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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 383-390

Diabetes care during 50 years of Bangladesh


1 Centre for Global Health Research, Diabetic Association of Bangladesh, Mirpur-10, Dhaka-1216, Bangladesh
2 Department of Health Education, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Mirpur-10, Dhaka-1216, Bangladesh
3 Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Mirpur-10, Dhaka-1216, Bangladesh
4 National Healthcare Network, Diabetic Association of Bangladesh, Mirpur-10, Dhaka-1216, Bangladesh
5 Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo 0318, Norway
6 Directorate General of Health Services, Mohakhali, Dhaka-1212, Bangladesh
7 Novo Nordisk Bangladesh, Mohakhali, Dhaka-1212, Bangladesh
8 Japan International Cooperation Agency (JICA), Gulshan-1, Dhaka-1212, Bangladesh
9 Bangladesh Institutes of Health Sciences, Dhaka, Bangladesh
10 Faculty of Health Sciences, Nord University, Bodø 8049, Norway, International Diabetes Federation (IDF), 166 Chaussee de La Hulpe, B - 1170 Brussels, Belgium & Centre for Global Health Research, Diabetic Association of Bangladesh, 166 Chaussee de La Hulpe, B - 1170 Brussels, Bangladesh

Date of Submission29-Mar-2021
Date of Decision14-Apr-2021
Date of Acceptance28-Apr-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Bishwajit Bhowmik
Centre for Global Health Research, Diabetic Association of Bangladesh, 122 Kazi Nazrul Avenue, Shahbagh, Dhaka-1000.
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_37_21

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  Abstract 

Similar to many other countries around the world, Bangladesh is also suffering from a pandemic of diabetes. It makes the most significant contribution to morbidity and mortality in this country. Despite the high burden of diabetes, health care is still geared toward episodic care. The government has not yet invested substantial efforts into developing a national policy to detect, prevent, and control diabetes. Still, diabetes care is restricted to capital and other big cities. More than 60% of people with diabetes usually sought treatment and advice from private facilities, including the Diabetic Association of Bangladesh. For the past six decades, the Association has been trying to develop a proper organizational framework, health care, educational institutions, rehabilitation facilities for poor people with diabetes, appropriate diabetes prevention, and education programs. To address the pandemic, the country should focus on nationwide diabetes prevention and control programs, such as creating community awareness and changing lifestyle practices through well-designed public health programs. The country also needs public–private partnerships and multi-sectoral approaches to overcome the diabetes burden.

Keywords: 50 years, Bangladesh, diabetes care


How to cite this article:
Bhowmik B, Siddiquee T, Ahmed T, Afsana F, Samad M A, Pathan MF, Moreira Nd, Alim A, Milon SU, Rahman MM, Ozaki R, Khan FA, Hossain AE, Mahtab H, Hussain A, Khan AA. Diabetes care during 50 years of Bangladesh. J Diabetol 2021;12:383-90

How to cite this URL:
Bhowmik B, Siddiquee T, Ahmed T, Afsana F, Samad M A, Pathan MF, Moreira Nd, Alim A, Milon SU, Rahman MM, Ozaki R, Khan FA, Hossain AE, Mahtab H, Hussain A, Khan AA. Diabetes care during 50 years of Bangladesh. J Diabetol [serial online] 2021 [cited 2022 May 27];12:383-90. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/4/383/335586




  Background Top


Diabetes is a chronic metabolic disease that is characterized and identified by persistent hyperglycemia in the absence of treatment.[1] There are two major types: type 1 diabetes (T1DM) and type 2 diabetes (T2DM).[1] T2DM accounts for more than 90% of all diabetes and has already become a worldwide epidemic.[2] The UN General Assembly passed a resolution (61/225) on 20 December 2006 and declared 14 November as World Diabetes Day.[3] This UN resolution identifies diabetes as a costly chronic disease associated with considerable complications that create severe risks to families, societies, countries, and the entire world. This resolution invites all the member states to develop their national policies to prevent and care for diabetes. It is a matter of pride that the Government of Bangladesh sponsored the resolution on request from the Diabetic Association of Bangladesh (BADAS).

T2DM is now considered a significant public health burden in Bangladesh. The International Diabetes Federation (IDF) reported that 8.4 million people living in Bangladesh had T2DM in 2019, and of them, 56% were unaware of their diabetes status.[2] At present, Bangladesh is the 10th of the countries with the total number of people with diabetes. By 2045, it is projected to move to the ninth position, with 15 million people with T2DM, unless preventive measures are taken.[2] Based on published studies, the prevalence of T2DM among adults in Bangladesh has increased substantially from 3.8 to 10.4% between 1995 and 2019.[4],[5] Older age, higher education, affluent socioeconomic status, carbohydrate-rich foods, physical inactivity, obesity, smoking, hypertension, dyslipidemia, increased age at pregnancy, and depression are significant risk factors for T2DM.[4],[5],[6],[7] The prevalence of major macrovascular complications, including coronary artery disease (30.5%), stroke (10.1%), peripheral artery disease (12%), and microvascular complications, including nephropathy (34%), retinopathy (25%), and neuropathy (5.7%), related to T2DM are found to be high in Bangladesh.[8] Around 129,300 deaths occurred due to T2DM in Bangladesh in 2019 and more than 62% before 60 years, which is too high for any developing country.[2] Studies have also shown that people with T2DM receive two times more inpatient treatment days and require one and half times more outpatient visits and more than nine times more medications than normal individuals.[9] Overall, people with T2DM in Bangladesh spend 9% of their annual household income on managing the disease. The total annual per capita expenditure on medical care is six times higher for people with T2DM (US$635 vs. US$104, respectively). Using productivity-adjusted life years (PALY), it is projected that more than nine million PALYs (20.4%) are attributable to having T2DM. In Bangladesh, the loss in PALYs was linked to a total of US$97.4 billion loss (US$16 987 per person) in gross domestic product.[10],[11] The IDF atlas reported the rate of T1DM in Bangladesh as being 3.4 new cases of T1DM/100,000 children (0–14 years)/year, and a total of 18000 children had T1DM in 2019.[2] Population-based studies have revealed that the prevalence rates of GDM are between 6% and 14%.[12],[13]

[TAG:2]Diabetic Association of Bangladesh (BADAS)[14],[15][/TAG:2]

In Bangladesh, health care is geared toward episodic care, and noncommunicable diseases (NCDs) such as diabetes remain neglected. Besides, lack of health consciousness, lack of financial resources, cultural barriers, misconceptions, and communication issues are the major concerns for the lack of organized care for lifelong diabetes and other NCDs in Bangladesh. The government has no particularly dedicated care network for people with diabetes. Diabetes care is provided mainly by the BADAS. The late national Professor Dr. Mohammed Ibrahim first thought of diabetes care in the country. He established BADAS (then Pakistan) on 28 February 1956 in a tin shed at Segun Bagicha, Dhaka. At the beginning of the 1970s, few short-stay beds were established to take care of serious patients. Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine, and Metabolic Disorders (BIRDEM), the central institution of the Association, was established in 1980 on a government plot at Shahbagh in Dhaka and financed by the government. In 1984, BIRDEM was designated as a WHO Collaborating Center for Research on Prevention and Control of Diabetes; this was the first one outside Europe and the second one of all the collaborating centers. BADAS is currently looking after 50% of all people with diabetes in Bangladesh and is hoping to contain 75% by 2025. The Association owns more than 114 institutions, 100 large–medium–small-sized hospitals with more than 4000 beds, providing primary, secondary, and tertiary care in all disciplines, including organ transplantation (kidney, liver), cardiac bypass, stenting, vascular, and neurosurgery. The Association has also tried to create country-wide diabetes and NCD networks in Affiliated Associations (AAs). The Association has 69 AAs, almost one in every district (69 in 64 districts) [Figure 1]. The Association has created a safety net for poor people with diabetes. The Association also provides free insulin to all the kids and adolescents with T1DM in Bangladesh through its Changing Diabetes in Children (CDIC) and Life for a child (LFC) program. BADAS has also established a Rehabilitation and Vocational Training Center (RVTC) to train the poor kids with T1DM to get employment after getting befitting training in different trades. [Table 1] shows some key events of diabetes care conducted during 50 years of Bangladesh.
Figure 1: BADAS across Bangladesh

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Table 1: Some key events of BADAS during 50 years of Bangladesh

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  Health-care Facilities Related to Diabetes Top


A major obstacle to optimal health care is that only half of the people with T2DM in Bangladesh have access to diabetes care, with obvious devastating consequences. Today, the characteristics of the diabetic population are young age, nonobese, and high complication rates. As the economy grows, the people will get older, and the prevalence of T2DM will increase, as has already been seen in Bangladesh. Along with BADAS, Bangabandhu Sheikh Mujib Medical University (BSMMU), a few medical college hospitals in the public sector, and several private corporate and nonprofit hospitals now have the provision for diabetes treatment. The government has also started the Department of Endocrinology in eight medical college hospitals. These facilities are mostly in the capital and major cities. The National NCD Risk Factor Study 2018[16] reported that 10.4% of the people with diabetes were only aware of their diagnosis but not about treatment, and among the people with diabetes who were on treatment, only 13.6% had their blood glucose under control, and 24.7% still had raised blood glucose levels. The study also reported that 62% of people with diabetes usually sought treatment and advice from private facilities and only 26.9% from government facilities. A total of 95.2% of adults usually get their prescribed medication only from private facilities, 1.1% only from government facilities, and 4.3% visit a traditional healer for controlling their blood sugar.[16] A series of studies also reported that more than 80% of people with T2DM in Bangladesh did not achieve the recommended HbA1c target of lower than 7%.[17],[18],[19] Only 21% of people with T2DM practice home blood glucose monitoring (HBGM), and more than 75% prefer it done at the doctor’s office.[18] All types of conventional and modern antidiabetic medications (including oral, insulin, and non-insulin injection), glucose monitoring tools (including glucometers and strips, continuous glucose monitoring system), and insulin pumps in the global market are now available in Bangladesh. A total of 11 pharmaceutical companies are now marketing insulin, and around 46 pharma companies are marketing oral antidiabetic drugs (OADs). The most used OAD is Metformin, and human premix insulin is the most prescribed insulin.[19] Annual payments for diabetes medications are on average BDT 35,385 (US$ 429), and these are 22 times higher than the average medication costs for patients who are nondiabetic.[20] However, in primary public health settings, there is a provision to obtain OADs, such as Metformin and Sulfonylureas (Gliclazide), but insulin is not yet available.[21] Blood glucose measurement and urine strips for glucose and ketone measurement are only available, but oral glucose tolerance test (OGTT), HbA1C test, lipids, and screening of other complications, including cardiac, eye, and foot examination, are generally not available in primary care settings.[21]


  Manpower Development for Diabetes Care Top


The availability of trained manpower is an important limiting factor for delivering diabetes care in resource-poor countries, including Bangladesh.[15] Both government and nongovernment organizations such as BADAS, Bangladesh Rehabilitation Assistance Committee (BRAC), and ICDDRB (International Centre for Diarrheal Disease Research, Bangladesh) have already taken several initiatives to overcome this problem. BIRDEM Academy, which was established in 1986, conducts diploma and degree courses, such as a diploma in endocrinology and metabolism (DEM), MD, MPhil, and Ph.D. in Endocrinology.[14] Besides BIRDEM Academy, BSMMU and Dhaka Medical College conduct MD in Endocrinology, and Mymensingh Medical College conducts only DEM. Bangladesh College of Physicians and Surgeons started FCPS in Endocrinology in 2004. More than 200 endocrinologists have already emerged from these institutes, and they are now working in different government and public hospitals. More seats for post-graduation in endocrinology have been allocated for better treatment provision.

In 2004, BADAS launched the Distance Learning Program (DLP) to train doctors in diabetes care. Certificate Course on Diabetology (CCD) through DLP was started with Regional Tutorial Centers (RTCs) all over the country.[22] So far, BADAS has been able to train more than 16000 doctors. This has revolutionized diabetes care in Bangladesh.[23] The IDF endorsed the course in March 2015. The DLP program is now being converted from a tutor-centered face-to-face program to an E-learning program. Bangladesh University of Health Sciences (BUHS) also started MPH in NCDs.

BADAS has also developed a month-long certificate course for diabetes educators. Approximately 150 educators have already completed their training and are working in different BADAS institutions nearest to their home. More than 350,000 people with diabetes have also been given education by these trained diabetes educators.[14] The Non-Communicable Disease Control (NCDC) Programme of the Directorate General of Health Services (DGHS) has developed an NCD management model based on WHO-PEN in collaboration with NCD partner organizations such as the WHO, Japan International Cooperation Agency (JICA), BADAS, BRAC, ICDDRB, and the National Heart Foundation.[20],[24] The NCD management model was developed to ensure the provision at the primary healthcare (PHC) level of essential NCD services, especially for people with hypertension and diabetes. Team-based care, which includes primary care physicians, nurses, Sub-Assistant Community Medical Officer (SACMO), and community health workers, is also included in PEN to provide patient-centered continuous care.[24]


  Programs and Policies Related to Diabetes and Related NCDs Top


The 2030 Agenda for Sustainable Development Goal (SDG) recognizes NCDs (including diabetes, cardiovascular diseases, cancer, and chronic respiratory diseases) as a major challenge for achieving SDG.[25] Two of the nine voluntary targets under the WHO Global Action Plan are directed at global diabetes control. Numerous policies and programs have been designed and introduced to address the challenges posed by increasing diabetes and other chronic NCDs. Bangladesh has also committed to reducing premature mortality from diabetes and other major NCDs by one-third by 2030. Bangladesh has integrated glycemic control as one of the key indicators in its multi-sectoral action plan for the prevention and control of NCD 2018–2025.[26] BADAS and the WHO developed “Guidelines for Care of T2DM In Bangladesh” in 2013,[27] and then, BADAS and the NCD control program of DG Health jointly developed “Diabetes Care BADAS Guideline 2019”[28] to initiate evidence-based diabetes care. Besides, to address the COVID-19 crisis, BADAS, NCDC, and JICA together developed the “COVID-19 and Diabetes- BADAS Guideline” for health professionals (in English) and people with diabetes (in Bangla).[29],[30] More than 16000 people, including health professionals and general people, completed the online course on COVID-19 and diabetes. BADAS has replaced its paper-based patient registry with an electronic registry in its countrywide networks. Also, the government has installed a District Health Information Software (DHIS2) system for obtaining hospital data.[31] These two registries will help caregivers, care recipients, and policymakers to monitor trends in diabetes care processes, risk factors, indicators, and complications over time.

The major ongoing programs addressing diabetes and other NCDs in Bangladesh include the following:

  1. The NCDC program deals with building awareness on NCD, providing NCD care, establishing dedicated NCD corners in government hospitals, and equipping facilities with necessary instruments.


  2. Upazila NCD project deals with developing the providers’ capacity for NCD diagnosis and management at the primary care level.


  3. Tertiary care providers such as BADAS, BRAC, ICDDRB, etc. are involved in providing both preventive and clinical care services, especially targeting the disadvantaged population in some remote/hard-to-reach areas.


Insulin for T1DM is a human right; the government has finally decided to provide insulin free of cost to all those with T1DM, as Bangladesh is the first low-middle-income country to do so.[20]


  Prevention Program Top


Similar to other South Asian (SA) countries, Bangladesh is also facing an increased health challenge associated with rapid economic transition, migration from traditional rural to more urban locations, and changes in their dietary and physical activity practices.[32],[33],[34] An increased predisposition to NCDs is an adverse consequence of these changes, with an increased prevalence of obesity and central adiposity leading to an increased risk of T2DM. The Government of Bangladesh has universally adopted the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020, and they have further committed to universal health coverage (UHC) by 2030. Although the country has a national action plan for facing the epidemiological transitions of diabetes, still countrywide implications have received less attention. One Bangladeshi study showed that overall, US$297 could be saved annually by preventing only one case of diabetes.[35] The government should give greater priority to diabetes prevention and control programs, such as creating mass awareness and changing lifestyle habits through well-designed public health programs. In Bangladesh, BADAS has successfully included religious leaders to influence the improvement of community awareness about the prevention of T2DM: “Diabetes Prevention through Religious Leaders” and the prevention of GDM and future T2DM: “Preconception Care through Religious Leaders”.[36],[37] The Bangladesh DMagic trial reported that community mobilization using the participatory learning and action (PLA) approach improved knowledge and awareness about diabetes and significantly lowered the prevalence of diabetes and intermediate hyperglycemia.[38] BADAS has already submitted a national policy for public awareness and prevention of diabetes mellitus, and the relevant ministries of the government have declared their support. It is now waiting for government approval.


  Research Related to Diabetes Top


Research activities are essential for developing prevention and management policies. Thousands of scientific articles related to diabetes have been published in 50 years of independence of Bangladesh.[4],[5] Most of the studies used a cross-sectional research design. Cohort studies are extremely limited. In urban areas, many people are either residents or slum people who change their houses very frequently. In rural areas, there is constant migration to the cities for employment. These are some critical challenges for conducting cohort studies in Bangladesh. West and Kalbfleisch conducted a study in Uruguay, Venezuela, Malaya, and East Pakistan (former East Pakistan) in 1966.[39] This was the first documented study on diabetes prevalence. Hajera Mahtab and her team in BIRDEM conducted the first extensive survey in Bangladesh in 1982.[40] The study was conducted to determine the prevalence of diabetes mellitus in rural and semi-urban populations in Bangladesh. Chandra Rural Diabetes Study, a research initiative of BADAS, was the first reported 10-year follow-up study.[41] The first incidence paper of diabetes was published by Akhter Hussain and his team in 2011 based on the Chandra Study.[42] National STEPS Survey for NCD Risk Factors in Bangladesh and the Bangladesh Demographic and Health Survey (BDHS) are the nationally representative surveys that reported the prevalence of diabetes and related factors.[16],[43]

The DABCare Asia is the first study of its kind that reported the management, control, complications, and psychosocial aspects of people with diabetes in Bangladesh.[18],[44] Changing Diabetes Barometer is the first nationwide survey following the management, control, and complications among 200000 people with T2DM since 2015.[19] Kazi Rumana first estimated the 15-year incidence of diabetic retinopathy (DR) among T2DM subjects in Bangladesh.[45] Abu Sayeed first reported the GDM prevalence,[12] and Kiswar Azad wrote about the T1DM in Bangladesh.[46] Shariful Islam reported the health-care use and expenditure for diabetes, and Afroz reported the cost of illness for diabetes.[9],[10] Bishwajit first reported using HbA1c as a diagnostic tool for diabetes and prediabetes and reported the use of a simple noninvasive risk score to detect people at high risk for diabetes.[47],[48] AK Azad Khan and Liaquat Ali wrote on the tropical calcific pancreatitis and fibrocalculus pancreatic diabetes in Bangladesh, and they also reported its genetic susceptibility.[49],[50],[51] To date, no study has reported the effect of occupational, nutritional (i.e., sodium, refined sugar intake), and different environmental factors (i.e., migration, water, and air pollution) on diabetes. Besides the government, the European Union, World Bank, JICA, DFID (The Department for International Development), UK, and World Diabetes Foundation (WDF) are the leading NCD research funding agencies in Bangladesh.


  Conclusion Top


Sustainable prevention and management of diabetes in Bangladesh is required for effective national advocacy to convince the government policymakers, who set up health priorities and allocate budgets. The use of best available evidence, engagement of stakeholders, and plans that are appropriate to unique local contexts will also be needed for effective diabetes prevention and care management. Primary attention should be given to primary prevention strategies to respond to risk factors and behaviors during preconception, in utero in infancy, and during childhood and adolescence. All people with diabetes will benefit from the early detection and appropriate treatment of complications. A stronger controlling framework is needed—including taxes on sugar-sweetened beverages and dietary fats and limiting the use of trans fats. The government should ensure that people with diabetes have continuous access to diabetes care services and getting medicines and devices at affordable costs. These will be required for achieving UHC. Finally, an improvement of health professionals’ skills, organized periodical training to nonphysician health-care workers at the primary care level, and the development and regular updating of national guidelines will also be essential to improve diabetes care in Bangladesh.

Acknowledgment

The authors express their admiration to the BADAS authority, leaders of the government programs related to diabetes and related NCDs, and finally, all those individuals involved in these filed for their dedication to improve diabetes care in Bangladesh.

Financial support and sponsorship

Diabetic Association of Bangladesh.

Conflicts of interest

There are no conflicts of interest.

Contributors

All authors conducted the literature search and drafted sections of the article. All authors subsequently revised the final article.



 
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