Diabetes in Pakistan: A nation's struggle

0:00Lubna Kerr:This BBC podcast is supported by ads outside the UK.

0:06At QVC, fall shopping is more than just checking out. It's discovering the brands you love across beauty, fashion, home and culinary, all in one place. Whether you're getting ready for crisp mornings, cozy nights or everyday moments, QVC has what you need for the season ahead. with brands like Laura Geller, Philosophy, Ninja, and so many more. Shop now at QVC.com. Episodes of World of Secrets are released weekly wherever you get your BBC podcasts. But if you can't wait, you can listen to episodes a week early by subscribing on BBC.com.

0:52Lubna Kerr:Everyone in Pakistan knows someone who's affected by type 2 diabetes. My elder brother has been into diabetes from about two to three years. My husband had diabetes. My father was diabetic. My father's elder brother was diabetic. And because my father was diabetic, so I am at risk. After six months, I must go to a physician, which I don't do. Whenever I take lecture, I always make a question. Then please raise your hand if somebody has no diabetic in their family or their home. And unfortunately, in these days, I don't see one hand. Diabetes is now at epidemic proportions across this huge country.

1:34Lubna Kerr:What can be done to stem or reverse the tide? This is the documentary Diabetes in Pakistan, A Nation's Struggle, from the BBC World Service.

1:52Lubna Kerr:Hi, I'm Lupna Kerr. I'm a British Pakistani pharmacist and also an actor, writer and comedian. My mum and brother both had type 2 diabetes and as a pharmacist I've worked in the sector for nearly 20 years, seeing it firsthand the impact the disease can have on individuals and families.

2:17Lubna Kerr:In Pakistan, numbers collected by the International Diabetes Federation are staggering. Diabetes isn't just a medical condition, it's a national crisis. Saleh Azeem is a researcher specialising in diabetes and public health at the King Edward Medical University in Lahore. Approximately 11.1 % of the global population aged 20 to 79 is living with diabetes. In Pakistan, this figure is significantly higher, approximately 31.4%, giving the country the highest 8 standardized diabetes prevalence in the world. 34.5 million people are living with diabetes, and that is expected to rise to 70.2 million by the year 2050.

3:02And then unfortunately, Pakistan also ranks fifth globally in the number of undiagnosed diabetes cases with 27 % of people unaware that they have the condition. And it is also safe to assume that an even greater proportion of the population is pre-diabetic.

3:20Lubna Kerr:Deaths related to the disease in the country have also risen from 65 ,000 in 2011 to more than 220 ,000 in 2024. Diabetes is caused by the body either not producing enough insulin or not using it effectively, leading to high blood sugar levels. Type 1 diabetes is an autoimmune condition, while type 2 diabetes is often linked to genetics, poor diet, lack of exercise and insulin resistance.

3:54Lubna Kerr:If diabetes is identified early, it can be delayed and research has shown it can be reversed if caught within 5 to 10 years of diagnosis. But many people here who are diabetic don't realise they have the disease until they've sought medical support for another condition. Either you have stroke or your eyesight is weakening. So Bera Faisal Abasi is a public health campaigner who advises the government around areas of obesity and diabetes. You have some problem with your cardiac system or there's some wound which is becoming incurable. So you go to a doctor and then by chance you are diagnosed as a diabetic.

4:36Most common is foot complications, diabetic foot ulcers, diabetic foot infractions which can lead to amputation. We have a large number of patients who have diabetes and they develop renal failure. And when they develop kidney failure, they have to be put on dialysis or the other alternative is, of course, transplantation. When I joined this Transplantation Institute, the first cause of renal failure was infection and number two was diabetes. Now for the last maybe 25 years, it is diabetes which is the first leading cause of renal failure. Dr.

5:20Lubna Kerr:Fatima Javad has been a clinician for more than 50 years. Based in Karachi, she's witnessed a lot of change in that time. Oh, at that time, we did not have this variety of drugs for treatment. We did not have so many varieties of insulin. and now we have the facilities of having the pen injector. We even didn't have the insulin syringes. They were the normal syringes which we had to calculate and tell the patients how to calculate the dose in that. Then for the monitoring, there were no glucometers. Population of maybe about 10 % or 12 % of the population which had type 2 diabetes. And now, of course, we are number one in the world.

6:04It's important to look into factors and shed light on factors that prevent people from getting that early diagnosis.

6:11Lubna Kerr:Salia Azeem co-authored the report, The Increasing Rate of Diabetes in Pakistan, A Silent Killer. Firstly, there's a lack of awareness. There's low health literacy. That is a very important factor contributing to low diagnosis rates. Many people remain unaware of the life-threatening, long-term complication of diabetes. It is also a disease that does not develop overnight. It takes years to progress to a significant level and early mild symptoms like I'm more thirsty than usual or I have to go to the bathroom more than usual or there's pain in my distal extremities, etc. or numbness. These things are ignored.

6:47There's limited access to screening and diagnostic services, particularly in rural areas. Public hospitals are stretched and a very huge population of Pakistan lives below the poverty line. Getting tested is also heavy on the pocket. Many individuals do not want to miss work or they do not want to put an effort into getting tests for something that they don't currently perceive as a problem.

7:11Lubna Kerr:Shahid Ali Khan is one of the young people volunteering with Pakistan Youth Change Advocates. My elder brother being younger than 40 years, a university professor, he was having diabetes. He was only teaching and not exercising and not a professional cricketer, but I do exercise and I put myself into it because I can feel that it's coming. But I can't say that the whole society, that the people who are not that much educated and they have low literacy, so they don't know about it. We have done some studies, some trials through teaching through the pharmacists and all, and they have shown good results.

7:53But it's not possible for the entire population. It's a big population. Even the number of doctors are not enough. The number of pharmacists are not enough. They hear from maybe a neighbor or an elderly relative that, okay, eat this vegetable and you'll feel good, or have this and you'll feel good and your sugar will go away. You can see so many of these videos on the YouTube telling people that stop your insulin, take this, this, this and people believe that.

8:28Lubna Kerr:In Peshawar, the air is thick with the scent of charcoal-grilled kebabs and slow-cooked bulao as vendors serve up jarsi dikka, chapli kebabs and kabili bulao in bustling streets.

8:47Lubna Kerr:Across Pakistan, from Karachi's Burns Road to Lahore's Gabal Mandi, street food remains a cornerstone of daily life. But Pakistan's diabetes surge is fuelled by urbanisation, influx of American-style fast food outlets, processed foods high in refined sugars, and increasingly sedentary lifestyles. In Pakistan, you will find the fast food culture in each and every city. You will find the fast food culture now in villages. Nadeem Naeem is a doctor treating people with diabetes in Karachi. We are so much keen in using ghee. Now what's ghee? Basically it's butter which has gone to the boiling point.

9:25And we are against even in Pakistan we were using mustard oil. I don't know from where it came but the mustard oil is being used for the cooking purpose which is banned in many, many countries. A couple of years ago fast food wasn't that prevalent. People were not going to KFC or McDonald's every day. But now, because of also the nature of work and lifestyles getting much faster, people are more likely to get takeout. If you go to McDonald's and you ask for a burger that will cost you about 1500 rupees, everybody can't afford it. But then the same thing or maybe worse ingredients, you can get it on the footpath for just 50 rupees.

10:04Another very important aspect which leads to diabetes is the wrong eating times. Somehow in the big cities that people are eating their dinner very late and they're sleeping late, these fast food suppliers say that if you call after midnight, you'll get a big rebate.

10:28Lubna Kerr:Many traditional dishes are high in refined carbohydrates and trans fats, contributing to insulin resistance. These are different types of oils that are mixed together and put through a process of hydrogenation. Ariba Shahid is an executive director of Pakistan Youth Exchange Advocates. The PYCA works with young people in the field of public health and food safety. What happens is this increases the shelf life of the product. This artificially enhances the taste of the product. and is slightly, and not even significantly, slightly cheaper to produce than oils that would be considered healthier.

11:11Lubna Kerr:Industrially produced trans fats were recently restricted to less than 2 % of total fat across all food categories. I wrote a policy brief around it. Health ministry supported that campaign and industry also agreed. So it is a success story. We have gone up on WHO scale. Now we are part of the League of 63 countries who have this best practice policy. While this is a major policy step, critics argue that enforcement remains weak. If you check food from all over Pakistan and we have porous borders with Iran, Iran does not have this kind of legislation. And some other countries can also sell food in Pakistan.

11:56and it does not come through the regular channels, but it is smuggled. So we have a risk factor in international trade that food containing high quantities of intensely produced transphalic acid can filter into Pakistan. And we are taking up this matter with our border agencies too. Now we have actually stepped up our campaign and now we are saying that partial hydrogenation of oil should be banned. Absolutely, there should be no partial hydrogenation. in the country.

12:32Lubna Kerr:Though there aren't any official figures for children with type 2 diabetes, people working in the field who we have spoken to all report incidents of the disease among younger and younger people. Eram Ghafours from Karachi, she is president of the National Association of Diabetes Educators in Pakistan. Children with type 2 diabetes are very common. My own patient She is 11 years old and she is type 2. The level of processed food consumption in the younger generation, in children right now, is absolutely off the charts. Amar Rashid is a research lead at Heartfile, a leading health policy think tank in Islamabad.

13:14And it's unlike anything we've ever seen before in Pakistan. The Obesity Federation estimates that childhood obesity in Pakistan is rising at like 9 % a year. and in the next three years, it's estimated that 6 million Pakistani children will be suffering from generalized obesity and if this is not addressed at these earliest stages, then this will be a crisis beyond what we can imagine over the next decade. I had a client and he was eight years old and his body weight was 40 kg because their parents are very busy, They have good jobs, so they actually don't cook any food at home. And that child was like eating zinga four times a day.

14:05And there was no physical activity since the parents are so busy. so he was like at home and he used to even play the cricket on the tab. So he doesn't know that he can play that cricket outside the home in the ground. Now we have started taking some baby steps. Like in Punjab, we have some basic regulations by the Punjab Food Authority that schools should not have visogenic and diabetogenic foods. They have declared some foods as green and red. So greens are available. Sweet and sugary sweetened beverages are not allowed. But it is only in Punjab.

14:52Lubna Kerr:I'm Lupna Kerr, and you're listening to the documentary Diabetes in Pakistan, A Nation's Struggle, from the BBC World Service.

15:05At QVC, shopping is more than just checking out. It's discovering something new every day. Start with today's special value. Then explore exciting finds across the brands and categories you love. From beauty and fashion to home, culinary and outdoor living. Shop now at QVC.com.

15:34Episodes of World of Secrets are released weekly wherever you get your BBC podcasts. But if you can't wait, you can listen to episodes a week early by subscribing on bbc.com.

15:48Lubna Kerr:The province of Punjab is cited as one area where proactivity around diabetes is strong. The minister there recently launched an initiative to get more insulin to children in the region. Type 1 diabetes and autoimmune condition is rising in Pakistan. many children remain undiagnosed, leading to severe health risks and death. Sana Ajmal, a leading diabetes advocate based near Rol Bundy, has played a key role in shaping Pakistan's Punjab insulin programme. She also lives with type 1 diabetes herself. Insulin alone is not enough. Test trips need to be given, which the Punjab government is giving now.

16:31And with that, there needs to be very good self-management education. Because you hardly get to spend, I mean, in Pakistan, it's probably less than an hour in a full year with your healthcare professional. And that's not enough. So you really need good diabetes self-management education services where people are taught how to manage their diabetes properly, how to manage insulin with food, insulin with exercise. And it is the most populated province in the country. Another province has got a few banks that they also give out insulin from, but the capacity of all these initiatives is way below the overall needs of the country.

17:11I really, really hope that the programme not only continues with regularity, but also scales to a national level.

17:23Lubna Kerr:There's also a genetic predisposition to developing diabetes in this country. Dr. Nadeem Naeem again.

17:58population, some actually genes are involved in another population. So they say that more than 1000 genes are involved but we surely know up to 80 genes. I would say if you ask me that type 2 diabetes is a genetic disease, the answer is yes. 80 % of the times. Type 2 diabetes is a genetic disease which occurs to each and everyone which has got that gene, the answer is no. It depends on you. Either you activate that gene or you do not activate that gene. So if you ask me that is type 2 diabetes purely genetic the answer is no if you ask me is type 2 diabetes majorly genetic the answer would be yes if you ask for me that if a person has got strong genetic predisposition then that patient changes his or her lifestyle that patient is going to develop type 2 diabetes the answer is no even with a strong predisposition if you are not activating those genes but most of the type 2 diabetes genes are there.

18:53Genes are going to be activated by your lifestyle and if you don't change your lifestyle, you have a wonderful lifestyle, you are not going to activate those genes. In Pakistan, there are very high levels of cousin marriages that has been seen to be associated with genetic passing on of high levels of insulin resistance, which can increase the likelihood of diabetes related genetic traits. It runs in families and so whatever you have inherited doubles up for the coming child. It's so unfortunate we have not been able to get rid of thalassemia also. If you see in other countries, thalassemia has finished because before a girl and a boy decide to get married, they have to get themselves tested and if they are positive, they can't marry.

19:41There is no such law or rule in our country. So children are born with thalassemia and the father and mother both have diabetes and then they produce eight children. And all these eight children, as they grow up and become adults, develop diabetes. But specifically, we're trying to push for a conversation on how this is contributing to our diabetes and NCD. There's proposals floating of trying to legally limit cousin marriages in Pakistan, though obviously there's going to be a lot of resistance to that because of various cultural factors.

20:13Lubna Kerr:Malnutrition in mothers and in babies in early life can also lead to the development of diabetes. These first thousand days actually create a condition of rebound adiposity. Once you have a platform where slight increase in the intake of sugar and fats can bump it up. So I think this is a very particular situation of South and East Asian economies. We rebound adiposity and then the complications related to diabetes and cardiovascular events and other things. It is really taking its toll.

20:52Lubna Kerr:Costs for diabetes treatment vary. Even the minimum monthly support can be expensive. One of the families I support in my personal capacity is a poor family and the lady also has diabetes. Zubair Faisal Abasi again. So sometimes when she requires money, she calls me up that she needs money for tests or medicine. Sometimes it is 3 ,000 rupees per month, 2 ,000 for the medicine and 1 ,000 for the doctor. And sometimes it shoots up to 5 ,000 to 6 ,000 rupees. And at this point in time, she does not have many complications. But if she gets some complications, then it will not be possible for her to manage it.

21:33A month's worth of test reps costs around$9 to$10. and almost 30 % of our population lives under$2 a day. So you can imagine the burden on the pocket.

21:44Lubna Kerr:For anyone with complications, the monthly costs can be astronomical. I would say that it is around$200 per person, almost 12 ,000 to 15 ,000 in Pakistani rupees, which includes the medication and investigation. And if the person is on insulin or they are having any other condition which need medication, sometimes they don't even take full medications intentionally. I'm telling you a very bitter truth that either they will buy the medication or they will buy food for their children. So how is healthcare structured and funded in Pakistan? We have two sets of systems. One is the private system, which is entirely managed by the private companies, private institutions.