 And good evening, everyone. I am Dr. Durin Ishaad and I am Secretary Spice Truth Pakistan. On behalf of Spice Truth Wonka Young Doctors Movement South Asia, I welcome you all in today's webinar just organized to celebrate World Diabetes Day. Diabetes mellitus is one of the most commonly encountered disease in the family practice. And according to the recent data, around 20 to 30% of the patients visiting family practice have diabetes or one of its complications. So it's very important to discuss this disease and to see what role we can play as family practitioners. So moving on towards today's session, I would like to invite Dr. Sankar Ranthini Kumara, who is the regional chair of the Spice Truth for the introductory remarks. Dr. Sankar is a family practitioner from Sri Lanka. He's active member of College of General Practitioner of Sri Lanka and also council member of Sri Lanka Medical Association. After his leadership, Spice Truth has taken multiple initiatives, and one of them is to organize these webinars, in which we get a chance to discuss and share and impact to learn and share from each other's knowledge and experiences. So over to Dr. Sankar. Thank you, Noor, for that superfluous introduction. Anyway, good evening everybody. And I would like to wish happy Diwali to all our Hindu colleagues and also many of our colleagues were worrying about participating in this webinar because of this Diwali festival and they have to participate in that. But I am happy to say that this webinar is being recorded and that will be on our Spice Truth Facebook page and also on Wonka Facebook page. So anybody who's willing to watch this again, they are welcome to watch it later on. So, so again, good evening everybody and thank you for joining. I would like to welcome you all, especially, Professor Shamali Samaranayake, Dr. Anam Beg from Pakistan and my friend and brother Kyla from India, who are the resource persons for persons for the webinar today. Today's webinar is about diabetes. I mean, today is the World Diabetes Day and the diabetes is one of the most or say, I would say that is the worst disease. Whoever, any person would experience because if you take a cancer, most of the time, if you detect the cancer early, you can cure it or you can either limit whatever the consequences to a very low level. When you take AIDS, you have treatment now, but when you take diabetes, it's not like that. It would be there with you every day till you die. So today on the World Diabetes Day, we are going to rethink and reiterate about the importance of one, preventing diabetes and also early detecting diabetes and how we are going to do the secondary prevention and so on as the family fictions or the doctors who are closest to the hearts of the community or the patients. So with that, I think while welcoming you all again, I would like to hand over this again to Noor. Is that Durey who's going to moderate the session, Durey, and go ahead with the rest of the things. Thank you very much. Okay. Thank you, Sankha, for the remarks and yes, it's Durey. So moving on towards our first talk, which is on the topic which is important to realise the global and regional burden of the diabetes as we all know that it's also labelled as to be an epidemic. And for this, I would like to introduce our speaker, Dr. Kelas from India. So we are very thankful to Dr. Kelas for taking our time and also happy Diwali and taking our time on Festival Day. I would like to introduce Dr. Kelas. He's a medical officer in Kerala Government Health Services and is presently working in COVID control team of Palakkar District. The Arbitology, Palliative Care and Geo-diatrics are his areas of special interest and he also holds possession of FMP60 coordinator in Spice Street, India. So over to Dr. Kelas. Thank you, Durey, for the nice welcome. So I'll start, I'll just share my screen and we'll start the presentation. Is it visible? Yes. Yes, it's visible. Okay. Good evening to you all. Greetings from India and happy Diwali to you all. And on this World Diabetes Day, it was indeed a pleasure for me to be given a chance to talk on this topic, global and regional burden of diabetes. So straight away I'm going to the topic, what is diabetes militants? It is a serious long-term chronic condition that occurs when there is high levels of glucose in person's blood because their body cannot produce any or enough of the hormone insulin or cannot affect the use when it is produced. Cannot effectively use the insulin, it produces. Now, why diabetes is so important? What are the problems? Insulin deficit, if left unchecked over the long term, can cause damage to many of the body's organs leading to disabling and life-threatening complications such as cardiovascular disease, nerve damage, kidney damage and eye disease. However, if appropriate management of diabetes is achieved, these serious complications can be delayed or prevented altogether. Yes, this area where we fellow family physicians or primary care physicians have a crucial role. Now, what's happening across the world? In 2000, you can see from the figures, I have taken all my data from IDF Atlas of 2019. And in 2000, the global estimate of diabetes prevalence in age group of 20 to 79 years age group, you can see that the prevalence was around 151 million people in 2000. But estimates have since shown an alarming increase, tripping to around 463 million people affected by diabetes in 2019. This represents 9.3 percentage of the world population in this age group. And future projections also shows that the continuity of this alarming increase reaching around 578 million by 2030 and around 700 million people by 2045. And this is a world map showing the estimated total number of adults with diabetes in 2019. You can see the countries in dark red that is India, China, United States, Pakistan, Bangladesh, Brazil are the highest affected regions in all of the world. Most were the highest number of people with diabetes are living. And diabetes estimates shows a typically increasing prevalence of diabetes by ages. Similar trends are predicted for the years 2030 and 2045. Now, estimated prevalence is slightly lower in women that is compared to men that is around 9 percentage is the prevalence in women and with 9.6% prevalence in men. Expected prevalence is likely to increase both in men and women by 2030 and 2045. And in 2019, more people with diabetes are living in urban areas that is around 10.8 percentage that is 310 million people are living in urban areas than in the rural areas which is only around 152.6 million people. And prevalence of diabetes is expected to increase in urban areas in 2030 and 2045. Now, in this slide, you can see the number of adults living as number of adults living with diabetes as per World Bank income classification. You can see that here the high income countries and middle income countries have higher prevalence of diabetes compared to the low income countries. And the projection also shows that by 2045, the gap between the high income and middle income countries is narrowed and maybe due to the rapid urbanization of the world population. And these are the 10 countries or territories for number of adults living with diabetes. You can see, as I already told, China, India, United States and Pakistan are the first four places. And the future projection shows that Pakistan, if the current trend goes on, Pakistan may overtake the United States and take the third position by 2045. And coming to the number of people older than 65 years with diabetes. You can see that almost all the countries are equally affected, all the countries are equally distributed, the number of people with more than 65 years with diabetes. And a prevalence of this slide shows that in older than 65 years, the prevalence of diabetes is around 20% and it will remain so in 2030 and 2045. Now, coming to the undiagnosed diabetes. In 2019, one in two, that is around 50.1% or 201.9 million or 463 million others living with diabetes are unaware that they have this condition. These estimates point to an urgent need for prompt detection of improved global screening of diabetes. Here is a world map showing the number of adults with undiagnosed diabetes in 2009, which shows the same trend as we said earlier. India, China, United States, Pakistan and Brazil are the top five countries. And this is the same thing. And coming to the global burden of type one diabetes. That is around one million people. There are one million existing people, children or adolescents living in the world with type one diabetes. And every year around 120,900 people, new type one cases are being detected all around the world. And in the top 10 countries, again shows India, United States and Brazil are the first three countries with number of new cases. And also the number of estimated existing cases in type one diabetes. Now, compared to coming to the impaired glucose, impaired glucose tolerance. Why impaired glucose tolerance is very, very important because they pose a significant risk of developing diabetes militants. And this is an important target for primary prevention. In 2019, approximately 7.5% of the world population is having impaired glucose tolerance. And which may rise as a future projection shows it may rise to 8% in 2030 and to 8.6% in 2045. And this slide also shows that 50% of those with impaired glucose tolerance are below the age of 50 years. So it is important to note that nearly one third of all those who are currently impaired glucose tolerance are in 20 to 39 years of age group and therefore likely to spend many years at risk of type 2 diabetes and adverse cardiovascular disease outcomes. And coming to hyperglycemia in pregnancy. That is out of the total 129.5 million labors happening in any year, the approximately 15.8% that is around 20.4 million of the labors are affected by some kind of hyperglycemia in pregnancy. Out of which 83.6% are due to gestational diabetes militants. That is 8.5% are due to other types of diabetes first detected in pregnancy and 7.9% of cases are due to diabetes detected prior to pregnancy. And coming to deaths related to diabetes, approximately 4.2 million adults age 20 to 79 years are estimated to die as a result of diabetes and its complication in 2019. And this is equivalent to one duck every eight seconds. That's an alarming point. One duck every eight seconds. And coming to the economic impact of diabetes. Yes, economic impact can be discussed under two headings. One other that one is the direct cost of diabetes militants and the others are the indirect cost of diabetes. And in 2019 it was estimated that around 760 billion US dollars are spent, spent for diabetes, and which which will increase to around 825 billion US dollars in 2030 and to 845 billion US dollars in 2045. And regarding the indirect cost of diabetes and some study conducted by Mr Bomer et al's overall estimate of indirect cost of diabetes is that this constitute 34.7% of the total global estimate of cost of diabetes of US dollars of around 1.313. And the four sources of indirect cost considered by Bomer et al have a forced dropout mortality, absenteeism and prosenticism. And at a glance what we are at a glance what we have so far in a population of 7.7 billion world population in an adult adult population of 5 billion global prevalence of diabetes is 9.3 percentage, and that is around 463 million people are living with and around 4.2 million deaths are happening and total expenditure of around 760 billion US dollars are happening for diabetes with 15.8 percentage of live birds affected with some kind of hyperglycemia and a global prevalence of 7.5 percentage of embed group was tolerance is percentage and around 1 million people are affected with type one diabetes all around the world and the projections are also being given in the slide for 2030 and 2% 45. Now coming to the regional regional burden that is in South Asia. What we can see is with around 90 997.4 million adult population, the regional prevalence is only 8.8 percentage that is number of people living with diabetes is around 87.6 million. The regional health expenditure in the US dollars is only 8.1 billion. This is one of the lowest among the all the regions, all the regions for diabetes of the legend health expedition, and the regional prevalence of embed glucose tolerance is 3.1 percentage. And the next thing the undiagnosed diabetes, the regional prevalence is 56.7 percentage that is a very big huge number that is 56.7 percentage people are undiagnosed living with undiagnosed diabetes and they are more prone to have publications and more impact on the economy also it will be. And around 184,000 people are living with type one diabetes and with around 21,300 new cases detected every year. And in Southeast Asian region 8.4 percentage of the total health expenditure was allocated to diabetes. The highest percentage was in Mauritius that is around 16.9 percentage and the lowest was in Nepal 4.2 percentage. The highest estimate in 2019 for mean annual expenditure per person with diabetes in this region was US dollars 1794 in Maldives, while the lowest was US dollars 64 in Bangladesh. In India, which accounts for 87.9 percentage of adults living with diabetes in the region US dollars 92 was spent per person. And these are some of the data regarding the Southeast Asian countries like Bangladesh, Bhutan, India, Maldives, Mauritius, Nepal and Sri Lanka. And IDF calculates classified Pakistan in the Mediterranean region. So the data is separate from the other group, not in the Southeast Asia. So I have taken and put the same data also here, which I am not going to discuss in detail. Now, before concluding, what are the key points that we have seen in this topic? Around the world in 2019 only 463 million people were affected with diabetes, which may rise up to 700 million in 2000 that is a 51 percentage increase is expected in the next 25 days. And in Southeast Asia, from 88 million it may reach up to 153 million that is around a 74 percentage increase is expected to happen. And what all we have learned the estimated number of an estimated 463 million adults is 20 to 79 years are currently living with diabetes, which represents 9.3 percentage of the world population in this age group. And it may predict to raise to 578 million and 700 million by 2% 45. And the estimated number of others is 20 to 79 years with embedded glucose tolerance is 374 million that is 7.5% of the world population in this age group and estimated 1.1 million children and adolescents have type one diabetes. And the number of deaths resulting from diabetes and its complication in 2019 is estimated to be 4.2 million. And estimated 15.8% of live birds are affected by hyperglycein and pregnancy in 2019. And annual global health expenditure on diabetes is around 760 years, billion US dollars and it is projected that expenditure will reach around 825 billion US dollars by 2030 and 845 billion US dollars by 2045. Keeping this in mind, let's move on to the other presentations and see what what's happening across the what what we can do and what we can think ahead for diabetes in primary care or family practice. Thank you. Thank you, Dr. Kailas. And I thank you very rightly summarized that the numbers are alarming and Pakistan and India will expect it to be in the top five countries of the world to have this disease and definitely complications and an economic burden. So, the next topic is very relevant and important that what is the role of the primary care in prevention and screening of diabetes. So there's around 56.7% people you mentioned they're living with undiagnosed diabetes. So there comes the role of screening. And I would like to introduce our next speaker. We're honored to have Professor Shyamili Samarnaika. She's head of family medicine department and faculty of medical sciences at University of Sri Jevardhanipura. She's also chairperson of board of studies in family medicine postgraduate institute of medicine. She is an exam convener for MRC GP South Asia International exam. Research has been her areas of interest and she has 14 publications and fair review journals and 33 abstract publications. She has been awarded three presidential awards and one national research council award for publication and also fellowship of College of General Practitioner of Sri Lanka. So over to ma'am. Thank you Spice Road for inviting me to do this presentation. Good evening to all of you and happy Diwali to the friends celebrating from India and other parts for joining with us. I can't share my screen. Can you enable me to send up a door? Yeah, yes ma'am. Okay. Yeah, now I can. Yeah. Can you do it now? So, following on to Kailash, I'm going to talk about role of the primary care in prevention and strain of diabetes. So this is the overview of my presentation. And the need of course after the speech of Kailash, I think I don't have to really say much about the need. It's very obvious the increasing prevalence globally as well as in the South Asian region and the complication profile. So, you know, the diabetes can cause complications from head to toe and serious complications like amputations, blindness, cardiovascular events, cerebral accidents. So, with that, the amount of the expenditure gain Kailash touch upon the cost of treating diabetes and the complications is so huge and the effects of detection prevention and delaying diabetes will definitely delay the onset of complications and thereby the health burden to the individuals, to the families and to the country economics and even to the region will be reduced if we can do this with the duration of delaying the onset, especially with the aging population or the longer life expectancy if people develop diabetes early, then they will develop complications also early and they will live for a longer time with complications, which will in return increase the burden to everybody. So, we can actually start preventing diabetes from a very early stage so primary prevention has a role in here where the preventive measures that will prevent or delay the onset of illness before the disease process begins is the primary so how can we actually do this in relation to diabetes. There are evidence to support even the intrauterine growth retardation will increase the risk of diabetes in their later life. We can start very early by preventing IUGR in new bones I'll come to the details as to how we will be doing SGPs a little bit later, and also maintaining a healthy body weight from the childhood up until the adulthood As an Asian people we know all of us will adore chubby babies so mothers want the babies to be chubby so as family physicians again we have a very big role to play in changing these like beliefs and the images they have about being healthy and also we know the extremes of body weights like very low and very high both are bad when it comes to the diabetes so it's a paramount that we promote healthy body weight from a very younger age and to do that we need to promote healthy lifestyle for everyone. Again diet and the exercise goes a long way when it comes to diabetes prevention I'll discuss this again in detail. So actually secondary prevention is screening and managing to prevent complications but here we talk a lot about screening the importance of screening is very very high when it comes to diabetes. As you've heard according to highlights we have 56.7% of undiagnosed diabetes in South Asian region. So only with effective screening program we will be able to detect these people in order to get them to our treatment regimes and control their in order to prevent complications so screening is the process of identifying those individuals who are at risk of a specific disorder. In general there are certain principles when we talk of screening I'm just putting for the sake of completeness so the condition should be an important health problem. There should be a recognizable latent or early asymptomatic period where we could diagnose the disease early. There should be facilities to diagnose and there should be an acceptable treatment for patient with diagnosis and acceptable test which is cost effect on population cases and there should be agreed upon policy of management plans for the patients and cost of finding the cases and the benefit of treating early should be beneficial and health expenditure point of view. So when it comes to diabetes it almost I mean it fulfills all these criteria. No doubt about the rising prevalence of diabetes worldwide. And the available test screening are very low cost and affordable for most of the people and populations and to the countries. These tests are very much have a very high sensitivity and specificity so we can reliably use them for the purpose of diagnosis and we have effective interventions and treatment plans developing day by day to combat diabetes. We have early defined diagnostic points and treatment plans we have and there is substantial evidence of the benefit with early diagnosis. So, again going back to what the previous presentation we know very large proportion of people with diabetes are asymptomatic or under diagnosed. The very well known fact is a substantial proportion of newly diagnosed patient already have evidence of microvascular complications of diabetes. So again this is very very important thing. If we diagnose early we can actually catch them before they develop these complications, which will in turn improve their outcome. And it comes to long term diabetes. There are serious long term complications of diabetes which we will be hearing in our next presentation. There is definite evidence of efficacy of intensive blood glucose control in preventing or delaying the complications of diabetes. So, how can we test? What are the tests available? There's an array of tests available from very low sensitive to very sensitive. If you take urine glucose test very crude test that maybe it's very cost effective in specially population screening wise and wherever we find people with low urine glucose positive then we can send them for definitive testing. So, maybe a gross screening procedure we can use it still. Again capillary blood glucose is not very accurate but very important specially now I'm sure all of us are involved in this health camps and things where we go for community screening. So, when we do not have facilities to do the plasma glucose capillary blood glucose again is a very good alternative to arrive not really for diagnostic purposes but as a screening tool where again we can get them to do the confirmatory test to diagnose. Venus plasma glucose and glycated hemoglobin are the things that we use actually for the diagnostic purpose. Again, we need to be mindful about the place of glycated hemoglobin in patients with low hemoglobin and hemoglobinopathy. So, this is just again for the sake of completeness I'm putting I know all of you are aware about the cutoffs of the plasma glucose fasting and the NHB1C for diabetes. Important thing again to diagnose with one plasma glucose or a Prandial glucose if that is not a glucose tolerance we the patient has to be symptomatic or should present in a hyperglycemic crisis that is one important thing for the diagnostic criteria. In diabetes we have a very good window of opportunity actually that is the pre-diabetes stage. So, from screening if we can detect the pre-diabetes stage that is the fasting glucose of 100 to 125, Prandial glucose of 140 to 199 and again NHB1C of 5.4 to 6.4. Now, this is a very good opportunity actually to prevent diabetes and there's very much positive evidence that intervention at this stage actually can delay the onset of diabetes or the incidence of diabetes in substantial amounts I'll get back to that in a little while. So, how are we going to do the screening? Two main approaches we can adopt as family physicians targeted screening for people at risk so whenever we see a patient coming to our practices which belong to high risk category then we can initiate screening. Or else very famous thing again for family medicine or being family physicians the opportunistic screen so patient may come for some other problem or maybe a problem of another family member we get hold of them we catch them at that opportunity we take that opportunity to do this screening in a routine consultation. So, who are at high risk? Now this is actually I took this from our independent logist and the college guidelines with Sri Lanka but I'm sure this is applicable to most of South Asia. So, individuals age more than 40. Again, we just heard, we now see the onset of diabetes is much earlier. I mean type two diabetes we can see much early in certain individuals so if they're at high risk then we have to still screen and actually in our practices we start opportunistic screening. This is actually under the high risk category but opportunistic screening we start even earlier maybe even at the age of 30. So, overweight, BMI we take as more than 23 because it is the Asian region, Asian overweight cut off point. First thing to do with type two diabetes and women with gestational diabetes or has given birth to an overweight baby that is more than 3.5 kg at birth. And individuals with diagnosed previous impaired fasting or glucose tolerance. Hypertensive people and people with dyslipidemia they have a tendency to develop hyperglycemia as well part of metabolic syndrome. So, if we have people with hyperlipidemia or hypertension again we need to screen them for diabetes as well. We know there are other medical conditions associated with incident assistance like polycystic COVID-19 syndrome, acanthosis or we have patients who are on long term steroids for various other complications so high risk people we need to screen. Also people who have vascular disease again we need to screen them as well for diabetes because people can have more, they will become more if they have diabetes as well. How frequently do we have to screen? If the initial test is in the normal range then the recommendation is three yearly if they do not have any additional risk factors. However, if the initial test is in the pre-diabetic range then yearly we need to do the screening and depending on the risk status of the individual's frequency can be changed. So, coming back to our main part the role of primary care where are we and what are we going to do with our population when it comes to prevention of diabetes and screen. So, why primary care? Because we are actually we are the people who know about the individual and the family the best. The relationship we have with our patients they will take our advice without much hesitant especially when it comes to lifestyle advice they need somebody they have a good relationship and trust to follow those instructions. We are providing first contact so whatever the problem they have individual maybe the family members they will come to us so that is a very good opportunity to get hold of them for the screening purposes. And the knowledge we have about the individual and the family we can really provide this personalized care. So, we know their lifestyle what they're doing who is there in the family so we can have an individualized care plan in order to prevent and screen for these people. And because we provide continuity of care with our medical records plus follow up that again this is very important when we try to do lifestyle changes the continuity is very very important because if we give just one of. Then very unlikely for that to be successful that is a very very well known fact if you do not reinforce if you do not follow up that the lifestyle interventions or the main state of preventing diabetes we are going to miss. And we do have access to the family again this is very important because sometimes we get our middle age men coming with maybe impaired glucose or in the high risk category. What we say about how to prepare their meals and what to take and things very unlikely when they go and telling their households we know that as a fact so we need I mean because we know the family, we can get hold of the person who is cooking with the wife and then advice about how to do the meal that will be for the entire family because we know when the parents are having diabetes the children are at risk. So we can target the entire family and we can give health advice to the entire family that is actually the beauty of primary care and the importance of primary care in this venture. So this is the main reason actually the WTO the World Bank and the governments in the region really looking at promoting primary care to overcome or come back the NCD epidemic specially the diabetes because our ability. In catching these people early and the ability of motivating people to do this very, very important lifestyle changes. So again, most of you are familiar with this family life cycle. So, where can we start this our prevention part of diabetes actually the very stage one of family life cycle where the married couple, no children. So, as family physicians we can improve the health of the girl child. By doing that, we can prevent the entire population of the child. We are looking after them during the pregnancy pregnancy so just correcting the nutrition as well as looking after them for other probably conditions which would give rise to IUGR will help in preventing the diabetes in the offspring. Similarly, if we advise them about their lifestyle being healthy during pregnancy they will prevent if we can prevent gestational diabetes among them. So the girls also will be safe when it comes to diabetes in the future. So again in the next stages like stage two three, we need to advise on physical exercise for the mothers because we know again sort of cultural when they preoccupy with the children they tend to neglect themselves they don't look after they don't go for regular exercises they don't care about their diet they think they need to feed they really well so they actually put their the themselves at risk of developing diabetes in the future. Again, as I told you before, the bed management of children at this age is very important we should somehow prevent the obesity among children in order to prevent diabetes in the future among them. So when it comes to the stage four of the family life cycle where the children start schooling, this is the time the parents become high risk of developing diabetes 30 to 40 years that way. So they may come with their children to us. It's up to us to catch them and get them to do the screening for diabetes as well as reinforce their attitudes about the health lifestyle in order to prevent diabetes. So, one word about managing pre diabetes because the next speaker is going to talk about managing diabetes so I'm just touching on pre diabetes management because this is a very good opportunity for us to delay the onset of diabetes because again we have evidence coming from DPP study and the Finnish DPS study where the intensive lifestyle of behavioral modifications has reduced the incidence of type two diabetes by 58% up to over three years so that is a very very huge number actually so and this is not very difficult to inculcate among our patients in a family practice setting and cessation of tobacco use is to reduce the diabetes then becoming diabetes as well as preventing cardiovascular complications. Use of metformin controversial in certain scenarios but again, they are providing level A evidence of using metformin to people with BMI more than 35 kilograms so that is huge to overweight people or like obese people. That's a definite benefit and also they have shown some evidence to be in people less than 60 years and gestational diabetes patients to treat the pre diabetes status with metformin. Of course, again, they also they highlight the importance of lifestyle they emphasize lifestyle effect is very much more than metformin. And we need to monitor and treat for other CBD risk factors like hypertension and dyslipidemia in these pre diabetes patients. We have to do annual screening of blood sugar levels in pre diabetes to catch them early the moment they get into the real diabetes status. And a little bit more about behavioral and lifestyle modifications. Again, according to DPP study they recommend 7 to 10% of weight reduction over six months to prevent the pre diabetes patient going into the diabetes state. So that is about 1 to 2 pounds a week, not more than that. How can we do that? So, talent restriction is one important thing. So, again, we need to consider about the amount of food they are taking and the quality of food they are taking. So, whether it's the carbs has to be refined, not refined carbs. Therefore, like bran and the the cereals, those things will be good fruits, vegetables has to be encouraged in the food. And they also carry about the beneficial effect of nuts, berries, yogurt, coffee and tea in preventing diabetes and preventing cardiovascular events, but no very solid evidence still. Again, exercises, they say 150 minutes per week, moderate intensity and minimum of 10 minutes. This is again something important to assess family positions because we know it's how difficult to motivate our people to do a 30 minute at a stretch. So even 10 minute slots is enough if they can achieve the target. And they can do strength training up to 75 minutes a week and reducing prolonged sedentary time. This is very much they are into this now, even in our, I mean, in Sri Lanka, the Health Ministry has introduced this even to the officers whenever they are having meetings to stop in between and to move around a bit just to break this prolonged sedentary time because it has been proven to have an effect in weight management and I mean, towards NCDs. Actually, this behavioral therapy, they say not only reduce the mortality benefits or morbidity benefits towards diabetes, but overall mortality and mortality due to cardiovascular events also has been reduced with this weight reduction or lifestyle modification. So, lastly, few practical points or the traps actually we get into very often. We need to take a proper history from our patients. When we ask past history, I mean, I'm sure all of you are very familiar. Do you have diabetes? No doctor, I don't have anything. So, you also happily move okay and then you go but stop and ask have you checked most of our people will say no doctor I didn't check, but I don't have any problem. So I don't have diabetes. So that is a very, very common thing in our clinical setup. I'm 100% sure almost all of you are familiar with this scenario. So make sure you cross check. Have you checked? When you ask about have you checked, then they say yes doctor I checked and it was normal. Please ask when did you check? Yes, they would say it was checked when I was pregnant doctor or about five years back it was checked and it was normal doctor. I don't have anything. So I don't have diabetes. So our people are in very much denial. They don't want to have the disease. So they will say no, I am fine because actually we also know they are fine, especially in the prediabetes stage. They don't have any symptoms or even diabetes until their sugar levels come up to substantial level, they are asymptomatic. So make sure you verify double check about what they are saying when they say they don't have diabetes. And also, when you're taking the history, when you want to do this lifestyle modification, please ask about their lifestyle because we all know our plate method, this method, that method, food pyramid, everything. And we have one cup of rice and I mean standard diets we have in our mind because we have learned, but can we actually apply into our real patients? If you just ask, I mean tell them okay eat one cup of rice and this like that and the other so they won't be faithful to the doctor. Today eat one cup and for the person who had been eating three cups, one cup means nothing. One hour time he is hungry and he will eat three more cups and the purpose lost. So make sure you just ask about the individual lifestyle and again you advise on exercising. You say okay you need to exercise 150 minutes like 30 minutes a day for five days a week. Just think how many of us are doing it. So will our patients do it right? So it has to be something practical. If we can link something to their lifestyle, then maybe they will do something. So as I said before also, if they can't devote just 30 minutes at a stretch, maybe 15 minutes, two slots, 10 minutes, three slots, whatever is practical depending on their lifestyle. And whenever we advise, try to advise not only to the individual but to the family and make it a family routine, family diet, family exercise time. So that will improve the unity of the family and it will improve the compliance to whatever the lifestyle programs that you are trying to give. And personalized plan, that's what actually I said before, like knowing about our patients and their other disease conditions, their income level, their level of education, the level of understanding are very important when we give them a lifestyle plan. And frequent follow-ups are mandatory with appreciation and encouragement whenever even if they have gained slight benefit, maybe a bit of a reduction or if they're heading to a routine exercise program or at least trying to follow the diet encouraged them. So this is, they respect you a lot as the family physician and your encouragement appreciation was a long way and frequent follow-ups reinforcements are mandatory if we want to get a success with the lifestyle modification plan. So these are the main things I wanted to highlight in my talk as family physicians what we could do, how we could do and how we could avoid some traps that we are getting into frequently in order to prevent our patients becoming diabetes. Thank you SpiceRoot for giving the opportunity and thank you all for listening. Thank you ma'am for very comprehensive presentation and highlighting this prevention and the role of the screening for diabetes. I enjoyed your presentation and really enjoyed the practical points and hopefully all our participants and have learned a lot. So over to Dr. Noor that there is a question by one of the attendees. Can you take that question? No, you have to unmute yourself. Okay, sorry. So we have Fazana Athas. She has raised her hand. Fazana you want to ask something? Fazana, you can unmute yourself and then speak. Okay Noor I think maybe it's some... You can take the questions last maybe. Okay, we'll take it in the end. Maybe this is some technical literature at the end. Okay, moving on towards the last presentation which is a very important topic which is a holistic approach to prevent complications of diabetes. And our speaker is Dr. Anam Arshabegh. She is assistant professor and head of department family medicine at the University of Health Sciences Karachi. She's also program director of postgraduate training in family medicine at the University and also academic coordinator of eDoctor which is an online learning program in family medicine for non-practicing female doctors at home. So over to Dr. Anam. Thank you very much Dr. Noor. And hello and welcome everybody. Good evening. And I happy Diwali to all those who are celebrating Diwali today. Okay, let me start my screen share. So today I will be talking about the holistic approach to preventing complications of diabetes. The previous two speakers as team speakers have been very kind enough to give a very comprehensive overview so far and I'd say that actually it's made my talk much more simpler, much more easier. Thank you. Okay, I will not be going very much into the burden which has already been covered very, very nicely by the first speaker. But just quickly giving a slight introduction I'd say from this is taken from the World Health Organization fact sheet of 2020. So from 2000 to 2016 there was a 5% increase in premature mortality that was seen with diabetes. Now this was the overall mortality, which included the complications that because because of long standing diabetes. The burden of complications decides the burden of diabetes itself is of course as has already been mentioned rising very rapidly but more so in the low and middle income countries. Diabetes as we all know is a major cause of blindness, kidney failure, heart attacks, stroke, limb amputations. Actually there are multiple problems all primarily because of end organ damage or target organ damage. In 2016 an estimated 1.6 million deaths were directly caused by diabetes itself and almost half of all deaths attributable to high blood glucose occur before the age of 70 years. We're talking about an age of maximum productivity. We're talking about an age group which is responsible for contributing significantly to the workable community and the society. The World Health Organization estimates that diabetes was the seventh leading cause of death by 2016 I'm sure it's been updated more but this was the most recent that I found. So what do we mean by a holistic approach? How many of us know that? And why am I talking about a holistic approach? So we're talking about a comprehensive, complete care, which is regarding diabetes itself, pre-diabetes as was previously mentioned by Professor Shanti. And then we're talking about diabetes and its complications being the primary domain of family medicine, that is the concept of primary care starting at the foundation of any disease, the cross-due level. So when you're talking about pre-diabetes, we are talking about preventing diabetes itself. Then we talk about, in a way, secondary prevention in terms of preventing the complications that have been caused once diabetes has started. So we're talking about nipping it all in the bud basically nipping it all in the bud. Sorry, there's a slight problem in this, we're talking about the comprehensive medical evaluation or the clinical. Okay, so when you talk about the comprehensive medical evaluation, we start first of all by the clinical assessment by which of course the most important step is taking a complete history. The next is examination. So I've taken this from the American Diabetic Association guidelines of 2020, quoting my reference. So what we have is checking the blood pressure, how often does it need to be done at the initial visit, every follow-up and then annually. Then we come to the skin inspection, initial visit, every follow-up and then annually again. A complete dental assessment, initial visit and then annually. A thyroid palpation at the initial visit and then annual, then dilated eye exam, again initial visit and annual. A comprehensive foot exam, again initial visit and then annually. So this is the first step in providing comprehensive medical evaluation to preventing the complications, catching it, nipping it in the bud. The next that we have is investigation. So when we talk about investigations, we talk about the spot urinary protein creatinine ratio, which is done annually. A lipid profile again on an annual basis, liver function tests annually, a TSH, which is, and now we're talking about those which are indicated in certain circumstances. For example, a TSH is done in type 1 diabetes, a vitamin B12 level if the patient is on metformin, serum creatinine and estimated GFR when the patient is 65 years or older. So all of these investigations, as you can all understand, are aiming at preventing end organ damage or catching it actually, not just preventing it but catching it as well. Now we come to the next step or as I see it, the next component, the lifestyle modifications, which become a part and parcel of any diabetes management with the aim of preventing what, the complications again. So when we talk about the medical nutrition therapy, this is not done in isolation by the primary care physician. This is more of a shared care including the nutritionist as well. Then we go talk about physical. These two points have already been very, very nicely put forward by Prof Shanley. And she has very rightly mentioned that we can't just say that the patient has to follow a certain kind of dietary pattern. It has to be tailored according to the person who's affected basically. Similarly, because otherwise the patient may hide the facts from us. Then we come to physical activity as recommended is supposed to be 150 minutes a week with at least three consecutive days and no more than two days being exercise free in between. Moderation of alcohol intake, which means two drinks per day for men and one drink per day for women depending on the units of the drinks. Smoking a tobacco cessation if the patient uses it. And then the most important thing addressing the psychosocial to understand what we're telling them what kind of a support system do they have. How are they helped basically. Again, I would say last but not the least, the vaccinations, which are very, very important and in the hepatitis B vaccine when we talk about the annual vaccine what I sorry the pneumococcal vaccine. I just quickly like to point out that when we talk about children who are less than two years of age. We are talking about the PCV 13 or the pneumococcal vaccine 13. When we talk about the individuals between two to 64 years of age we're talking about the PCV 13 followed up by the BPS we 23. Given these 12 months later or at any point that the patient comes in and it's easier than to repeat the BPS we 23. And hepatitis B vaccine to all those who have not been patient by a quick take home message. How do we prevent complications basically the tiny inappropriate management of hypoglycemia right at the onset, keeping an eye out for the initial stages of any of the interventions. And we provided. As I've already mentioned. Thank you. Thank you Dr. Nice presentation of highlighting the holistic approach the examination need to be done by a family physician so that the complications can be. The patient can be treated and also can be picked up earlier. So, next, this brings us towards the end of our presentations and for Q&A session, I would like to hand over to Dr. Dr. Zainab who is a pre-60 coordinator of Spice with Pakistan and also Dr. Zainab who's that chair of Spice with Pakistan. So what do you Thank you, Dr. Zainab. Do we have any questions. No, we don't have any questions in the chat box as yet. If any of the participants has any queries that they can very well noted down in the chat box and then we can address them to our speakers. If not, then we can end the webinar. Zainab there's a comment on FB. It's a comment but if you want to clarify it, probably, even from Professor Shamali or else from Dr. Beg. I think it's Dr. Rick has commented that lifestyle medicine can reverse diabetes. I mean, most of the time we tell that diabetes cannot be reversed. So is there any chance that's it. Okay, so we can direct this question to either Dr. Anand or Professor Shamali. Any of them if they can answer this question for us. Professor Shamali here. Actually, I don't know really we can say whether we are reverting because once we like make a diagnosis is the diagnosis is there. Of course, we know in a patient with diagnosed diabetes with the this medical nutrition therapy and with physical exercises we can of course prevent them even taking medication because we have like patients who are on only lifestyle modifications over a long period of time. So maybe that's what he's referring to but I really don't know because it's the pathology which has taken place with the VR reverting the the entire thing I don't know but definitely the sugar control will be normal. I mean, can we can make it normal with the medical nutrition therapy as well as thereby we can reduce the complications and things on the long term. Thank you Professor that's so far what everybody says we've seen so far definitely as I agree with it as far as pre diabetes is concerned. Definitely we've seen longer management on tight but going back and reversing is yet to be seen I believe. Thank you, Dr. Anand and Dr. Shamali for answering this question for us. I don't think we have any more questions at the moment. Okay, so last one question. Yeah, I want to ask. Yes, basically, when Professor Shamali discuss about the P diabetes. So she mentioned the role of metformin to be controversial. So I really want to know what, what she practice like to which patients you prescribe metformin because we see very commonly patients who have either and most have got impaired fasting, and they have run a normal random blood sugars. So we do advise this lifestyle modifications and telling them the risk of developing diabetes and how frequently we're going to screen them, but like when to start metformin or any other group of drugs like insulin sensitizers. Actually, according to the American Diabetes Association guidelines, they recommend the prescribing of metformin to patients above 35 BMI. And so that is a level A evidence they're giving. So that is the, I mean the best evidence we can have so. But again for gestational diabetes patients if they're pre diabetes and they give us level A. So much of the time I also agree with you like I mean our patients being so reluctant to take medication for I mean, of course not fall less than 60 years I really don't give metformin but I also practice lifestyle modification. Gestational diabetes patients if they're like finding it difficult to go for lifestyle modification then I start them on metformin. But whoever who can really go on strict lifestyle like changes, then we go along with that and but we monitor them frequently to see where they are, but definitely for people more than 35 BMI as we have to give. Great. Thank you. Okay, so we have a question for Anna. Doctor, how we have a question that what are the investigations and their and their frequency that you would suggest for a diabetic patient. Okay. So you see I as I've mentioned in my slide, the list of investigations. Well, the thing is, there are some that are there are almost all investigations which are done at the initial visit then we do it at there are some which are done at the quarter and then those are done. So I guess it would I would recommend that if you can go over the American Diabetic Association guidelines of 2020 there's a lovely chart in there. A table that's made and it's specifically giving the frequency of investigations as well. Thank you for the answer. We haven't. We had a hand raised by a mistral talk on. I think it is not there anymore. Okay. Right. So, no, we have some more questions. Sorry, more questions from the audience. Okay. So there's one question about the management of weight loss in pre-diabetic management actually I'm not really aware about that so I can't comment on that but I haven't seen like I mean American Diabetes Association guidelines they don't even the nice dialysis to mention anything about this but obese patients, the weight reduction is very important, but medical nutrition therapy is the one they really recommend and along with the exercises that's why they say like seven to 10% of weight reduction, definitely, is going to be beneficial. And again, that's another question should we start made common in all patients with pre-diabetes under 60. Again, that is her recommendation by the American Diabetes Association but that's why I said even I do not really practices it as a routine, unless the patient cannot adhere to lifestyle modifications. They can first go for the lifestyle modifications and see whether I mean how their sugar sort of is changing or varying whether it's going up going down so it's an individual decision I take as a routine I don't give even if they are in the pre-diabetes because I mean, we have seen most of our patients revert from the pre-diabetes to normal glycemia with the lifestyle changes. I mean, very quickly I mean within a month or two if they really follow the advice I shall modification the glycemic status becomes normal glycemic. Thank you for answering the questions. So I can't see any other questions. Yeah. I don't think there are any more questions at the moment. Okay. So, in the end, I would like to thank all of you for celebrating the World IBT's day with a spice routine. A lot of thanks to all our speakers, Dr. Kailas, Professor Shamali, Samran Aike and Dr. Anam for their wonderful presentations and contributing their time in creating awareness. Indeed, it was a very informative webinar. Thank you, Harris, our Wonka CEO, Dr. Sankha, our regional spice road chair and Dr. Zainab, our national chair, Pakistan for organizing this event. And I would also like to thank Dr. Durenisha for moderating such a wonderful session. Thank you all for listening and participating, have a wonderful weekend and stay safe. Any other comments from any other sides are welcome. Yes, Nur. Let me thank you all. Let me thank you all, Zainab and his Able team, Dure, Nur and all the Pakistan spice route for organizing such a fine webinar and for all the work you did for this and also coordination you did with the support of all the other countries. Very well done. Thank you very much. Thank you everyone. Thank you.