WHO South-East Asia Journal of Public Health
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   2016| January-June  | Volume 5 | Issue 1  
    Online since May 18, 2017

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Strengthening policy and governance to address the growing burden of diabetes in Nepal
Senendra Raj Upreti, Guna Raj Lohani, Akjemal Magtymova, Lonim Prasai Dixit
January-June 2016, 5(1):40-43
DOI:10.4103/2224-3151.206551  PMID:28604396
Diabetes poses a major challenge to Nepal’s health-care system. Deaths due to noncommunicable diseases (NCDs) have increased from 51% of all deaths in the country in 2010 to 60% in 2014. In 2014, diabetes and other essential NCDs accounted for 46% of the total deaths and 22% of premature deaths in the country. As diabetes is common in adults of working age, the impact will further impoverish individuals and families in Nepal, where out-of-pocket expenditure for health remains high. To halt the rise in diabetes and obesity, the government of Nepal will have to adopt a public health approach that balances individual and population-level interventions. Awareness, early diagnosis and prevention are key to management and control of diabetes. To date, there has been no nationwide robust programme for diabetes prevention in the country and services are inaccessible to much of the Nepalese population. However, under the NCD Multisectoral Action Plan (2014–2020), there will be phase-wise implementation of the World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings. The NCD PEN brings opportunities to strengthen the health workforce, diagnostics, medicines and supplies, the health information system, and research and surveillance and to reduce inequity in diabetes care in Nepal.
  7 2,901 353
Childhood obesity and type 2 diabetes in India
Pradeep A Praveen, Nikhil Tandon
January-June 2016, 5(1):17-21
DOI:10.4103/2224-3151.206547  PMID:28604392
India is witnessing an increase in the burden of childhood obesity, especially among the upper socioeconomic strata and in urban areas. Emerging literature suggests a link between childhood obesity and the diabetes epidemic in India. Asian-Indian children and adolescents are increasingly susceptible to a high percentage of body fat and abdominal adiposity. Further, they are exposed to an obesogenic environment, created by rapid urbanization and nutrition transition in India. Obese children have a higher risk of developing abnormalities that are recognized as precursors to diabetes, such as subclinical inflammation, insulin resistance and metabolic syndrome, which often track to adulthood. A review of the literature suggests the need for more longitudinal studies to improve understanding of the long-term consequences of childhood obesity in India. A life-course approach with a combination of population- and risk-based strategies is warranted, to prevent childhood obesity and curtail its consequences in adulthood.
  6 4,168 383
Slowing the diabetes epidemic in the World Health Organization South-East Asia Region: the role of diet and physical activity
Viswanathan Mohan, Vaidya Ruchi, Rajagopal Gayathri, Mookambika Ramya Bai, Vasudevan Sudha, Ranjit Mohan Anjana, Rajendra Pradeepa
January-June 2016, 5(1):5-16
DOI:10.4103/2224-3151.206554  PMID:28604391
The nutrition transition occurring in the World Health Organization South-East Asia Region, as a result of rapid urbanization and economic development, has perhaps made this region one of the epicentres of the diabetes epidemic. This review attempts to evaluate the role of diet and physical inactivity in the South-East Asia Region in promoting this epidemic and points to strategies to slow it down by lifestyle modification. The emerging new food-production technologies and supermarkets have made energy-dense foods more easily available. This includes refined carbohydrate foods like those with added sugars, and refined grains and unhealthy fats. In addition, increased availability of modern technology and motorized transport has led to decreased physical activity. South Asian diets tend to be based on high-carbohydrate foods, with a predominance of refined grains. All of these accentuate the risk of diabetes in people of this region, who already have a unique “south Asian phenotype”. However, there is increasing evidence that altering diet by replacing refined cereals like white rice with whole grains (e.g. brown rice) and increasing physical activity can help to prevent diabetes in high-risk individuals. An urgent, concerted effort is now needed to improve diet quality and encourage physical activity, by introducing changes in policies related to food and built environments, and improving health systems to tackle noncommunicable diseases like diabetes.
  6 3,257 276
Diabetes in South-East Asia: burden, gaps, challenges and ways forward
Gojka Roglic, Cherian Varghese, Thaksaphon Thamarangsi
January-June 2016, 5(1):1-4
DOI:10.4103/2224-3151.206546  PMID:28604390
  4 2,306 214
An approach to diabetes prevention and management: The Bhutan experience
Tandin Dorji, Pemba Yangchen, Chencho Dorji, Tshering Nidup, Kinley Zam
January-June 2016, 5(1):44-47
DOI:10.4103/2224-3151.206552  PMID:28604397
Bhutan has been witnessing a trend of increasing diabetes in recent years. The increase is attributed to a rise in risk factors such as overweight, high blood pressure, unhealthy diet and sedentary lifestyle among the population. To address the rising burden, the health-services response has been to establish diabetes clinics in all hospitals and grade one basic health units. People visiting the health centres who have high risk factors and symptoms for diabetes are screened using the World Health Organization cut-off level for blood glucose. They are then classified into prediabetes and diabetes. Accordingly, diet, medicine and physical activity are recommended as per their body mass index. To improve prevention and control of noncommunicable diseases, which include diabetes, the country piloted the WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings in 2009, to promote early screening, treatment and follow-up, and adopted it in 2013. The WHO PEN has now been successfully integrated into the primary health-care system nationwide. It is planned that diabetes clinics will be upgraded to NCD clinics.
  4 2,624 250
Assessment of risk of type 2 diabetes using the Indian Diabetes Risk Score in an urban slum of Pune, Maharashtra, India: a cross-sectional study
Reshma S Patil, Jayashree S Gothankar
January-June 2016, 5(1):53-61
DOI:10.4103/2224-3151.206555  PMID:28604399
Background: The urban poor is a group that is known to be vulnerable to adoption of a more urbanized lifestyle that places them at a higher risk for diabetes. Individuals who are unaware of their disease status are more prone to micro- and macrovascular complications. Hence, it is necessary to detect this large pool of undiagnosed participants with diabetes and offer them early therapy. The aim of this study was to use the Indian Diabetes Risk Score, developed by the Madras Diabetes Research Foundation (MDRF-IDRS), to assess the prevalence of people at high risk for developing diabetes, and the correlation with known risk factors. Methods: A cross-sectional study was conducted in the field practice area of the urban health training centre of a private medical college in Pune, Maharashtra. A total of 425 participants aged 20 years and above were screened for risk factors, including age, waist circumference, family history of diabetes and physical activity. Random testing of the blood glucose level of participants with a high risk score was carried out using a glucometer. Statistical analysis of the data was performed by using the chi-squared test and logistic regression analysis. Results: The prevalence of people at high risk of diabetes was 36.55%. Among high-risk participants on univariate analysis, primary education (P = 0.004), lower socioeconomic class (P = 0.002), less physical activity (P< 0.001) and high waist circumference (P < 0.001) were major contributing factors, while in the moderate-risk group, lower socioeconomic class and high waist circumference were the prominent risk factors for diabetes. Multivariate analysis showed that higher education, moderate to vigorous activity and high waist circumference were significantly associated with risk status. Out of 140 high-risk participants, 68 (49%) had a random capillary blood glucose level of 110 mg/dL or above. Conclusion: As the prevalence of people at high risk for diabetes was high, lifestyle changes and awareness regarding risk factors is needed to take control of the diabetes in the study population.
  3 3,069 330
Gaps and challenges to integrating diabetes care in Myanmar
Tint Swe Latt, Than Than Aye, Ko Ko, Ko Ko Zaw
January-June 2016, 5(1):48-52
DOI:10.4103/2224-3151.206553  PMID:28604398
In common with other low-income countries, diabetes is a growing challenge for Myanmar. Gaps and challenges exist in political commitment, policy development, the health system, treatment-seeking behaviour and the role of traditional medicine. National policies aimed at prevention – such as to promote healthy food, create a healthy environment conducive to increased physical activity, restrict marketing of unhealthy food, and initiate mass awareness-raising programmes – need to be strengthened. Moreover, existing initiatives for prevention of noncommunicable-disease (NCD) are channelled vertically rather than being horizontally integrated. Primary health care is traditionally orientated more towards prevention of infectious diseases and staff often lack training in prevention and control of NCDs. Capacity-building activities have been modest to date, and retaining trained health workers in diabetes-oriented activities is a challenge. The World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings has been piloted in Yangon Region and country-wide expansion awaits ministerial approval. Recently, the Myanmar Diabetes Care Model was proposed by the Myanmar Diabetes Association, with the aims of both bridging the gap in diabetes care between rural and urban areas and strengthening care at the secondary and tertiary levels. However, implementation will require policy development for essential drugs and equipment, capacity-strengthening of health-care workers, and an appropriate referral and health-information system.
  3 2,590 320
Metabolic syndrome among elderly care-home residents in southern India: A cross-sectional study
Nirmalya Sinha, Ananta Bhattacharya, Pradeep Ranjan Deshmukh, Tanmay Kanti Panja, Shamima Yasmin, Nimmathota Arlappa
January-June 2016, 5(1):62-69
DOI:10.4103/2224-3151.206556  PMID:28604400
Background: The health of the elderly population and the emergence of noncommunicable diseases have become major public health issues in recent years. Metabolic syndrome is thought to be the main driving force for the global epidemic of cardiovascular diseases, as well as for type 2 diabetes. This cross-sectional study aimed to determine the prevalence of metabolic syndrome and its correlates among the residents of care homes for the elderly in Hyderabad city, India. Methods: A total 114 elderly persons (aged ≥60 years) were evaluated in a cross-sectional study. Metabolic syndrome was defined by the 2005 criteria of the International Diabetes Federation. Data were collected on selected sociodemographic, behavioural and nutritional variables and cardiometabolic risk factors. Blood pressure and anthropometric measurements were also recorded. Fasting blood samples were collected for measurement of blood glucose and serum lipid levels. Univariable logistic regression was applied to investigate the associations between metabolic syndrome and known risk factors; adjusted analysis was then done by multivariable logistic regression for significant variables. Results: The overall prevalence of metabolic syndrome was 42.1% (48/114) among the study population. A higher prevalence (50.9%; 27/53) was found among women. High blood pressure or taking antihypertensive medication was found to be the most common (95.8%; 46/48) cardiometabolic component. The risk of metabolic syndrome did not differ significantly by age group, sex, caste, religion, type of diet (vegetarian or non-vegetarian), educational status, behavioural factors such as tobacco use and alcohol intake, physical activity (assessed by modified Eastern Cooperative Oncology Group [ECOG] scale), or physical exercise. However, a body mass index ≥23 kg/m2 was associated with metabolic syndrome (unadjusted odds ratio [OR]: 8.97; 95% confidence interval [CI]: 3.78–21.28); adjusted OR: 9.31; 95% CI: 4.12–22.14) Conclusion: The overall prevalence of metabolic syndrome in this study population of elderly care-home residents in India was more than 40%. Further research on the burden of metabolic syndrome in the elderly population is warranted.
  2 2,201 212
Prevalence of hypercholesterolaemia among adults aged over 30 years in a rural area of north Kerala, India: a cross-sectional study
Ottapura Prabhakaran Aslesh, Anandabhavan Kumaran Jayasree, Usha Karunakaran, Anidil Kizhakinakath Venugopalan, Binoo Divakaran, Thekkel Raghavannair Mayamol, Charappilli Bhaskaran Sunil, Kizhakkedathu Joseph Minimol, Kannankai Shalini, Ganesh Bhagyanath Mallar, Thazhathe Peedika Mubarack Sani
January-June 2016, 5(1):70-75
DOI:10.4103/2224-3151.206557  PMID:28604401
Background: Cardiovascular disease is a leading cause of death in India. In order to reduce the burden of the disease, it is important to know the level of modifiable risk factors in the population. The aim of this study was to estimate the prevalence of hypercholesterolaemia and associated factors among the population aged over 30 years in a rural area in north Kerala, India. Methods: A cross-sectional study was carried out to find the prevalence of hypercholesterolaemia among 533 residents of Kulappuram village. The fasting blood glucose level, total serum cholesterol level, blood pressure and body mass index of the residents were also assessed. The significance of association of hypercholesterolaemia with age, sex, body mass index and blood pressure was tested using the chi-squared test. Logistic regression was carried out to estimate the adjusted odds ratios (OR). Results: The prevalence of hypercholesterolaemia was 63.8%. It was more prevalent in women (adjusted OR: 1.56; 95% confidence interval [CI]: 1.07-2.27), in those with body mass index in the range 23.0-24.9 kg/m2 (adjusted OR: 1.78; 95% CI: 1.04-3.02) and in those with blood pressure >140/90 mmHg (adjusted OR: 1.62; 95% CI: 1.1-2.38). Conclusion: The prevalence of hypercholesterolaemia is high in the study population.
  2 1,904 133
Diabetes prevention and care in the universal health coverage context: The example of Thailand
Walaiporn Patcharanarumol, Warisa Panichkriangkrai, Sangay Wangmo, Jadej Thammatacharee, Masaaki Uechi, Yaowaluk Wanwong
January-June 2016, 5(1):27-33
DOI:10.4103/2224-3151.206549  PMID:28604394
Universal health coverage (UHC) is a key policy issue in countries of the World Health Organization (WHO) South-East Asia Region. However, despite projections of significant increases in burden, there is little protection against the financial risks associated with noncommunicable diseases (NCDs), including diabetes. Thailand achieved UHC of all 67 million of the population in 2002, under three public health insurance schemes. The country therefore provides a case-study on diabetes prevention and care in the context of UHC. Although the budget for the Thai Universal Coverage (UC) scheme, which covers nearly 80% of the population, increased significantly during 2003-2013, the proportion allocated to clinical prevention and health promotion declined from 15% to 11%. The financial case for investment in diabetes prevention is made, particularly with respect to a focus on primary care and the use of community volunteers. The UC scheme can expand to nearly 100% population coverage, with a comprehensive benefit package and financial risk protection. Although the rates of complications and fatalities in patients with diabetes have improved over the last few years, achievement of well-controlled fasting blood glucose for all patients is still the main challenge for further improvement. It is recommended that, in order to improve coverage of diabetes care and prevention, it is essential for countries in the WHO South-East Asia Region to include major NCD services, in particular primary prevention, in their UHC strategies. Since a resilient health system is key to UHC delivery, strengthening of the health workforce and infrastructure should be part of any action plan to prevent and control diabetes.
  2 2,274 320
Capacity-building of the allied health workforce to prevent and control diabetes: Lessons learnt from the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project
Chandrika Wijeyaratne, Carukshi Arambepola, Palitha Karunapema, Kayathri Periyasamy, Nilmini Hemachandra, Gominda Ponnamperuma, Hemantha Beneragama, Sunil de Alwis
January-June 2016, 5(1):34-39
DOI:10.4103/2224-3151.206550  PMID:28604395
In 2008, to tackle the exponential rise in the clinical burden of diabetes that was challenging the health systems in Sri Lanka, a shift in focus towards patient-centred care linked with community health promotion was initiated by the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project of the Sri Lanka Medical Association. Specific training of “diabetes educator nursing officers” (DENOs), field staff in maternal and child health, footwear technicians, and health promoters from the community, was instituted to improve knowledge, skills and attitudes in the area of control and prevention of diabetes. This article highlights some of the activities carried out to date with the allied health workforce and volunteer community. Specifically, it describes experiences with the DENO programme: the educational and administrative processes adopted, challenges faced and lessons learnt. It also highlights an approach to prevention and management of complications of chronic diabetic foot through training a cohort of prosthetics and orthotics technicians, in the absence of podiatrists, and an initiative to provide low-cost protective footwear. Harnessing the enthusiasm of volunteers – adults and schoolchildren – to address behavioural risk factors in a culturally appropriate fashion has also been a key part of the NIROGI Lanka strategy.
  2 2,061 201
Population-based dietary approaches for the prevention of noncommunicable diseases
Noel P Somasundaram, Nishan Sudheera Kalupahana
January-June 2016, 5(1):22-26
DOI:10.4103/2224-3151.206548  PMID:28604393
As the incidence of noncommunicable diseases such as diabetes continues to rise at an alarming rate in South-East Asia, it is imperative that urgent and population-wide strategies are adopted. The most important contributors to the rise in noncommunicable disease are a rise in mean caloric intake and a decrease in physical activity. The evidence for population-based dietary approaches to counter these factors is reviewed. Several structural and cohesive interdepartmental coordination efforts are required for effective implementation of prevention strategies. Since low- and middle-income countries may lack the frameworks for effective and integrated multi-stakeholder intervention, implementation of population-based dietary and physical-activity approaches may be delayed and may be too late for effective prevention in current at-risk cohorts. Evidence-based strategies to decrease energy intake and increase physical activity are now well established and their urgent adoption by Member States of the World Health Organization South-East Asia Region is essential. In the context of Sri Lanka, for example, it is recommended that the most effective and easy-to-implement interventions would be media campaigns, restrictions on advertisement of unhealthy foods, taxation of unhealthy foods, subsidies for production of healthy foods, and laws on nutrition labelling that introduce colour coding of packaged foods.
  1 2,125 202
Poonam Khetrapal
January-June 2016, 5(1):0-0
  - 1,064 62