faisal Masood, to name a few. DAP under the leadership of (Late) Prof. A. S. Shera, in collaboration with the World Health Organization (WHO), conducted the First National Diabetes Survey of Pakistan from 1994 to 1998. The survey found that the overall prevalence of DM was 11.47%, and age, strong family history, and obesity were the major risk factors [9–13].

According to the WHO, Pakistan had three times lesser number of healthcare professionals than the rest of the world (1.4/1000 vs. 4.5/1000 people) [14]. In 1996, BMU established BIDE. The primary purpose of its establishment was capacity building. Postgraduate training in diabetes was not known, and undergraduate curricula were insufficient for DM. It might be worth mentioning that during the whole MBBS course of 5 years, only 2 h were for DM. A newly passed doctor was neither competent nor confident in treating PWD. The phase of this journey to get diabetes and endocrinology recognized as a medical specialty was very challenging and painful. The medical fraternity was adamant that DM has to be taken care of by an internist. Regulatory bodies felt that there was insufficient workload to give DM a separate specialty recognition. Political will, which plays a pivotal role in establishing healthcare systems, was weak, or communicable diseases burden was not allowing policymakers to give DM enough priority. Even those working at different levels worked in silos, exposing their efforts to poor sustainability and reproducibility.

There was hardly any concept of a multidisciplinary diabetes care team. Dietitians were not involved, and there were no diabetes educators. There were several myths regarding insulin administration, and even people with type 1 diabetes (T1DM) were deprived at times of insulin, therefore, risking their lives. Affordability and accessibility to diabetes care were also significant issue, and as a responsible part of a community, the need was felt to address it as well. There was no diabetic foot clinic in the country, and diabetic foot was not treated by diabetologists. Trained personnel as foot care assistants were nonexistent. Management of gestational diabetes was overall disorganized, and very few setups had its idea.

As one of the most prominent Islamic countries, Pakistan faced another challenge of fasting during the holy month of Ramadan. There were no guidelines regarding safe fasting for PWD [15]. The low literacy rate was one of the main obstacles to public awareness and getting community support for such a disease, reaching epidemic proportions (Fig. 1.1).

Fig. 1.1

Fig. 1.1 Reasons for establishing Baqai Institute of Diabetology and Endocrinology (BIDE). No permission required.

What were the steps in the progression and development of BIDE?

To tackle the rising burden of DM through capacity building

BIDE was established as Pakistan's first diabetes-focused teaching institute. (16) It proposed that primary care settings should be developed and strengthened for millions of PWD. As a result, in 1999, a 1-year university-based Diploma in Diabetology for Family Physicians (DDM) was launched. The fundamental objective was to train personnel in current diabetes management through evidence-based curricula and the latest skills through structured courses. As a result, the majority of 430-plus doctors qualified are involved in diabetes management at the primary care level. For the last 4 years, the diploma involves 1 year of research for the family physicians, and the diploma is extended to 2 years [16].

Another critical step was the collaboration with the University of Oslo (UIO); the initiative known as Norad's Program for Master Studies (NOMA). The goal of NOMA was to contribute to the academic training of faculty in public and private sectors and civil society in selected developing countries through North-South collaborations [16]. This was accomplished through increasing capacity building at the master’s level in southern higher education institutions. This program offered master’s and PhD degrees helping our capacity building. The research work entrusted to those students was primarily concerned with identifying scientific solutions to unresolved community-based issues related to DM and other noncommunicable diseases (NCDs).

Diabetes and Endocrinology is a specialty that has been contending for recognition in Pakistan for almost 15 years. Pakistan Endocrine Society (PES) has been a trailblazer in pursuing the cause. The College of Physicians and Surgeons Pakistan (CPSP) eventually started a second fellowship in diabetes and endocrinology in 2009. BIDE is proud to be an active founder member of PES and made a reasonable effort in this regard. As a result, numerous consultants have received second fellowship training in diabetes and endocrinology in the recent decade, contributing to secondary and tertiary care levels.

Diabetes education was introduced in the country, 20 years ago, as a vital component of diabetes care. Unfortunately, the healthcare system, both public and private, did not originally support it. BIDE started 1-year diploma in Diabetes Education (DDE). This diploma is the first to train specialty-based healthcare professionals (HCPs) such as dietitians, diabetes nurses, and paramedical staff, and the DDE is awarded by the BMU [16]. The contents of the course are based on the international curriculum for Diabetes Health Professional Education at the IDF. DDE was started in 2008, and 192 certified diabetes educators have been trained. Since 2009, the International Diabetes Federation (IDF) has recognized the pioneering efforts of BIDE in diabetes education.

BIDE offers online certificate courses as well. BIDE diabetes care update is a 1-month certificate course aiming to educate the family physicians on the latest developments in diabetes care. Gestational diabetes course is designed to develop the understanding of diabetes in pregnancy and its diagnostic and management protocols. On the other hand, Diet and Education course helps the participants to realize the significance of diet and education in the management of diabetes. It promotes the empowerment of PWD for self-management. Lastly, Ramadan and diabetes course provides the knowledge of the management of diabetes during Ramadan and ensures safe fasting. An 11-month online certificate course in DM management is aimed to build the capacity of primary care physicians through structured education in diabetes care according to local needs. It promotes the practice of national guidelines and develops the ability to contribute to preventive strategies.

Diabetic Foot Care Assistant (DFCA) course involves 6-week foot care training for paramedics [16]. It is an 83-hour course designed to build capacity for screening and examination of the diabetic foot, cutting and filing nails, removing simple callus, and assessing footwear. Further, it involves delivering education in footwear, foot care, and hygiene, giving general advice to PWD, and understanding its implications. So far, more than 120 DFCAs are trained and provide diabetic foot care services in different parts of Pakistan.

BIDE has developed a diploma course to prepare preventive managers/specialists by developing professional skills to analyze the NCD’s underlying determinants and formulate and implement preventive strategies to reduce the NCD burden (DPH-NCD) [2]. With the regulatory body’s approval, BIDE will offer the program to develop NCD prevention specialists at all levels of care in Pakistan.

To help in establishing national-level diabetes care programs

Creation of the National Association of Diabetes Educators Pakistan (NADEP)

BIDE has the honor of being the pioneer of Diabetes Education. BIDE realized that nonphysicians’ contribution to diabetes care can be improved tremendously if their strengths are jointly mobilized. Therefore, NADEP came into existence in May 2010 [16]. It is an association of diabetes educators, dietitians, other healthcare professionals, and those who have a keen concern for diabetes care. The primary aim of NADEP is to provide, facilitate, and promote education for the prevention and management of diabetes and its related disorders among the general population and PWD. The secondary aim of NADEP is to create awareness about the role and importance of diabetes education. Finally, after years of experience and evidence-based research, there is growing acknowledgment that diabetes education is more than simply teaching patients with diabetes what to and what not to do in daily life. It is a unique platform where not only healthcare providers (HCPs) can be gathered, but PWD and their carers are also facilitated. The basic aim of gathering HCPs and PWD is to promote the concept of peer education because the family`s role and social support are vital in the management of DM. NADEP conducts awareness and education sessions, seminars, annual awareness walks, and conferences to provide facilitation on the mass level. NADEP is the association that constantly emphasizes the rationalization of knowledge and information to implement the best diabetes practices in Pakistan. In this regard, NADEP arranged its first ever conference in 2015 with the theme of DIABETES EDUCATION FOR ALL and has been annually doing since.

National diabetic foot program

The concept of Multidisciplinary Diabetic Foot Care Team (MDFCT) has successfully revolutionized foot care services all around the world. In Pakistan, BIDE was instrumental in the creation of this idea, which has altered people's perceptions about diabetic foot care on several levels. Podiatric services were first rare and very expensive. BIDE came up with the concept of diabetic foot care assistants (DFCAs). An organized course is used to teach personnel with experience in wound dressing and management for 6 weeks [17]. The Pakistan Working Group on Diabetic Foot (PWGDF) was formed in 2006 to disseminate knowledge through systematic seminars, events, training courses, and yearly conferences. These training courses and programs have been endorsed by the International Working Group on Diabetic Foot (IWGDF) and are being emulated in many countries throughout the world [16]. These DFCAs have been trained in incision and drainage (I&D), plaster cast (PoP), and nonhealing ulcer unloading. In addition, a domiciliary dressing service was launched to reduce the direct and indirect costs of foot ulcer management [17]. The World Diabetes Foundation (WDF) provided seed funding for the establishment of a national diabetic foot care program in 2007. Following the success of the Step-by-Step (SbS) program in India and Tanzania, the program was launched in Pakistan [16,18]. The diabetic foot care teams, comprising clinicians and their DFCAs, were trained for the introduction course and subsequently for advanced training that assisted in the establishment of diabetic foot clinics after a year of experience. In three years, their initiatives culminated in the establishment of 115 diabetic foot clinics. Furthermore, the amputation rate in these clinics was reduced by 50% [17]. After lowering the amputation rate, the next goal was to lower the development of diabetic foot ulcer (DFU). As a result, another initiative was launched with the support of World Diabetes Federation (WDF) by the title Footwear for all diabetics (FED). Through FED, a countrywide training program for footwear technicians has commenced, and customized low-cost footwear is currently being developed in more than 10 cities across the country, significantly lowering the occurrence of foot ulcers. Furthermore, the IWGDF's foot management recommendations, which have been translated into Urdu, are being distributed throughout the country [17].

Gestational diabetes mellitus (GDM) prevention and control program—Pakistan

We at BIDE have recently completed a 3-year project titled Gestational Diabetes Prevention and Control Program Pakistan in collaboration with WDF and DAP [19]. The project was started to address challenges and critical gaps in effective care for GDM. This project’s significant achievements and challenges were to realize that unawareness is the primary barrier to GDM care in Pakistan. With the help of its awareness campaign, the project has successfully created awareness in many parts of the country. Also, doctors’ training and HCPs leading to capacity building are one of the project’s notable achievements. Before the initiation of this project, GDM was a neglected health issue, and it was not addressed at the healthcare facilities. The project’s establishment of GDM centers and clinics has contributed to the capacity building. The project has promoted the concept of universal GDM screening, which is now being practiced in several institutions. A GDM Advocacy board was established comprising gynecologists, obstetricians, diabetologists, dietitians, and media personnel as part of the project [20]. GDM manual, which is the first of its kind in Pakistan, has compiled all essential and updated knowledge from screening to postpartum follow-up with scientific evidence. As all relevant aspects of GDM management are not available from a single source, this manual helps HCPs simplify screening, diagnosing, and managing this condition promptly and according to international standards. Some of the templates are generated explicitly for this project and are shared in the manual. Lately, based on this initial work, PES and Society of Obstetrics and Gynecology (SOGP) has developed GDM guidelines [21].

The Ramadan and Hajj Study Group Pakistan

As there is a high prevalence of DM, hypertension, cardiovascular disease and other NCDs in the Pakistani population, a significant proportion of Pakistani individuals who fast during Ramadan or those who go for the hajj pilgrimage might have been suffering from one or more of these ailments. Millions of PWD fast during Ramadan, and it is estimated that about 250,000 individuals with DM participate in the Hajj pilgrimage every year. Many of them are elderly and have comorbidities. If necessary precautions are not adopted, PWD while fasting may be at increased risk of developing certain adverse conditions such as hypoglycemia, aggravation of hyperglycemia, and dehydration. DM has progressively been reported as a leading cause of morbidity and mortality during hajj. They include people with poor glycemic control, severe and recurrent episodes of hypoglycemia and hypoglycemic unawareness, and those with a recent history of diabetic ketoacidosis or hyperosmolar state. Moreover, PWDs who have developed chronic complications such as peripheral neuropathy, peripheral arterial disease, retinopathy, or nephropathy are at greater risk.

Given this noble notion of Islam, it becomes the sacred duty of every Muslim individual to take care of their health, while fasting or performing the hajj pilgrimage and prevent any untoward situation. Simultaneously, doctors and other HCPs have a religious, moral, and professional obligation to guide and timely advise their patients for safe fasting and hajj. Nevertheless, there have been no distinct, evidence-based guidelines for people with chronic diseases such as DM and hypertension who want to fast during Ramadan or proceed for hajj pilgrimage. Standardized principles guiding any medical decisions before and during Ramadan fasting or hajj in PWD have primarily been unknown. The evidence-based prospective and/or retrospective studies have been nonexistent. The available recommendations were simply the opinions of the experts or suggestions based on personal experiences, while many relevant questions remained unanswered. Even within this scenario, it remains crucial to disseminate whatever knowledge is at hand. Focused education and awareness are the keys to safe fasting and Hajj. The diabetes care team at BIDE felt the responsibility, and an initiative was taken in 2008 to constitute the Ramadan Study Group Pakistan (RSGP). In the subsequent years, the spectrum of the group was widened to include awareness and education on Hajj, and the group is now known as Ramadan and Hajj Study Group Pakistan (RHSGP) [16].

Establishment of Advisory Board for the Care of Diabetes (ABCD) of Pakistan

BIDE set up this national advisory board with the participation of key opinion leaders from 12 teaching institutions across the country representing all the provinces of Pakistan [16,17,22]. In addition, ABCD has played a vital role in developing guidelines.

BRIGHT guidelines

BRIGHT (Better Recommendations, Implementation, and Guideline development for Healthcare providers and their Training) guidelines were evolved by ABCD in 2014. The main aim of these guidelines was to provide a structured way of self-monitoring blood glucose (SMBG) in different conditions and types of DM. Furthermore, these guidelines have a unique feature that it provides plans for both affording and nonaffording PWDs on various tables [22].

PROMPT guidelines

PROMPT (Pakistan’s Recommendations for Optimal Management of diabetes from Primary to Tertiary care level) guidelines are national guidelines for managing DM with limited resources. This document was created in 2016 by the ABCD. These guidelines were an updated revision of the first such document developed in 1999 by (Late) Prof. A. S. Shera and a group of senior colleagues. The most salient feature of PROMPT guidelines is the referral policy from primary to secondary to tertiary care and vice versa. This will allow appropriate use of resources when implemented nationwide. Only recently, the document has been revised again under the umbrella of the PES (Table 1.1) [23].

Table 1.1

No permission required.

Linkages between multiple stakeholders especially through advocacy

BIDE IDF Center of Education (IDF-CoE)

BIDE has realized the importance of developing collaborations and/or linkages with national and international bodies from its inception. As a result, BIDE was recognized for its meritorious services in 2008 by the International Diabetes Federation (IDF) as the IDF Center of Education. The IDF is an umbrella organization of over 230 national diabetes associations in 170 countries and territories. The primary goal of the IDF-CoE was to become a member of a worldwide collaborative volunteer network to initiate, organize, and coordinate high-quality education for healthcare professionals in DM and other chronic conditions [16,17,24].

IDF YLD program/faculty

The IDF Young Leaders in Diabetes (YLD) Program was initiated by IDF in 2011 to create a voice for young PWDs worldwide. The program provides young PWDs with diabetes with continuous education for 2 years to empower and help them become efficient advocates for themselves and others living with diabetes worldwide. Currently, the network is composed of 90 members (63 trainees and 27 mentors) from 65 countries including representatives from BIDE.

Linkages of BIDE with DAP and WHO collaborating center

BIDE was led into the IDF and the IDF Middle East North Africa (MENA) region through Prof. A. S. Shera (late), Honorary President IDF and Secretary-General, DAP-WHO collaborating center. This gave BIDE and its activities an international impetus and enabled BIDE to facilitate LMICs in various trainings and projects. Diabetes in Asia Study Group (DASG) is another international collaboration across LMICs. It has been a known fact that diabetes management cannot be comprehensive without integration with various disciplines. Therefore, BIDE has constantly been collaborating with national and regional societies and foundations working in eye, kidney, heart, and obstetrics, especially Kidney Foundation, Ibrahim Eye, Pakistan Hypertension League/Pakistan Cardiac Society, and Society of Obstetrics, and Gynecology of Pakistan respectively. Also, BIDE has been instrumental in identifying that PWD cannot be given comprehensive care without the active participation of nutritionists/dietitians, diabetes educators, behavioral therapists, pharmacists, and civil society, to name a few. Hence, BIDE is closely linked and/or affiliated with organizations and associations such as Pakistan Nutrition and Dietetic Society (PNDS), NADEP, Pakistan Society of Health Pharmacists (PSHP), Diabetes Champions, Meethi Zindagi, and Health Promotion Foundation (HPF), to name a few.

Advocacy

BIDE, since its inception, has been actively advocating to involve policymakers and implementers in diabetes programs. Considering the challenges faced commonly in LMICs, it has not been a smooth sail, but by the Grace of Almighty Allah, BIDE has always enjoyed the guidance, well wishes, and support of all the stakeholders including policymakers and hence, has reached where it stands today. Our surveys and guidelines are endorsed by the government, and lately, our SOPs are accepted to be followed in the public health sector, at both primary and secondary care levels within two out of four provinces. Moreover, WHO has always taken DAP/BIDE as their torch bearers for rolling out diabetes programs across the country, whether as specific National Action Plans for diabetes or as an integral part of NCD alliances.

To address issues of affordability and accessibility

Insulin My Life (IML)

The history of Insulin my life (IML) dates back to early 2000, when a baseline study was published in the Journal of Pediatric Diabetes by BIDE and DAP, presenting the trends of type 1 DM in Pakistan [25]. Realizing the need for comprehensive care along with the availability and accessibility of insulin and other essential management tools, BIDE initiated the IML project through initial support by WDF [26]. Later on, Life for a Child (LFAC) joined hands to extend their support for the people with type 1 DM in Pakistan. Initially, the project began in the Sindh Province of Pakistan, and then the services were extended to the province of Baluchistan. So far, around 2500 subjects with type 1 DM are registered that are being served by type 1 model clinics, established through IML, and supervised by specialized doctors and diabetes educators. At the start of this project, these postgraduate diploma holder doctors and educators were trained explicitly in a 3-day extensive workshop. In addition, essential gadgetry was also provided to these clinics. So far, 34 and three clinics are working in the Sindh and Baluchistan provinces of Pakistan, respectively [26].

The main aim of this project was to provide integrated and comprehensive care to people with type 1 DM in Pakistan. Free insulin, glucometers, glucose strips, and HbA1c testing are being furnished to the registered subjects regularly. The data for these subjects are recorded on customized software. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines are being followed to care for people with type 1 DM. Education and awareness at the community level were initiated from the platform of IML, and print and electronic media were used to sensitize the people of Pakistan about this condition. A dedicated website, http://www.insulinmylife.com, is also a very functional tool for this continuous awareness campaign, having all information for the people with type 1 DM, their parents, and the community in general. Along with English and Urdu, for the first time, insulin technique and other educational information are being electronically uploaded in the local (Sindhi) language as well. Local NGOs such as Health Promotion Foundation (HPF) and philanthropists support BIDE to ensure the sustainability of the project, while the precious backing of LFAC has been continued for the last 10 years.

To help increase public awareness, including primary prevention strategies

DAP and other platforms have been arranging public awareness programs for many years. BIDE organized the first diabetes awareness walk in 1999. Since then, it has become an annual event for general awareness [16,17]. In subsequent walks, many celebrities and public figures have participated in enforcing the messages of BIDE for healthy lifestyles. BIDE had promoted Blue lightening at historical buildings, roundabouts, and public places as a sign of diabetes awareness on World Diabetes Day. By the Grace of Almighty Allah, hundreds of awareness programs from many platforms are now undertaken annually across the country covering DM and its various aspects including complications.

BIDE has developed a simple DM risk score based on three questions to identify high-risk individuals without blood tests. Risk assessment of Pakistani individuals for diabetes (RAPID) score uses age, waist circumference, and family history of DM and helps in screening surveys. This score has helped us develop the Primary Prevention Program across the country [27].

To encourage diabetes-related research

In January 1999, BIDE opened a medical research department pioneering research activities in DM in Pakistan. It is now fully developed research department comprising an honorary research consultant, research officers, a biostatistician, and a research coordinator. The research department actively interacts with BIDE faculty [28]. So far, 200-plus studies have been published in various international and national indexed journals. Worth mentioning research of BIDE are conducting national prevalence surveys, developing risk scores, defining our cutoffs for HbA1c, analyzing amputation rate and foot ulcer rate, and assessing risk reduction in intermediate hyperglycemia with intervention.

The research department of BIDE is maintaining an electronic database of patients with DM on a specialized Healthcare Management Software (HMS). So far, we have a database of more than 0.1 million PWD and around 10,000 patients with diabetic foot. In 2016, BIDE initiated the Diabetes Registry of Pakistan (DROP) in collaboration Health Promotion Foundation (HPF). DROP is facilitated by Health Research Advisory Board (HRAB) and is owned and housed at the National Institutes of Health (NIH) with the support of Ministry of National Health Services Regulations and Coordination (MoNHSRC).

The aim of DROP is to provide national data on numbers of PWD and on outcomes for use in audit and research to inform national policymaking and guidelines. DROP was started as Diabetes Registry of Pakistan for type 1 Diabetes (DROP-1), followed by four other divisions of DROP: Diabetes Registry of Pakistan for people with type 2 diabetes (DROP-2), Diabetes Registry of Pakistan for people with foot ulcers (DROP-F), Diabetes Registry of Pakistan for women with gestational diabetes (DROP-G), and Diabetes Registry of Pakistan for People with Peripheral Vascular Disease (DROP-P). Our registry has already started to be considered as one of the model diabetes registries for the LMICs by various national and international stakeholders. The first report on DROP-1 was published last year (Table 1.2) [29].

Table 1.2

No permission required.

How can BIDE experiences help establish diabetes care services especially in LMICs?

To tackle the rising burden of diabetes through capacity building

Some 422 million adults live with DM worldwide, accounting for 6% of the world population. This prevalence is four times more than the incidence in 1980 [30,31]. The figure is estimated to rise to 578 million and 700 million by 2030 and 2045, respectively [32,33]. The rise in the prevalence of DM has been most rapid in LMICs, with highest burden of diabetes-related costly complications and premature deaths [32,34]. Around the globe, DM incurs high and long-standing direct and indirect costs for individuals, their caregivers, and communities, affecting the lowest income quintiles disproportionately. In addition, it results in higher rates of death and complications such as blindness, kidney failure, amputations, heart attacks, and stroke among the poor. It is well recognized that diabetes hits the poorest the hardest [35].

Capacity building, especially training of primary care physicians and allied healthcare professionals, stays the backbone of tackling this epidemic at the grass-root level and is used as a successful tool for tackling the burden in quite a few LMICs. BIDE model can be worth studying in this regard. With the progress of digital technology from 1996, when BIDE was established, to 2021, which is the post-COVID era, virtual trainings and capacity buildings have scaled up tremendously.

To help in establishing national-level diabetes care programs

National-level programs shall be an essential part of each country’s diabetes care strategy. In LMICs primarily, the utilization of resources pragmatically can serve the masses in various aspects of diabetes. Important issues such as diabetic foot, gestational diabetes, and diabetes education can be cost-effective if specifically addressed through learning from the success of BIDE model.

To develop linkages between multiple stakeholders, especially through advocacy

WHO aims to set sustainable development goals (SDGs) to reduce NCD-related premature mortality by 25% and 33% by 2025 and 2030, respectively [36,37]. Only a few nations have been successful in limiting the DM epidemic. It is the only major NCD that has shown a 5% rise in premature mortality since 2000 [31]. In comparison, the likelihood of dying from any of the four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases, or diabetes) has decreased by 18% globally between 2000 and 2016. Governments have also dedicated to progressively covering 1 billion additional people by 2023 with essential health services. As a matter of fact, no national strategy can be successful ideally unless integration between multiple stakeholders with support from the government is established. Being in the private sector, BIDE has learned this lesson after an extended period, whereas Bangladesh, on the other hand, has developed this integration from day 1 of the inception of BIRDEM [38]. Hence, the primary differentiating factor for success stories is and will continue to be Advocacy involved, especially at the governmental level.

To address the issues of affordability and accessibility

Insulin and oral hypoglycemic agents are generally available only in a few low-income countries. Further, essential medicines critical to DM management, such as agents to lower blood pressure and lipid levels, are often unavailable in low and low middle-income countries (LICs and LMICs). As a result, primary HCPs in low-income countries do not have access to the essential technologies needed for standardization of care to help PWD. In addition, only one third of low- and middle-income countries have the most basic technologies for DM diagnosis and management available in primary healthcare facilities. Therefore, scaling-up access to affordable insulin and associated delivery and self-monitoring devices is a priority for partners helping governments realize their commitments.

To help increase public awareness

Many countries among LMICs are now successfully running public awareness programs. As a result, global awareness regarding DM, its complications, and prevention is rising. However, the extent to which the growing prevalence demands awareness is much more than available at present. Successful primary prevention programs in the USA, Finland, and Germany are guiding the nations, but multiple barriers and limitations are underplaying the efforts of HCPs in many countries. Therefore, the role of civil societies, media, donors, PWD, and their carers has to be identified and well defined. Furthermore, its practical implementation must be ensured to support the multiple stakeholders trying to run a successful nationwide DM care model.

To encourage diabetes-related research studies

One of the main aspects of running a successful disease management program nationally is to enhance research capacity. Research in etiopathology, management, and prevention at each geographic, ethnic, and socioeconomic level will guide the development of customized DM care models with proportionate emphasis. Research can be initiated with minimal resources but does pay back enormously in the future (Fig. 1.2).

Fig. 1.2

Fig. 1.2 Establish diabetes care services especially in LMICs. No permission required.

In conclusion, it is crucial to bring together relevant partners to drive innovation, supporting countries to implement and monitor evidence-based, locally applicable policies and programs to achieve tangible and sustained improvements in diabetes within primary health care and toward realizing universal health coverage. We hope, through this chapter, we have conveyed the message to our readers that much more can be done than anticipated. Learning from success stories may help us reduce the suffering of millions of PWDs globally.

References

[1] Baqai Medical University (BMU) ACT 1996. Available from: https://baqai.edu.pk/bmu/BMU-ACT-1996.pdf. 2021.

[2] University Portfolio Report 2019. Baqai Medical University. Institutional performance evaluation report quality enhancement cell. Available from: https://baqai.edu.pk/doc/UPR-BAQAI-MEDICAL-UNIVERSITY.pdf. 2021.

[3] Population, Total – Pakistan. The World Bank Data. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?end=2020&locations=PK&start=1960&view=chart. 2021.

[4] GDP Growth (Annual %) – Pakistan. The World Bank Data. Available from: https://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=PK. 2021.

[5] Rural Population (% of the Total Population) – Pakistan. The World Bank Data. Available from: https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS?locations=PK. 2021 Accessed 16 July 2021.

[6] Anwar T., Qureshi S.K. Trends in absolute poverty in Pakistan: 1990-91 and 2001. Pak Dev Rev. 2002;41:859–878. doi:10.30541/v41i4iipp.859-878.

[7] Ghaffar A., Kazi B.M., Salman M. Health care systems in transition III. Pakistan, Part I. An overview of the health care system in Pakistan. J Public Health Med. 2000;22:38–42. doi:10.1093/pubmed/22.1.38.

[8] Diabetic Association of Pakistan – Wikipedia. Available from: https://en.wikipedia.org/wiki/Muhammad_Ibrahim. 2021.

[9] Shera A.S., Basit A., Fawwad A., Hakeem R., Ahmedani M.Y., Hydrie M.Z.I., et al. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan. Prim Care Diabetes. 2010;4:79–83. doi:10.1016/j.pcd.2010.01.003.

[10] Shera A.S., Jawad F., Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract. 2007;76:219–222. doi:10.1016/j.diabres.2006.08.011.

[11] Shera A.S., Rafique G., Ahmed K.I., Baqai S., Khan I.A., King H. Pakistan national diabetes survey prevalence of glucose intolerance and associated factors in north west frontier province (NWFP) of Pakistan. J Pak Med Assoc. 1999;49:206–211.

[12] Shera A.S., Rafique G., Khawaja I.A., Baqai S., King H. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Baluchistan province. Diabetes Res Clin Pract. 1999;44:49–58. doi:10.1016/S0168-8227(99)00017-0.

[13] Shera A.S., Rafique G., Khwaja I.A., Ara J., Baqai S., King H. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province. Diabetic Med. 1995;12:1116–1121. doi:10.1111/j.1464-5491.1995.tb00430.x.

[14]Global Health Workforce Statistics. Geneva: World Health Organization; 2021. Available from: http://www.who.int/hrh/statistics/hwfstats/i.

[15] Ahmedani M.Y., Haque M.S., Basit A., Fawwad A., Alvi S.F.D. Ramadan Prospective Diabetes Study: the role of drug dosage and timing alteration, active glucose monitoring and patient education. Diabetic Med. 2012;29:709–715. doi:10.1111/j.1464-5491.2011.03563.x.

[16] Basit A., Riaz M., Fawwad A. Improving diabetes care in developing countries: the example of Pakistan. Diabetes Res Clin Pract. 2015;107:224–232. doi:10.1016/j.diabres.2014.10.013.

[17] Basit A., Fawwad A., Siddiqui S.A., Baqa K. Current management strategies to target the increasing incidence of diabetes within Pakistan. Diabetes Metab Syndr Obes. 2019;12:85–96. doi:10.2147/DMSO.S141356.

[18] Abbas Z.G., Lutale J.K., Bakker K., Baker N., Archibald L.K. The Step by Step diabetic foot project in Tanzania: a model for improving patient outcomes in less-developed countries. Int Wound J. 2011;8:169–175. doi:10.1111/j.1742-481X.2010.00764.x.

[19] Riaz M., Nawaz A., Masood S.N., Fawwad A., Basit A., Shera A.S. Frequency of gestational diabetes mellitus using DIPSI criteria, a study from Pakistan. Clin Epidemiol Global Health. 2019;7:218–221. doi:10.1016/j.cegh.2018.06.003.

[20] Riaz M., Basit A. Integrating GDM management in public health: Pakistan perspective. J Pak Med Assoc. 2016;66:S101–S104.

[21] Masood S., Baqai S., Naheed F., Masood Y., Sikandar R., Chaudhri R., et al. Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP) #. J Diabetol. 2021;12:83. doi:10.4103/jod.jod_88_20.

[22] Basit A., Khan A., Khan R.A. BRIGHT guidelines on self-monitoring of blood glucose. Pak J Med Sci. 2014;30. doi:10.12669/pjms.305.6006.

[23] Shera A.S., Basit A., Miyan Z., Riaz M., Khan A., Khan R.A., et al. Pakistan’s recommendations for optimal management of diabetes from primary to tertiary care level (PROMPT). Pak J Med Sci. 2017;33:1279–1283. doi:10.12669/pjms.335.13665.

[24] IDF Centres of Excellence in Diabetes Care. Available from: https://idf.org/our-activities/education/centres-of-excellence.html. 2021.

[25] Shera A.S., Miyan Z., Basit A., Maqsood A., Ahmadani M.Y., Fawwad A., et al. Trends of type 1 diabetes in Karachi, Pakistan. Pediatr Diabetes. 2008;9:401–406. doi:10.1111/j.1399-5448.2008.00309.x.

[26] Ahmedani M.Y., Fawwad A., Shaheen F., Tahir B., Waris N., Basit A. Optimized health care for subjects with type 1 diabetes in a resource constraint society: a three-year follow-up study from Pakistan. World J Diabetes. 2019;10:224–233. doi:10.4239/wjd.v10.i3.224.

[27] Riaz M., Basit A., Hydrie M.Z.I., Shaheen F., Hussain A., Hakeem R., et al. Risk assessment of Pakistani individuals for diabetes (RAPID). Prim Care Diabetes. 2012;6:297–302. doi:10.1016/j.pcd.2012.04.002.

[28]BIDE celebrates 200th scientific publication to showcase its research output. Pulse International; 2020. Available from: http://www.pulsepakistan.com/index.php/main-news-august-15-20/3614-bide-celebrates-200th-scientific-publication-to-showcase-its-research-output Accessed July 2021.

[29] Basit A., Fawwad A., Baqa K. Diabetes registry of Pakistan. Pak J Med Sci. 2020;36. doi:10.12669/pjms.36.3.1877.

[30] World Health Day, the report was released with theme Beat Diabetes. Available form: https://www.dw.com/en/who-diabetes-cases-in-adults-quadrupled-since-1980/a-19166765. 2016.

[31] World Health Organization (WHO) factsheet of Diabetes. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes. 2021 Accessed 16 July 2021.

[32] Karachaliou F., Simatos G., Simatou A. The challenges in the development of diabetes prevention and care models in low-income settings. Front Endocrinol. 2020;11. doi:10.3389/fendo.2020.00518.

[33] Saeedi P., Petersohn I., Salpea P., Malanda B., Karuranga S., Unwin N., et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas. 9th ed. Diabetes Res Clin Pract.