Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, India. )
Mark Peyrot  ( Department of Sociology, Loyola University Maryland, Baltimore, MD, USA. )
Soren Skovlund  ( Department of Global Affairs, NovoNordisk, Copenhagen, Denmark. )

Diabetes is a major public health challenge for Pakistan today. Current estimates count 6.6 million adult Pakistanis who live with diabetes, a number that makes Pakistan the tenth largest nation with diabetes worldwide, bringing it into the company of neighbouring Asian and Middle Eastern countries such as China, India, and Egypt.¹
Recent publications reveal that the average glycaemic control is suboptimal in Pakistan, with an average HbA1c of 9.2% at time of insulin initiation or substitution.² This state of affairs exists in spite of the availability of modern, effective diagnostic and therapeutic modalities. The poor health that our citizens with diabetes suffer, despite adequate, safe, and well tolerated pharmacological options being made available, needs attention.
The first DAWN (Diabetes Attitudes Wishes and Needs) study, conducted in 12 countries, over a decade ago, reported the various concerns and challenges faced by people with diabetes.³ It was followed by a five-point DAWN Call to Action, which highlighted the need to address psychosocial issues in diabetes management.⁴ The universal applicability of this action plan was evident from the global attention and acceptance that it received. Though we tend to measure only "biological" breakthroughs as advances in medical science, the DAWN Call to Action truly represents a major advancement in our understanding of diabetes mellitus, as it emphasizes the need to address psychosocial issues in diabetes care. This in no way suggests that physicians should neglect the biological aspects of disease management: on the contrary, enhanced attention to psychosocial morbidity may help improve overall health outcomes.
The DAWN2 study is a large, multinational, multidisciplinary effort, spread over 17 countries in 4 continents, which assesses potential barriers to optimal diabetes management. It goes a step further in trying to identify facilitators of optimal diabetes care as well. This has been done by interviewing approximately 16000 adults, including about 9000 people with diabetes, 2100 family members of people with diabetes, and 5000 health care professionals who treat diabetes.⁵ Though DAWN2 was not conducted in Pakistan, many countries with similar ethnicity (India), religion (Algeria, Turkey), borders (China, India) and pay-from-pocket health care environment (Mexico) are part of this project. This allows Pakistan to extrapolate global DAWN2 data to its own diabetes care environment, while focussing on national data from socioculturally similar countries like India, Algeria and Turkey. The results of DAWN2, therefore, are of great relevance to us, in the fight against diabetes.
People with diabetes across the world do not observe optimal self-care practices, but this trend is especially marked in India, Algeria and Turkey, amongst others. This may be a paradox for Western observers, as India, Algeria and China score highest among DAWN2 countries in terms of patient empowerment or involvement as well.⁶ It is not surprising for other Oriental doctors, however: they understand that their patients do take their own independent decisions, though these decisions may not necessarily be the healthiest ones!
The traditional societies of Algeria and Turkey score worst in terms of societal discrimination against people with diabetes,⁷ a fact that may be painfully true in Pakistan as well. On the other hand, family support is strongest in India and China, highlighting the fact that Pakistan, too, can utilize the family as an effective resource in the fight against diabetes.
DAWN 2 also finds that diabetes related distress is common in people with diabetes, as well as in their family members. Self-reported health status is poorest in Algeria and India, along with another neighbour of ours — Russia.6 However, assessment of psychological health is the exception, rather than the rule, in countries similar to Pakistan.⁸
Health care professionals also wish to improve the way in which they manage diabetes, and people living with the condition self-manage themselves. Unfortunately, not all professionals or lay persons have access to medical education or information.⁸ In spite of this, Turkish and Indian health care professionals seem to be more successful in providing person centred chronic care than colleagues in most DAWN2 countries.
The DAWN2 results should stimulate and inspire us to initiate reforms in the way we manage diabetes. Enhanced involvement of the person with diabetes and his or her family, following the principles of person centred and family centred care,⁹ is an essential aspect. Improvement in health care provision must incorporate strategies to assess and improve psychological health in people with diabetes. The strong responses noted for family support and community discrimination seen in countries similar to Pakistan, open up a window of opportunity. Sustained and concerted efforts will be required in order to properly utilize this opening, which will also help us save huge costs spent on management of avoidable complications. This editorial by the JPMA, the first such editorial in an Asian or Middle Eastern journal, should herald the start of this effort.

1. International Diabetes Federation. Diabetes Atlas 5th Edition (2012). (Online) (Cited 2013 May 31). Available from URL: http://www.idf.org/diabetesatlas/5e/Update2012.
2. Hassan MI, Aamir AH, Miyan Z, Siddiqui LA, Qureshi MS, Shaikh MZ. Safety and effectiveness of biphasic insulin aspart 30 (BIAsp 30) in people with type 2 diabetes mellitus in the Pakistani population: results from the A1chieve study. J Pak Med Assoc 2012; 62: 929-36.
3. Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med 2005; 22: 1379-85.
4. 2nd International DAWN Summit: a call-to-action to improve psychosocial care for people with diabetes. Pract Diabetes Int 2004; 21: 201-8.
5. Peyrot M, Burns KK, Davies M, Forbes A, Hermanns N, Holt R, et al. Diabetes Attitudes Wishes and Needs 2 (DAWN2): a multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care. Diabetes Res Clin Pract 2013; 99: 174-84.
6. Nicolucci A, Kovacs Burns K, Holt RIG, Comaschi M, Hermanns N, Ishii H, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2TM): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med 2013; 30: 767-77.
7. Kovacs Burns K, Nicolucci A, Holt RIG, Willaing I, Hermanns N, Kalra S, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2TM): cross-national benchmarking indicators for family members living with people with diabetes. Diabet Med 2013; 30: 778-88.
8. Holt RIG, Nicolucci A, Kovacs Burns K, Escalante M, Forbes A, Hermanns N, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2TM): cross-national comparisons on barriers and resources for optimal care - healthcare professional perspective. Diabet Med 2013; 30: 789-98.
9. Kalra S, Megallaa MH, Jawad F. Perspectives on patient-centred care in diabetology. J Midlife Health 2012; 3: 93-6.