Open access Research

Prevalence of diabetes, pre-diabetes and

associated risk factors: second National

BMJ Open: first published as 10.1136/bmjopen-2017-020961 on 5 August 2018. Downloaded from http://bmjopen.bmj.com/ on August 1, 2025 by guest .
Diabetes Survey of Pakistan (NDSP),
2016–2017

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Abdul Basit,1 Asher Fawwad,2,3 Huma Qureshi,4 A S Shera,5 NDSP Members

To cite: Basit A, Fawwad A, Abstract

Qureshi H, et al. Prevalence Strengths and limitations of this study
Objective The second National Diabetes Survey of
of diabetes, pre-diabetes Pakistan (second NDSP) was planned to ascertain the
and associated risk factors: ►► To our knowledge, this is the largest survey on di-
updated prevalence of diabetes, pre-diabetes and
second National Diabetes abetes in Pakistan to include all the four provinces
associated risk factors at the national and provincial levels.
Survey of Pakistan (NDSP), and both urban and rural populations.
2016–2017. BMJ Open Research design and methods The survey was
►► Proper epidemiological methods with multistage
2018;8:e020961. doi:10.1136/ conducted by using multistage clustering technique in all
stratified sampling technique were used to conduct
bmjopen-2017-020961 four provinces of Pakistan from February 2016 to August
the survey.
2017. An estimated sample size of 10 800 was calculated
►► Oral Glucose Tolerance Test and haemoglobin A1c
Received 3 December 2017 using probability sampling and multistage stratified
Revised 12 June 2018 were done for the diagnosis of diabetes for a sample
sampling technique. Twenty-seven clusters were selected
Accepted 3 July 2018 of over 10 000 people.
out of total 213 clusters from all four provinces (strata) of
►► Apart from diabetes, prevalence of obesity, hy-
Pakistan. A total of 46 subclusters were selected by using
pertension and dyslipidaemia was also estimated
the ‘Rule of thumb’. Out of 12 486 targeted individuals,
through this survey.
10 834 study subjects finally participated in the study
►► We excluded individuals less than 20 years of age as
(87% response rate). Seventeen trained teams collected
the survey mainly was designed for the diagnosis of
data using the structured questionnaire. The clinical and
type 2 diabetes. However, we would not be able to
anthropometric measurements included height, weight,
differentiate between type 1 and type 2 diabetes on
blood pressure, waist circumference and waist-to-hip ratio
the basis of this survey.
while the blood tests included Oral Glucose Tolerance Test
© Author(s) (or their (OGTT), haemoglobin A1c and fasting lipid profiles. WHO
employer(s)) 2018. Re-use criteria were used for the diagnosis of diabetes and pre-
Diabetes-related complications are the major
permitted under CC BY-NC. No diabetes.
commercial re-use. See rights cause of premature deaths in the world,3 4
Results Overall weighted prevalence of diabetes was
and permissions. Published by 26.3%, of which 19.2% had known diabetes, and 7.1% with a death occurring in every 6 s due to the
BMJ.
were newly diagnosed people with diabetes. Prevalence consequences of diabetes.4 5 In 2015, approx-
1
Department of Medicine, Baqai of diabetes in urban and rural areas was 28.3% and imately five million diabetes-related deaths
Institute of Diabetology and were reported in low-income and middle-in-
25.3%, respectively. Prevalence of pre-diabetes was
Endocrinology, Baqai Medical
University, Karachi, Sindh,
14.4% (15.5% in urban areas and 13.9% in rural areas). come countries.4 6
Pakistan Age greater than or equal to 43 years, family history of The first National Diabetes Survey of Paki-
2
Department of Research, Baqai diabetes, hypertension, obesity and dyslipidaemia were stan (1st NDSP) was done by the Diabetic
Institute of Diabetology and significant associated risk factors for diabetes. Association of Pakistan (DAP) in collabora-
Endocrinology, Baqai Medical Conclusion The findings of the 2nd NDSP imply that tion with WHO between 1994 and 1998.7–11
University, Karachi, Sindh, diabetes has reached epidemic proportion and urgently
Pakistan
Overall, glycaemic dysregulation (diabetes
need national strategies for early diagnosis and effective
3
Department of Biochemistry, plus pre-diabetes) was reported to be 22.04%
management as well as cost-effective diabetes primary
Baqai Medical University, prevention programme in Pakistan. and 17.15% in urban and rural areas, respec-
Karachi, Sindh, Pakistan tively, by the 1st NDSP.7 The prevalence
4
Director, Pakistan Health of diabetes as assessed by fasting plasma
Research Council, Islamabad,
Pakistan
glucose had doubled from 7.2% in 2002 to
5
Secretary General, Diabetic Introduction 14.2% in 2009 in the rural areas of Baluch-
Association of Pakistan and The epidemic of diabetes is one of the most istan.12 Similarly, the prevalence of impaired
WHO Collaborating Centre, alarming public health issues of the 21st fasting glucose (IFG) has risen from 6.5%
Karachi, Sindh, Pakistan century, especially for lower middle-income to 11%.12 Furthermore, studies conducted
Correspondence to countries.1 It was predicted that from 2010 in school-age children had also warned of a
Professor Abdul Basit; to 2030, there will be a 67% increase in the rise in childhood obesity.13 Pakistan Health
a​ bdulbasit@​bide.e​ du.​pk prevalence of diabetes in these countries.2 Research Council (PHRC) conducted a

Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961 1

Open access

questionnaire-based survey using STEPS, a ‘WHO STEP- questionnaire was adopted from the WHO Questionnaire
wise approach to surveillance’, in the provinces of Punjab used in the 1st NDSP.8 Each team was led by a physician
and Sindh.14 This survey along with other studies reported as provincial coordinator of that cluster and each team

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the prevalence of diabetes between 13.1% and 26.9%.12–16 comprised laboratory technicians, paramedical staff and
Hence the epidemic of diabetes was predicted nearly a survey officers.
decade ago. Most of these studies had been smaller scale, Door-to-door assessment was done following systematic
focusing on specific towns or villages and because of sampling technique. The first household in the lane was
diversified ethnic groups within Pakistani population, selected randomly and afterwards every 10th house was
could not accurately reflect the prevalence of diabetes in identified. In case residents of the identified household
Pakistan. Therefore, there was a need for a repeat survey, were not present or if they refused to participate, the

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that is, second NDSP. next consecutive household was taken. Teams marked the
This led to a joint collaboration of Ministry of National houses and informed the adult residents. The selected
Health Services, Regulation and Coordination, PHRC, household members were requested to come after an
DAP and Baqai Institute of Diabetology and Endocri- overnight fast (at least 8 hours) to the camp on the specific
nology, Baqai Medical University, to conduct the second day. Two hundred and fourteen camps were conducted
NDSP. The aim of this survey is to ascertain prevalence to recruit the required number of study subjects. Each
of diabetes, pre-diabetes and associated risk factors at the participant was expected to stay within the screening
national and provincial levels. The results are expected facility for at least 2 hours, that is, for the post 75 g anhy-
to explore ethnic and geographical variation in diabetes drous glucose load. Meanwhile, the anthropometric and
and pre-diabetes phenotypes. clinical data were collected by the trained paramedic staff
under the supervision of the provincial coordinator.

Research design and methods Behavioural and social assessment

The second NDSP was conducted from February 2016 For each participant, we administered a detailed
to August 2017 in all four provinces of Pakistan, that is, behavioural and social assessment with the help of a
Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan. predesigned questionnaire. All information was gathered
Pakistani nationals aged 20 years or more were included through one-to-one interviews by a trained survey officer.
in the survey, whereas pregnant women and those not Tobacco users were defined as self-reported smoking and
residents of the selected households were excluded. An chewing of tobacco products daily irrespective of quantity
estimated sample size of 10 800 was calculated using prob- consumed and duration.
ability sampling and multistage stratified sampling tech-
niques.17 Sample size was calculated based on an expected Anthropometric and clinical assessment
prevalence of 18% (based on previous surveys), level of Height, bodyweight, waist circumference and blood
significance 97%, margin of error 1% with a design effect pressure were measured using standardised tech-
of 2, considering complex multistage design. niques.20 Weight was taken to the nearest of 0.1 kg
Stratification of population was done on the basis of with participants in light clothes and without shoes.
urban and rural domains for all four provinces as defined Height was recorded to the nearest of 0.1 cm, while
in the latest available census.18 Each province was consid- subjects standing in erect posture vertically touching
ered as a stratum and the districts (geographical subdi- the occiput, back, hip and heels on the wall. Body mass
vision of provinces legally described by government) index (BMI) was calculated as weight in kilograms
considered as clusters were selected from each stratum. divided by height in metre squared (kg/m 2). Waist
Tehsils or towns (further bifurcation of districts legally circumference and hip circumference were measured
described by government) considered as subclusters were between the centre point of the lower margin of the
selected from each identified cluster for the survey. ribs and iliac crest the mid-point. Blood pressure was
Clusters and subclusters were randomly selected using measured with mercury sphygmomanometer. Indi-
probability proportional to size technique, and number viduals were requested to take 10 min rest in a sitting
of clusters were selected from each province using the position before measurement of blood pressure to
‘rule of thumb’ number of clusters (k)=(sample size of reduce variation. Mean of two readings was taken.
stratum/2)0.5.19 Twenty-seven clusters were selected out
of a total 213 clusters from all over Pakistan. A total of
46 subclusters (21 from urban and 25 from rural) were Biochemical assessment
selected (figure 1). Blood samples were collected by using sterilised dispos-
Seventeen teaching hospitals and/or diabetes centres able vacutainer tubes containing sodium fluoride (for
participated in the second NDSP. The training sessions glucose), EDTA K2 (for haemoglobin A1c; HbA1c)
of these 17 teams were conducted from February 2016 to and gel (for lipids). Within 1 hour of blood collection,
July 2016. The teams were trained to identify households, the samples were centrifuged, separated and sent to
to fill the questionnaire, to take anthropometric and the laboratory. Plasma glucose was measured using the
clinical measurements and to collect blood samples. The glucose oxidase peroxidase method, total cholesterol

2 Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961

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Figure 1 Step-by-step approach for the National Diabetes Survey of Pakistan.

by cholesterol oxidase phenol 4-aminoantipyrine Interassay and intra-assay coefficients of variability for
peroxidase (CHOD-PAP) method, triglycerides by these biochemical parameters were within the accept-
glycerol phosphate oxidase-p-aminophenazone (GPO- able ranges.
PAP) method, high-density lipoprotein cholesterol
(HDL-C) by homogeneous enzymatic calorimetric Diagnostic criterion
method, low-density lipoprotein cholesterol (LDL-C) WHO definition was used to diagnose diabetes and
by CHOD-PAP method and HbA1c by high-perfor-
pre-diabetes (intermediate hyperglycaemia). Results
mance liquid chromatography method. 21 Plasma
of plasma glucose testing were categorised as follows:
glucose was performed both fasting and 2 hours post
isolated IFG was defined as fasting plasma glucose level
75 g glucose load (2-hour PGL) at the designated
laboratory close to the survey site with the specified between 110 mg/dL and 125 mg/dL with 2-hour PGL
methodology. Samples for HbA1c and lipid profile ≤140 mg/dL. Isolated impaired glucose tolerance was
were transported as per the standardised protocol22 to defined as fasting glucose level <110 mg/dL and 2-hour
PHRC, Jinnah Postgraduate Medical Centre, Karachi, PGL between 141 mg/dL and 199 mg/dL. Newly diag-
for analysis. Equipment with same specifications was nosed diabetes was defined as fasting plasma glucose
used throughout the study for standardisation and level ≥126 mg/dL or 2-hour PGL ≥200 mg/dL or both.23
as a measure of quality assurance. Calibration and Known diabetes was considered if the subject had been
controls were run as per the specified guidelines.22 diagnosed as diabetic by a physician.

Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961 3

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Table 1 Baseline characteristics of the study participants, by province urban and rural areas of Pakistan
Khyber

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Punjab Sindh Pakhtunkhwa Baluchistan Overall
Number of participants 6221 2531 1544 538 10 834
Age (years) 43.5±14.1 45.5±14.2 40.3±12.9 48.4±12.81 43.8±14.0
Gender
 Male 2457 (39.5) 1192 (47.1) 835 (54.1) 257 (47.8) 4756 (43.9)
 Female 3764 (60.5) 1339 (52.9) 709 (45.9) 281 (52.2) 6078 (56.1)

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Primary education or more 2675 (49.6) 1353 (61.3) 759 (55.6) 278 (54.9) 5065 (53.5)
Tobacco addiction 614 (11.2) 493 (22.2) 117 (8.9) 152 (29.1) 1376 (14.5)
Positive family history of diabetes 1509 (27.8) 760 (37) 240 (22.2) 236 (43.9) 2745 (30.2)
2
*Body mass index (kg/m ) 27.5±6.1 26.5±5.6 27.2±6.1 26.7±5.0 27.2±6.0
27.0 (23.3–31.2) 25.9 (22.6–29.6) 26.4 (23.4–30.1) 25.6 (23.5–29.2) 26.6 (23.1–30.5)
*Waist circumference (cm)
 Male 91.7±14.5 92.3±12.1 98.0 ± 12.4 96.7±11.7 93.1±13.8
91.0 (82–101) 93 (84–100) 98 (89–106) 97 (91–100) 93 (85–102)
 Female 92.4±15.0 94.3±13.4 82.3 (11.7) 101.1±15.6 93.2±14.5
92 (81–103) 95 (86–103) 81 (75–88) 97 (91–112) 93 (82–103)
Blood pressure (mm Hg)
 <140/90 2482 (45%) 958 (44.9%) 922 (65.5%) 187 (34.9%) 4549 (47.4%)
 ≥140/90 3032 (55%) 1178 (55.1%) 486 (34.5%) 349 (65.1%) 5045 (52.6%)
Data are presented as mean±SD or n (%).
*Median (IQR).

For the diagnosis of diabetes using HbA1c as diagnostic will help the National and International stakeholders
tool, the American Diabetes Association (ADA) standards to take appropriate measures for prevention of diabetes
of care were used. HbA1c ≥6.5% (48 mmol/mol) was diag- at all levels. With the informed consent, 10 834 individ-
nosed as diabetic while HbA1c between 5.7% and 6.4% uals from all four provinces of Pakistan were involved
(39 and 46 mmol/mol) was considered as pre-diabetes.24 in the survey. The participation of the study subjects
People were considered hypertensive if they were was limited to the collection of study data approved by
already diagnosed by a physician or if they were taking the ethical review committee while the whole survey
any antihypertensive medication or if the systolic blood was performed by the survey team members. The tests
pressure was ≥140 mm Hg and/or diastolic blood pres- involved in the survey were conducted free of cost and
sure ≥90 mm Hg.8 9 the results were communicated to study participants
As per WHO Asia Pacific Guidelines, obesity was as printed medical reports through local NDSP team
defined as a BMI of 25 kg/m2 or higher for both males members. Complimentary medical consultation was
and females with or without abdominal obesity.25 Central provided in case of any abnormal finding. Subjects with
obesity was defined as waist circumference ≥90 cm and newly diagnosed diabetes and impaired glucose toler-
≥80 cm in males and females, respectively.8 9 ance were referred to the nearest centre for registration
Using the Adult Treatment Panel III guidelines, dyslip- and treatment.
idaemia was classified as one or more of the following
conditions in fasting state: serum cholesterol >200 mg/
dL, serum LDL-C >130 mg/dL, serum HDL-C <40 mg/
dL and <50 mg/dL for male and female, respectively, Statistical analysis
and serum triglycerides >150 (mg/dL).26 People were Data analysis was conducted on SPSS V.20. Descriptive
also considered as dyslipidaemic if they were taking any analysis included the estimation of mean values and SDs
lipid-lowering medications. for continuous variables. Categorical variables and preva-
lence values were presented in the form of frequency and
percentage. For calculating the prevalence of diabetes,
Patient and public involvement the following formula was used27:
It is a community-based epidemiological survey Sample size of district
^
p = ( Sample size of province )
conducted to ascertain the prevalence of people with
Number of diabetics from that district
type 2 diabetes in Pakistan. The results of this survey ‍ ×( Number of individuals sampled from that district )
‍

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Table 2 Weighted prevalence of diabetes and pre-diabetes, by province urban and rural areas of Pakistan
Punjab Sindh Khyber Pakhtunkhwa Baluchistan

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Overall (urban and rural) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Diabetes
 Known diabetes 23.7 (22.6 to 24.7) 23.6 (21.9 to 25.2) 10.2 (8.7 to 11.7) 19.1 (15.7 to 22.4)
 FG 3.3 (2.8 to 3.7) 3.6 (2.8 to 4.3) 1 (0.5 to 1.5) 3.1 (1.6 to 4.5)
 2hGT 1.1 (0.8 to 1.3) 1.4 (0.9 to 1.8) 0.4 (0.1 to 0.7) 4.7 (2.9 to 6.4)
 Both FG and 2hGT 2.1 (1.7 to 2.4) 3.7 (2.9 to 4.4) 1.6 (0.9 to 2.2) 2.6 (1.2 to 3.9)

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 Newly diagnosed diabetes 6.5 (5.8 to 7.1) 8.7 (7.6 to 9.8) 3 (2.1 to 3.8) 10.4 (7.8 to 12.9)
 Total diabetes 30.2 (29.0 to 31.3) 32.3 (30.4 to 34.1) 13.2 (11.5 to 14.8) 29.5 (25.6 to 33.3)
Pre-diabetes
 FG 1.8 (1.4 to 2.1) 1.8 (1.2 to 2.3) 1.1 (0.5 to 1.6) 0.4 (0.1 to 0.9)
 2hGT 11.2 (10.4 to 11.9) 8.4 (7.3 to 9.4) 2.9 (2.0 to 3.7) 42.4 (38.2 to 46.5)
 Both FG and 2hGT 2.1 (1.7 to 2.4) 1.5 (1.0 to 1.9) 0.5 (0.1 to 0.8) 8.7 (6.3 to 11.0)
 Total pre-diabetes 15.1 (14.2 to 15.9) 11.7 (10.4 to 12.9) 4.5 (3.4 to 5.5) 51.5 (47.2 to 55.7)
Urban
Diabetes
 Known diabetes 21.7 (19.8 to 23.5) 21.5 (19.2 to 23.7) 7.4 (4.5 to 10.2) 17.4 (11.8 to 22.9)
 FG 5.5 (4.4 to 6.5) 2.5 (1.6 to 3.3) 1.2 (0.0 to 2.4) 1.9 (0.0 to 3.8)
 2hGT 1.8 (1.2 to 2.4) 1.6 (0.9 to 2.2) 1.1 (0.0 to 2.2) 5.7 (2.3 to 9.0)
 Both FG and 2hGT 2.6 (1.8 to 3.3) 2.7 (1.8 to 3.5) 0.6 (0.2 to 1.4) 0.9 (0.4 to 2.2)
 Newly diagnosed diabetes 9.9 (8.5 to 11.2) 6.8 (5.4 to 8.1) 2.9 (1.0 to 4.7) 8.5 (4.4 to 12.5)
 Total diabetes 31.6 (29.4 to 33.7) 28.3 (25.8 to 30.7) 10.3 (6.9 to 13.6) 25.9 (19.5 to 32.3)
Pre-diabetes
 FG 2.1 (1.4 to 2.7) 1.9 (1.1 to 2.6) 0.2 (0 to 0.6) 0 (0 to 0)
 2hGT 11.9 (10.4 to 13.3) 7.7 (6.2 to 9.1) 1.7 (0.2 to 3.1) 45.9 (38.6 to 53.1)
 Both FG and 2hGT 2.8 (2.0 to 3.5) 1 (0.4 to 1.5) 0.2 (0 to 0.6) 13.4 (8.4 to 18.3)
 Total pre-diabetes 16.8 (15.1 to 18.5) 10.6 (8.9 to 12.2) 2.1 (0.5 to 3.6) 59.3 (52.1 to 66.4)
Rural
Diabetes
 Known diabetes 21.4 (20.1 to 22.6) 19.4 (17.0 to 21.7) 10.3 (8.5 to 12.0) 15.1 (11.3 to 18.8)
 FG 2.3 (1.8 to 2.7) 6.4 (4.9 to 7.8) 1.7 (0.9 to 2.4) 5.1 (2.8 to 7.3)
 2hGT 0.6 (0.3 to 0.8) 1.5 (0.7 to 2.2) 0.7 (0.2 to 1.1) 5.7 (3.3 to 8.1)
 Both FG and 2hGT 1.7 (1.2 to 2.1) 4.8 (3.5 to 6.0) 2.7 (1.7 to 3.6) 4.4 (2.2 to 6.5)
 Newly diagnosed diabetes 4.6 (3.9 to 5.2) 12.7 (10.7 to 14.6) 5.1 (3.8 to 6.3) 15.2 (11.4 to 18.9)
 Total diabetes 26 (24.6 to 27.3) 32.1 (29.3 to 34.8) 15.4 (13.3 to 17.4) 30.2 (25.4 to 34.9)
Pre-diabetes
 FG 1.4 (1.0 to 1.7) 1.6 (0.8 to 2.3) 1.7 (0.9 to 2.4) 0.3 (0.0 to 0.8)
 2hGT 10.7 (9.7 to 11.6) 9.1 (7.3 to 10.8) 4.4 (3.2 to 5.5) 37.1 (32.0 to 42.1)
 Both FG and 2hGT 1.4 (1.0 to 1.7) 2.2 (1.3 to 3.0) 0.9 (0.3 to 1.4) 6.4 (3.8 to 8.9)
 Total pre-diabetes 13.5 (12.4 to 14.5) 12.9 (10.9 to 14.8) 7 (5.5 to 8.4) 43.8 (38.6 to 48.9)
OGTT criteria for diagnosis of diabetes: fasting ≥126 mg/dL and/or 2 hours ≥200mg/dL.
OGTT criteria for diagnosis of pre-diabetes: fasting 110–125 mg/dL and/or random blood sugar (RBS) 140–199 mg/dL.
2hGT, 2-hour glucose tolerance; FG, fasting glucose.

Associated risk factors of diabetes, pre-diabetes, hyper- Univariate logistic regression was carried out to select
tension, obesity and dyslipidaemia were investigated potential predictors (p≤0.25). Multivariate logistic
using multivariable logistic regression. regression analyses were undertaken to estimate the

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Figure 2 Age-stratified prevalence of diabetes among men and women with urban and rural distribution.

independent effect of predictors on the prevalence study (87% response rate). Basic characteristics of the
of diabetes and pre-diabetes. Models were built and study population are presented in table 1. A total of
compared by stepwise forward selection method and like- 10 834 subjects were screened for diabetes; 43.9% were
lihood ratio test. males and 56.1% were females. More than half of all the
Multicollinearity for variables was checked using vari- participants (53.5%) had at least primary level education.
ance inflation factor (VIF) with a cut-off point mean Around one-third (30%) of the population had positive
VIF >10. Goodness of fit for the final fitted model was family history of diabetes, and 14.5% were tobacco users.
checked using the Hosmer and Lemeshow test. Associa- Mean BMI of participants was almost similar in all prov-
tion between predictors and occurrence of diabetes and inces of Pakistan with an overall mean of 27.23±6.0 kg/m2
pre-diabetes was summarised using adjusted OR and
(mean±SD).
statistical significances were tested at p<0.05. Final model
According to OGTT criteria, overall age-adjusted
equation was written as:
weighted prevalence of diabetes was 26.3%, of which
∑k
‍g0 (t, X1 , X2 , ..., Xk ) = g0 (t) exp ( i=1 βi Xi)‍ 19.2% had known diabetes and 7.1% were newly diag-
nosed people with diabetes. Prevalence of diabetes in
For all estimates, the study population was weighted to
urban and rural areas was 28.3% and 25.3%, respectively.
the latest available demographic information at Pakistan
Highest prevalence of diabetes was observed in Sindh
Bureau of Statistics.18
followed by Punjab. Prevalence of pre-diabetes was 14.4%,
urban and rural distribution was 15.5% and 13.9%,
Results respectively. Overall glycaemic dysregulation (diabetes,
In this survey, 12 486 individuals were approached, out plus pre-diabetes) was 43.8% and 39.2% in urban and
of which 10 834 individuals finally participated in the rural areas, respectively. Prevalence of pre-diabetes and

Figure 3 Age-stratified prevalence of pre-diabetes among men and women with urban and rural distribution.

6 Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961

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newly diagnosed diabetes was higher in Baluchistan

P values

<0.0001
<0.0001

<0.0001
<0.0001
compared with other provinces (table 2). According to

0.001
0.032
the ADA standards of care, on the basis of HbA1c criteria,

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–
prevalence of diabetes and pre-diabetes was 30.1% and
P values Adjusted OR 5.9%, respectively.
Urban women showed significantly higher prevalence

1.4 (1.2–1.6)
1.4 (1.2–1.6)

1.2 (1.0–1.4)

1.7 (1.3–2.1)
1.7 (1.5–1.9)
1.1 (1.0–1.3)
of diabetes than rural women above the age of 40 years
Obesity

while in men this trend was seen in the age group of 60

years and above (p<0.05). On the other hand, urban

–
men in the age group 30–39 years showed significantly

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<0.0001 (p<0.05) lower prevalence of diabetes than rural men
<0.0001

<0.0001
<0.0001
<0.0001

0.019
(figure 2).

–
Rural men showed significantly higher prevalence of
pre-diabetes than urban men for the age group of 40–49
Hypertension

years while for women significant difference was seen in

P values Adjusted OR

1.3 (1.2–1.5)
2.2 (2.0–2.6)
1.3 (1.1–1.8)

1.7 (1.5–2.0)
2.3 (2.0–2.6)
1.6 (1.4–1.9)

urban compared with rural population for the age group

of 30–39 years (figure 3).
Table 3 shows the multivariable logistic regression
for identifying the associated risk factors for diabetes,
–

pre-diabetes, hypertension, obesity and dyslipidaemia.

<0.0001

<0.0001
<0.0001

<0.0001

Age (≥43 years), family history of diabetes, hypertension,

0.004

0.008

obesity and dyslipidaemia were significant risk factors

–

for diabetes (p≤0.0001). Similar were the risk factors

for pre-diabetes including education with the exception
Dyslipidaemia

0.70 (0.6–0.9)

1.84 (1.3–2.4)
0.55 (0.4–0.7)

0.53 (0.4–0.7)
P values Adjusted OR

of obesity (p≤0.05). Significant association was found

1.3 (1.1–1.7)
1.7 (1.3–2.1)

between diabetes, hypertension, obesity and dyslipi-

daemia (p≤0.05).
–
<0.0001
<0.0001

0.011
0.034

0.009

Discussion
We estimated the overall age-adjusted weighted preva-
Multivariable binary logistics regression was used for obtaining OR (95% CI) and p value.

lence of diabetes and pre-diabetes as 26.3% and 14.4%,

Risk factor of diabetes, dyslipidaemia, hypertension and obesity

respectively. Overall glycaemic dysregulation, that is,

Pre-diabetes
P values Adjusted OR

1.5 (1.1–2.1)
0.8 (0.7–0.9)
1.5 (1.2–1.8)

1.2 (1.0–1.4)
1.8 (1.5–2.2)

diabetes plus and pre-diabetes was 43.8% and 39.3% in

urban and rural areas, respectively. This suggests doubling
of glycaemic dysregulation compared with the 1st NDSP
done during 1994–1998.7
Our study has several strengths. To our knowledge, this
<0.0001
<0.0001

<0.0001
<0.0001
<0.0001

is the largest survey on diabetes in Pakistan to include all

the four provinces and both urban and rural populations.
Proper epidemiological methods with multistage strati-
fied sampling technique were used. Oral GTT and HbA1c
Adjusted OR

were done for the diagnosis of diabetes for a sample of

1.8 (1.3–2.4)
1.9 (1.7–2.2)

2.2 (1.9–2.5)
1.4 (1.3–1.6)
3.3 (2.9–3.8)

P<0.05 was considered statistically significant.

over 10 000 people. Another strength is that the whole

Diabetes

study was completed within 1 year with the help of 17

teams across the country. There are also some limitations
in our study. According to WHO, ideally blood tests shall
be repeated for the diagnosis of diabetes, but we were not
Education (primary or more)
Family history of diabetes

able to conduct the repeat specimen collection because

of resource constraints. We also excluded individuals less
than 20 years of age as the survey mainly was designed
for the diagnosis of type 2 diabetes. Furthermore, we
Gender (female)
Age (≥43 years)
Location (rural)

Dyslipidaemia
Hypertension

would not be able to differentiate between type 1 and

Risk factors

type 2 diabetes on the basis of our survey. This is because

Diabetes

Obesity
Table 3

diagnostic approach for type 1 diabetes entails different

methodological processes which were beyond the scope
of our study.

Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961 7

Open access

Various regional surveys have shown higher preva- This study has tremendous future implications.
lence of diabetes among Indo-Asians compared with Diabetes has now become a major public health chal-
other ethnic groups which support our findings. The lenge in Pakistan. If appropriate actions are not taken,

BMJ Open: first published as 10.1136/bmjopen-2017-020961 on 5 August 2018. Downloaded from http://bmjopen.bmj.com/ on August 1, 2025 by guest .
prevalence of diabetes in Malaysia was 22.9% but among the burden of disability and deaths from diabetes will
Indians residing in Malaysia, its prevalence was 37.9%.28 be enormous. The existing infrastructure of healthcare
In addition, studies from Bangladesh and Turkey had services for managing diabetes and its complications is
also shown similar results.29 30 A recent study from China suboptimal. Poverty both as a cause and consequence of
showed that 11.6% adults (≥18 years) had diabetes and diabetes and its complications is a major threat to health,
almost 50% of the population had pre-diabetes.31 Simi- and economic and social development.
larly, a recent study from 15 states of India showed that It requires multiple stakeholders including poli-

Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.
7.3% had diabetes and 10.3% of the population had cy-makers to integrate and execute their actions to
pre-diabetes.32 Also worth noting is the prevalence of save millions of people from premature morbidity and
diabetes in the UK which had doubled from 2.39% in mortality. Urgent strategies need to be developed for
2000 to 5.32% in 2013.33 Moreover, the prevalence of nationwide network of diabetes care and management.
pre-diabetes had increased from 11.6% in 2003 to 35.3% Also, primary prevention ought to be addressed at all
in 2011.34 levels. More importantly, healthy lifestyle changes must
In our study, it was noted that in three out of four prov- be educated and encouraged at school level. Maternal
inces, the prevalence of diabetes was higher than the and child health must be given top priority to prevent
prevalence of pre-diabetes. The age and gender-weighted transgenerational obesity and diabetes.
prevalence also suggests that in early years pre-diabetes is
higher but diabetes prevalence rises steeply after the age
of 30. The possible explanation is the rapid transition to Conclusion
diabetes from pre-diabetes in these provinces. Whereas, The findings of the second NDSP imply that diabetes
in the province of Baluchistan, diabetes to pre-diabetes has reached epidemic proportion and urgently needs
ratio is almost 1:2, suggesting that a large number of indi- national strategies for early diagnosis and effective
viduals are at risk of developing type 2 diabetes. management, as well as cost-effective diabetes primary
Prevalence of diabetes on the basis of HbA1c was prevention programme in Pakistan.
slightly more than on the basis of OGTT. However, preva-
lence of pre-diabetes was much lower comparatively, that Acknowledgements We acknowledge the support of Research and Laboratory
Department of Baqai Institute of Diabetology and Endocrinology (BIDE), Karachi
is, 5.9% by HbA1c criteria compared with 14.4% OGTT.
for data management and we would also like to thank Mr Abdul Rashid and Mr
This pattern has also been found in other studies.35 36 Muhammad Sohail from Pakistan Health Research Council (PHRC), Karachi. We are
Considering limitations of resources and HbA1c varia- grateful to all study subjects for their participation in the 2nd NDSP.
tion with anaemia and haemoglobinopathies, we would Collaborators NDSP members (with surnames in alphabetical order): (1) Dr
still take OGTT as a gold standard diagnostic tool in an Mujeeb Ur Rehman Abro, Assistant Professor of Medicine, Chandka Medical College,
epidemiological setting. Shaheed Mohtarma Benazir Bhutto Medical University, Larkana, Sindh; (2) Dr
Khawaja Ishfaq Ahmed, Ex-PGR, Pakistan Institute of Medical Sciences, Islamabad,
One of the unanswered questions from the study was Punjab; (3) Dr Khurshid Ahmed, Consultant Physician, Zahid Medical Centre, Hub,
much lower prevalence of diabetes and pre-diabetes Baluchistan; (4) Dr Sobia Sabir Ali, Assistant Professor, Department of Diabetes
in the province of Khyber Pakhtunkhwa. On the other and Endocrinology, Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa; (5)
hand, diabetes and pre-diabetes were much higher in Professor Ahmed Bilal, Professor and Head of Medical Department Faisalabad
Medical College, Faisalabad, Punjab; (6) Dr Anam Butt, Research Officer, Baqai
the province of Baluchistan. A number of smaller studies Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Sindh;
had already warned of higher prevalence of risk factors (7) Professor Bikha Ram Devrajani, Chairman, Department of Medicine and Director
leading to diabetes in Baluchistan in the last 20 years, but Sindh Institute of Endocrinology and Diabetes, Liaquat University of Medical and
still this high proportion needs to be evaluated.8 10 37 38 Health Sciences, Jamshoro, Sindh; (8) Mr Ijaz Hayder, Research Officer, Pakistan
Health Research Council, Karachi, Sindh; (9) Dr Yasir Humayun, EPI coordinator,
Further researches are required to study genetic and envi- DHO Office, Mansehra, Khyber Pakhtunkhwa; (10) Mrs Rabia Irshad, Research
ronmental influences among various ethnicities. Officer, Pakistan Health Research Council, Karachi, Sindh; (11) Dr Riasat Ali Khan,
Also addressed in this survey were parameters like Diabetologist, Canada Medical Group Hospital, Defence, Karachi, Sindh; (12) Dr
hypertension, obesity and dyslipidaemia in Pakistan. Asima Khan, Head of Diabetes Department, Sindh Government Hospital, New
Karachi, Karachi, Sindh; (13) Dr Aamir Akram Khowaja, Postgraduate Resident,
These numbers are also correspondingly high and Sindh Government Qatar Hospital, Karachi, Sindh; (14) Dr Raheela Khowaja,
strongly suggestive of the rise of risk factors leading to Postgraduate Resident, Baqai Institute of Diabetology and Endocrinology, Baqai
diabetes. Hypertension nationally was surveyed by the Medical University, Karachi, Sindh; (15) Professor Qazi Masroor, Professor of
Pakistan Health and Research Council (previously called Medicine and Head of Department, Quaid-e-Azam Medical College, Bahawalpur,
Punjab; (16) Dr Maqsood Mehmood, Head of Department, Fatma tu Zahra
Pakistan Medical Research Council) in 1998, and the Hospital, Gujranwala, Punjab; (17) Mr Hassan Moin, Statistician, Baqai Institute
prevalence of hypertension was reported as 33%.39 In our of Diabetology and Endocrinology, Baqai Medical University, Karachi, Sindh; (18)
survey, hypertension in the community is 52.6%. Similar Dr Wasif Noor, Diabetologist, Akhuwat Health Services Diabetes Centre, Lahore,
are the results for overweight and obesity. For overweight Punjab; (19) Mr Ibrar Rafique, Research Officer, Pakistan Health Research Council,
Islamabad, Punjab; (20) Dr Tahir Rasool, Diabetologist, Akhuwat Health Services
and obesity, we have chosen the WHO cut-offs, and the Diabetes Centre, Lahore, Punjab; (21) Mrs Rubina Sabir, Laboratory Manager, Baqai
prevalence is 62.1% and 47.5%, respectively, while from Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi,
Asian cut-offs, these figures are 76.2% and 62.1%. Sindh; (22) Dr M Arif N Saqib, Senior Research Officer, Pakistan Health Research

8 Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961

 Open access

Council, Islamabad, Punjab; (23) Dr Pir Alam Said, Medical Specialist DHQ, Sawabi, 13. Misra A, Vikram NK, Sharma R, et al. High prevalence of obesity
Khyber Pakhtunkhwa; (24) Professor Abrar Shaikh, Head Department of Medicine, and associated risk factors in urban children in India and Pakistan
Ghulam Muhammad Mahar Medical College, Sukkur, Sindh; (25) Mr Bilal Tahir, highlights immediate need to initiate primary prevention program for
diabetes and coronary heart disease in schools. Diabetes Res Clin

BMJ Open: first published as 10.1136/bmjopen-2017-020961 on 5 August 2018. Downloaded from http://bmjopen.bmj.com/ on August 1, 2025 by guest .
NDSP Coordinator, Baqai Institute of Diabetology and Endocrinology, Baqai Medical
Pract 2006;71:101–2.
University, Karachi, Sindh; (26) Professor Salma Tanveer, Professor of Medicine,
14. Non/communicable diseases (NCDs) Risk factors survey –
In-charge Diabetes and Endocrinology, Nishter Medical University, Multan, Punjab; Pakistan. https://www.​dropbox.​com/​s/​j72r5c8ylm49rq3/​NON%​
(27) Professor Bilal Bin Younus, Head of Sakeena Institute of Diabetes & Endocrine 20Communicable%​20Diseases%​20Risk%​20Factors%​20Survey%​
Research, Lahore, Punjab; (28) Professor Jamal Zafar, Professor of Medicine, 20Pakistan.​pdf?​dl=0 (assessed11 Oct 2017).
Pakistan Institute of Medical Sciences, Islamabad, Punjab. 15. Zafar J, Bhatti F, Akhtar N, et al. Prevalence and risk factors for
diabetes mellitus in a selected urban population of a city in Punjab.
Contributors AB: concept, design, interpretation of data, wrote and approved the
J Pak Med Assoc 2011;61:40–7.
final submitted version. AF: concept, design, literature search, designing quality 16. Zafar J, Nadeem D, Khan SA, et al. Prevalence of diabetes and its
assurance measures, research data, wrote and approved the final submitted

Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.
correlates in urban population of Pakistan: A Cross-sectional survey.
version. HQ: involved in the quality control, edited and approved the final submitted J Pak Med Assoc 2016;66:922–7.
version. ASS: concept, design and involved in the quality control. NDSP members 17. International Institute for Population Sciences (IIPS) and Macro
were responsible for the supervision of the survey, concept, design, involved in International. National Family Health Survey (NFHS-3). Mumbai: IIPS,
the quality control and data management in their respective areas. All members 2007:2005–6.
approved the final submitted version. AB and AF are the guarantors and undertake 18. Pakistan Bureau of Statistics. Population Census. 2017. http://www.​
the full responsibility for the contents of the article submitted for publication. pbscensus.​gov.​pk/​sites/​default/​files/​Population_​Results.​pdf
19. Multiple indicator cluster survey manual. Chapter 4: Designing
Funding Haemoglobin A1cs and lipid profiles were performed by Pakistan Health and selecting the sample. m ​ ics.​unicef.​org/​files?​job.​sha=​
Research Council (PHRC). Field visits and data collection including clinical and 3d97a05358bb0e37 (assessed 12 Oct 2017).
anthropometric measurements and also fasting plasma glucose and 2-hour 20. Harrison GG, Buskirk ER, Lindsay Carter JE, et al. Skinfold thickness
post/glucose load samples were run by the respective teams through their own and measurement technique. In: Lohman TG, Roche AF, Martorell R,
funds. The whole survey was coordinated and supported by the Baqai Institute of eds. Anthropometric standardization reference manual. Champaign:
Human Kinetics Books, 1988:55–70.
Diabetology & Endocrinology (BIDE) on their own resources.
21. Fawwad A, Sabir R, Riaz M, et al. Measured versus calculated
Competing interests None declared. LDL-cholesterol in subjects with type 2 diabetes. Pak J Med Sci
2016;32:955–60.
Patient consent Obtained. 22. World Health Organization. Good laboratory practice training manual
Ethics approval National Bioethics Committee (NBC) of Pakistan (Ref: No.4-87/17/ for the trainer: a tool for training and promoting good laboratory
NBC-226/NBC/2664). practice (GLP) concepts in disease endemic countries - 2 ed, 2008.
http://www.​who.​int/​tdr/​publications/​documents/​glp-​trainer.​pdf
Provenance and peer review Not commissioned; externally peer reviewed. (assessed12 Nov 2017).
23. World Health Organization. Definition and diagnosis of diabetes
Data sharing statement No additional data are available.
mellitus and intermediate hyperglycemia: report of a WHO/IDF
Open access This is an open access article distributed in accordance with the consultation, 2006.
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which 24. American Diabetes Association (ADA). Standards of medical care in
permits others to distribute, remix, adapt, build upon this work non-commercially, diabetes—2016. Diabetes Care 2016;39:S1–S106.
and license their derivative works on different terms, provided the original work is 25. WHO Western Pacific Region, International Association for the
Study of Obesity, International Obesity Task Force. The Asia
properly cited, appropriate credit is given, any changes made indicated, and the use
Pacific perspective: redefining obesity and its treatment. Health
is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. Communications Australia Pty Limited: St Leonards, 2000.
26. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Executive summary of the third report of
the national cholesterol education program (ncep) expert panel on
detection, evaluation, and treatment of high blood cholesterol in
References adults (adult treatment panel iii). JAMA 2001;285:2486–97.
1. Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF Diabetes 27. Cochran WG. Sampling techniques. Canada: John Wiley and Sons,
Atlas: Global estimates for the prevalence of diabetes for 2015 and 1977.
2040. Diabetes Res Clin Pract 2017;128:40–50. 28. Ali O, Tan TT, Sakinah O, et al. Prevalence of NIDDM and impaired
2. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the glucose tolerance in aborigines and Malays in Malaysia and their
prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract relationship to sociodemographic, health, and nutritional factors.
2010;87:4–14. Diabetes Care 1993;16:68–75.
3. World Health Organization. Global report on diabetes, 2016.
29. Rahim MA, Hussain A, Azad Khan AK, et al. Rising prevalence of
4. International Diabetes Federation (IDF). Atlas. 7th edn, 2015.
type 2 diabetes in rural Bangladesh: a population based study.
5. World Health Organization (WHO) South/East Asia Diabetes fact
Diabetes Res Clin Pract 2007;77:300–5.
sheet. Fact Sheet - NCD (Diabetes), Department of Sustainable
30. Satman I, Yilmaz T, Sengül A, et al. Population-based study
Development and Healthy Environments, 2014.
of diabetes and risk characteristics in Turkey: results of the
6. Narayan KM, Zhang P, Williams D, et al. How should developing
turkish diabetes epidemiology study (TURDEP). Diabetes Care
countries manage diabetes? CMAJ 2006;175:733–6.
7. Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. 2002;25:1551–6.
Diabetes Res Clin Pract 2007;76:219–22. 31. Xu Y, Wang L, He J, et al. China Non communicable Disease
8. Shera AS, Rafique G, Khwaja IA, et al. Pakistan national diabetes Surveillance Group. Prevalence and control of diabetes in Chinese
survey: prevalence of glucose intolerance and associated factors in adults. JAMA 2013;310:948–59.
Shikarpur, Sindh Province. Diabet Med 1995;12:1116–21. 32. Anjana RM, Deepa M, Pradeepa R, et al. Prevalence of diabetes
9. Shera AS, Basit A, Fawwad A, et al. Pakistan National Diabetes and prediabetes in 15 states of India: results from the ICMR-INDIAB
Survey: prevalence of glucose intolerance and associated factors in population-based cross-sectional study. Lancet Diabetes Endocrinol
the Punjab Province of Pakistan. Prim Care Diabetes 2010;4:79–83. 2017;5:585–96.
10. Shera AS, Rafique G, Khawaja IA, et al. Pakistan National Diabetes 33. Sharma M, Nazareth I, Petersen I. Trends in incidence, prevalence
Survey: prevalence of glucose intolerance and associated factors in and prescribing in type 2 diabetes mellitus between 2000 and
Baluchistan province. Diabetes Res Clin Pract 1999;44:49–58. 2013 in primary care: a retrospective cohort study. BMJ Open
11. Shera AS, Rafique G, Khwaja IA, et al. Pakistan National Diabetes 2016;6:e010210.
Survey prevalence of glucose intolerance and associated factors 34. Mainous AG, Tanner RJ, Baker R, et al. Prevalence of prediabetes in
in North West at Frontier Province (NWFP) of Pakistan. J Pak Med England from 2003 to 2011: population-based, cross-sectional study.
Assoc 1999;49:206–11. BMJ Open 2014;4:e005002.
12. Basit A, Danish Alvi SF, Fawwad A, et al. Temporal changes in the 35. Zhou X, Pang Z, Gao W, et al. Performance of an A1C and fasting
prevalence of diabetes, impaired fasting glucose and its associated capillary blood glucose test for screening newly diagnosed diabetes
risk factors in the rural area of Baluchistan. Diabetes Res Clin Pract and pre-diabetes defined by an oral glucose tolerance test in
2011;94:456–62. Qingdao, China. Diabetes Care 2010;33:545–50.

Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961 9

 Open access

36. Lorenzo C, Wagenknecht LE, Hanley AJ, et al. A1C between 5.7 and 38. Basit A, Hydrie MZI, Ahmed K, et al. impaired fasting glucose
6.4% as a marker for identifying pre-diabetes, insulin sensitivity and and associated risk factors in a rural area of Baluchistan
secretion, and cardiovascular risk factors: the Insulin Resistance according to new ADA criteria. J Pakistan Med Assoc
Atherosclerosis Study (IRAS). Diabetes Care 2010;33:2104–9. 2002;52:357–60.

BMJ Open: first published as 10.1136/bmjopen-2017-020961 on 5 August 2018. Downloaded from http://bmjopen.bmj.com/ on August 1, 2025 by guest .
37. Fawwad A, Alvi SF, Basit A, et al. Changing pattern in the risk factors 39. Saleem F, Dua JS, Hassali AA, et al. Hypertension in Pakistan:
for diabetes in young adults from the rural area of Baluchistan. J Pak time to take some serious action. Br J Gen Pract
Med Assoc 2013;63:1089–93. 2010;60:449–50.

Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.

10 Basit A, et al. BMJ Open 2018;8:e020961. doi:10.1136/bmjopen-2017-020961

Open access Correction

Correction: Prevalence of diabetes, pre-diabetes and

associated risk factors: second National Diabetes Survey of
Pakistan (NDSP), 2016–2017

Basit A, Fawwad A, Qureshi H NDSP Members, et al. Prevalence of diabetes, pre-diabetes

and associated risk factors: second National Diabetes Survey of Pakistan (NDSP), 2016–
2017. BMJ Open 2018;8:e020961. doi: 10.1136/bmjopen-2017-020961.

The previous version of this manuscript contains incorrect versions of

figures 2 and 3 in the published article. Figures 2 and 3 should appear as:

Figure 2: Age-stratified prevalence of diabetes among men and women with urban
and rural distribution
­
­

Figure 3: Age-stratified prevalence of pre-diabetes among men and women with

urban and rural distribution

The following related text should read as:

Urban women showed significantly higher prevalence of diabetes than rural women
above the age of 40 years while in men this trend was seen in the age group of 60 years
and above (p<0.05) (figure 2).

BMJ Open 2018;0:e020961corr1. doi:10.1136/bmjopen-2017-020961corr1 1

Open access

Relating to figure 3, the following text should read as:

Urban men showed significantly higher prevalence of pre-diabetes than rural men for
the age group of 60 years and above while for women significant difference was seen
in urban compared with rural population for the age groups of 40-49 and 60 years and
above (figure 3).

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial
(CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes
made indicated, and the use is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and
permissions. Published by BMJ.

BMJ Open 2018;0:e020961corr1. doi:10.1136/bmjopen-2017-020961corr1

2 BMJ Open 2018;0:e020961corr1. doi:10.1136/bmjopen-2017-020961corr1