Fatema Jawad  ( Consultant Diabetologist, Sindh Institute of Urology and Transplantation (SIUT), Karachi )

The rising incidence of Diabetes Mellitus (DM) all over the world is a matter of concern for the authorities, health professionals and most of all the affected person. With changing lifestyles in the low and middle income countries, supplemented with inadequate health education, insufficient health care facilities, poverty and lack of awareness, Diabetes can be considered a pandemic in these regions. These countries house 80 percent of the world\\\'s people with diabetes.¹ The estimated prevalence of DM in Pakistan as stated in the WHO Fact sheet is 9.8% which is contributed by 10% males and 9.7% females.² The International Diabetes Federation gives figures of 7million in 2015 and anticipates a rise to 14 million by 2040.1 The number of deaths due to diabetes and its complications are estimated to be 48,800 between the ages of 30 to 69 years and 47,700 in the age group70 years and above.
DM, a metabolic disorder, demands special care to keep a person active and useful for society and enjoy a good quality of life. As there are no symptoms in the early stages of Diabetes, the condition is not given the due importance and in fact is often neglected. This carelessness takes its toll in the form of micro and macro vascular complications, one of them being Diabetic Neuropathy (DN).
Going back in history, DN was mentioned by the famous Orient. Persian philosopher and physician Ibn Sina, known as Avicenna (980-1037 AD) in the West, who described diabetes in his famous "El-Kanun". He observed gangrene and the "collapse of sexual function" as complications of diabetes.³
The same manifestation of autonomic neuropathy was recorded in ancient Japanese text containing a detailed description of the "water-drinking illness" (mizu nomi yami) as suffered by nobleman Fujiwara No Michinaga from the Heian Era.^4,5
Diabetic neuropathy, is a most frequently encountered microvascular complication of DM. It has been estimated that DN is present in approximately 60 percent subjects with a long duration of Diabetes both Type 1 and Type 2.⁶
There are no country wide cross sectional studies on the prevalence figures of DN in Pakistan. Institutional studies as a recent one from Lahore on 113 newly diagnosed T2DM patients found a prevalence of 68.5% in subjects with poor glycaemic control (HbA1c > 6.5%) and 50 % in those with good glycaemic control (HbA1c < 6.5%).⁷
Another study on frequency of peripheral neuropathy in newly diagnosed patients of diabetes mellitus on clinical and electrophysiological basis, conducted in the Department of Neurology, Civil Hospital, Karachi by Lakhiar et.al showed that 32.7 percent of these patients had symptoms of neuropathy.⁸
Besides Peripheral Neuropathy, Diabetic autonomic neuropathy is also commonly encountered. A study from Hyderabad on T2DM patients with a disease duration of more than 10 years reported Cardiac Autonomic Neuropathy in 30 percent of the studied cohort.⁹
Another questionnaire based cross sectional study on the knowledge and attitude of diabetic patients, conducted in the twin cities of Pakistan in 2015 revealed that there was poor knowledge on etiology, symptoms, and normal glycaemic levels and it was the prime cause for the development of complications.¹⁰
Complications of the feet in people with diabetes are higher in developing countries and are seen as ulceration secondary to neuropathy. This may lead to amputation if not checked in time. The risk of amputation is 10 to 30 times higher in this group of patients.¹¹
With insufficient rural health centres and lack of basic technologies in primary care facilities and no central registry, treating diabetes optimally is a big challenge. For diagnosing and treating DN, there are no laid down guidelines and health care providers are not trained adequately to make an early diagnosis of the complication. There is dearth of trained podiatrists and foot care personnel and a low education level especially health education makes people vulnerable to diabetes and its complications.¹² Use of suboptimal footwear, frequent barefoot walking, and tobacco use also predispose to neuropathic complications in Pakistan.
This issue of the Journal includes a comprehensive review article on Diabetic Neuropathy in South East Asia by Rayaz Malik et al which reveals the high figures of this complication and its consequences. Pakistan is not lagging behind, and the prevalence statistics compare equally to that of the SEA region. Intensive efforts have to be made to prevent DN in people with diabetes through education and guidance. Improvement in health care including diagnostic facilities and rehabilitation centres is of prime importance.
The opinion leaders and healthcare providers need to formulate guidelines for diagnosing, treating and most of all preventing diabetic neuropathy to keep the nation on its feet.

References

1.  IDF Diabetes Atlas Seventh Edition 2015 by International Diabetes ... (Online) (Cirted on 13 October, 2017). Available from URL: https://issuu.com/int._diabetes_federation/docs/idf_atlas_2015_uk.
2.  WHO Factsheet 2016. Updated in July, 2017. (Cited 14 October, 2017) Available from URL:  http://www.who.int/mediacentre/factsheets/fs312/en/.
3.  Grossman A (Ed.). Clinical endocrinology, in Notes on the history of endocrinology, Blackwell Sciences Publications, Oxford, 1992, pp. 1040-
4.  Kiple KF (Ed.). The Cambridge World History of Human Disease. Cambridge University Press, Cambridge, 1995, pp. 353-4.
5.  Hurst GC. Michinaga\\\'s Madalies. Monumenta Nipponica1979; 34: 101-12.
6.  Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology.1993; 43: 817-24.
7.  Ali A, Iqbal F, Taj A, Iqbal Z, Amin MJ, Iqbal QZ. Prevalence of microvascular complications in newly diagnosed patients with type 2 diabetes. Pak J Med Sci 2013; 29: 899-902.
8. Lakhiar M A, Shahbaz N, Bughio A H, PrakashJ.  Frequency of peripheral neuropathy in newly diagnosed patients of diabetes mellitus on clinical and electrophysiological basis.Pak J Neurol Sci (PJNS): 2014; 9 : 31-5.
9.  Khoharo HK, Qureshi F. Frequency of cardiac autonomic neuropathy in patients with type 2 diabetes mellitus reporting at a teaching hospital of Sindh. J Coll Physicians Surg Pak 2008; 18: 751-4.
10. Kanwal S, Malik TA, Noman M, Rehman A, Riaz M, et al. "A Cross-sectional Study Assessing Knowledge Attitude and Practice of Diabetic Patients at Tertiary Care Hospitals of Twin of Pakistan". J App Pharm 2015; 8: 210. doi:10.4172/1920-4159.1000210.
11. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA-J Am Med Assoc 2005; 293: 217-28.
12. World Health Organization — Diabetes Country Profile, 2016.