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Background: Understanding the prevalence of type 2 diabetes in Nepal can help in planning for health services and recognising risk factors. Design: This systematic review was conducted in adherence to the MOOSE Guidelines for Meta-Analysis and Systematic Reviews of Observational Studies. Conclusions: This is, to our knowledge, the first study to systematically evaluate the literature of prevalence of type 2 diabetes in Nepal. Competing interests and funding: The authors have declared that no competing interests exist.
Approximately 387 million people are living with diabetes worldwide with an estimated prevalence of 8.3% in 2014 and is predicted to increase to 10% by 2030 (1). Nepal is passing through a phase of epidemiological transition from a higher prevalence of communicable diseases to that of non-communicable diseases (NCDs) and is currently suffering from a double burden of diseases (5). This systematic review was conducted in adherence to the MOOSE Guidelines for Meta-Analysis and Systematic Reviews of Observational Studies (9). In the second stage, the total hits obtained from MEDLINE using the above criteria were screened by reading titles and abstracts.
We entered data in a pre-tested Microsoft Office Excel spreadsheet designed based on the Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) checklist (17).
Ten studies that fulfilled the inclusion criteria were used for the review (8, 10, 19–26). Meta-analysis was performed and pooled ORs were calculated from the adjusted ORs and 95% CI in each available study.
This is the first study, to our knowledge, to systematically evaluate the literature of prevalence of type 2 diabetes in Nepal.
Given the considerable burden of diabetes, there is a need for future research efforts focusing on preventive interventions and control measures in the Nepalese communities. Our pooled results support the finding that type 2 diabetes is currently a high-burden disease in Nepal suggesting a possible area for health promotion activities as well as early diabetes interventions to help control the disease.
Prevalence and trends of the diabetes epidemic in South Asia: a systematic review and meta-analysis. Obesity prevalence in Nepal: public health challenges in a low-income nation during an alarming worldwide trend.
Do non-communicable diseases such as hypertension and diabetes associate with primary open-angle glaucoma? What’s New in Ubeki-beki-beki-stan-stan-stan or the serious picture of global obesity [Internet].
The prevalence of diabetes mellitus and associated risk factors in the female population of Kavre in rural Nepal.
Diabetes mellitus and impaired hyperglycemia in a teaching hospital of south-western Nepal. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.
Evaluation of new WHO diagnostic criteria for diabetes on the prevalence of abnormal glucose tolerance in a heterogeneous Nepali population – the implications of measuring glycated hemoglobin.
Prevalence of non-insulin dependent diabetes mellitus in urban areas of eastern Nepal: a hospital based study. The prevalence of hypertension and diabetes defined by fasting and 2-h plasma glucose criteria in urban Nepal. The prevalence of type 2 diabetes mellitus and impaired fasting glucose in semi-urban population of Nepal. Hyperglycemia, glucose intolerance, hypertension and socioeconomic position in eastern Nepal. Prevalence of non insulin dependent diabetes mellitus and associated risk factors in the Mazatec population of the State of Oaxaca, Mexico. Physical activity level and its sociodemographic correlates in a peri-urban Nepalese population: a cross-sectional study from the Jhaukhel-Duwakot health demographic surveillance site. Prevalence and projections of diabetes and pre-diabetes in adults in Sri Lanka – Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Urban rural differences in prevalence of self-reported diabetes in India – the WHO-ICMR Indian NCD risk factor surveillance. Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation. Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West at Frontier Province (NWFP) of Pakistan. Population-based study of diabetes and risk characteristics in Turkey: results of the Turkish diabetes epidemiology study (TURDEP). A comparative study of body mass index (BMI) in diabetic and non-diabetic individuals in Nepalese population. Awareness regarding risk factors of type 2 diabetes among individuals attending a tertiary-care hospital in Bangladesh: a cross-sectional study. Prevalence of diabetes mellitus among the adult population in rural blocks of Haryana, India: a community-based study. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. Behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity.
A community-based participatory diabetes prevention and management intervention in rural India using community health workers. All treatment options shown may be appropriate, and final selection of therapy should be individualized based on patient eligibility and treatment availability at the physician's discretion. All treatment options shown may be appropriate and final selection of therapy should be individualized based on patient eligibility and treatment availability at the physician's discretion. Consensus statement policyThe Institute of Medicine's March 2011 Standards for Developing Trustworthy Clinical Practice Guidelines13 served as a model for organising and preparing this consensus statement. Consensus management of stage II melanomaThe panel is divided on the role of immunotherapy for patients with high-risk stage II melanoma (Figure 1) and recognizes the limited level A data available to inform clinical decision-making. Substitute Healthy Fats for Saturated Fats, Refined Carbs To Reduce Diabetes Risk - Review of 100 studies finds replacing saturated fats and carbs with unsaturated fats may reduce risk of getting type 2 diabetes or help manage it. Substitute Healthy Fats for Saturated Fats, Refined Carbs To Reduce Diabetes RiskBye, Bye Butter Guilt?
With commentary by Nicola Guess, PhD, RD, MPH, lecturer, Imperial College and Kings' College, London, and Fumiaki Imamura, PhD, investigator scientist, University of Cambridge.Want to reduce your risk of getting diabetes? Imamura, joined by researchers from Tufts University and other universities, reviewed 102 randomized controlled trials, the gold standard for research, involving more than 4,000 men and women. Sign up for our FREE DiabeticLifestyle eNewsletter, and receive diabetes-friendly recipes, news, treatment updates, lifestyle tips on managing your diabetes, and more.
The stress of obesity, combined with a genetically susceptible background, produces insulin resistance and impaired glucose tolerance. This review aims to systematically identify and collate studies describing the prevalence of type 2 diabetes, to summarise the findings, and to explore selected factors that may influence prevalence estimates. Medical Literature Analysis and Retrieval System (MEDLINE) database from 1 January 2000 to 31 December 2014 was searched for the prevalence of type 2 diabetes among Nepalese populations with a combination of search terms. Results showed that type 2 diabetes is currently a high-burden disease in Nepal, suggesting a possible area to deliberately expand preventive interventions as well as efforts to control the disease. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Diabetes caused 4.9 million deaths in 2014, costing 612 billion dollars in health care (1).
The prevalence of NCDs including type 2 diabetes is expected to increase rapidly in the near future (6). Data on the prevalence of diabetes among the Nepalese adults were obtained by a three-stage process.
Where available, odds ratios (ORs) with respective confidence interval (CI) for associated risk factors (gender, age, BMI, family history, physical activity levels, the area of residence, and hypertension) were recorded. We performed quality assessment of included studies to determine the potential for selection bias based on the presence of eligibility criteria, sampling strategy, sample size, non-response rate, explaining limitations of the study, and generalisability as well as for measurement bias which included measurement techniques (18).
The rural and urban categories were made based on the information provided by the individual studies.
The random effects model assumes that the observed heterogeneity is determined by real differences in the distribution.


This study summarised prevalence of type 2 diabetes in Nepal for a 14-year period (2000–2014). A wealth of studies has reported that the problem of diabetes is largely concentrated in urban areas (43, 44). There is a paucity of Nepal-specific studies depicting high risk of type 2 diabetes among women; however, a systematic review from India reported that women are at higher risk of type 2 diabetes (46). It is necessary to consider the development of cost-effective intervention methods for diabetes prevention and control such as routine diabetes care including lifestyle counselling, early screening, monitoring of hyperglycaemia, provision of diabetes education, and self-management care programs (54, 55). Our study is limited only to the selected database source and English-language publications and therefore might have missed a small number of relevant publications.
Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation.
The goal of this article is to provide evidence-based consensus recommendations for the use of immunotherapy in the clinical management of patients with high-risk and advanced-stage melanoma in the USA.
These standards include establishing a transparent process for guideline development and funding, managing and reporting conflicts of interest, inclusion of a multidisciplinary and balanced group composition, establishing an evidence-based foundation and rating system for the strength of the evidence, reporting the results through a peer-reviewed publication and publicly available website, and having a plan for updating the statement as changes in the field warrant revisions. This workup should include sentinel-lymph-node biopsy, when appropriate.3, 16 There is general agreement that patients with low-risk stage II melanoma can be safely observed and do not warrant treatment (Figure 1).
The majority of the panel recommends that high-risk patients be treated with standard 1-year interferon-α2b, although a minority suggest participation in clinical trials (assuming availability and eligibility to the protocol-specific patient selection criteria of the trial) or observation. The information and recipes on this site, although as accurate and timely as feasibly possible, should not be considered as medical advice, nor as a substitute for the same. Continued stress, from hyperinsulinaemia, gluco- and lipotoxicity, on the pancreatic-islet -cells results in failure to maintain sufficient insulin levels to compensate for the insulin resistance, leading to elevated glucose levels and the diagnosis of diabetes. We exploded the search terms to include all possible synonyms and spellings obtained in the search strategy.
More than 80% of diabetes deaths are reported in low- and middle-income countries (LMICs) (2). There is a lack of reliable and representative data on the prevalence of type 2 diabetes in Nepal. The studies identified for inclusion in the second stage were further screened for suitability during the third stage by reading the selected manuscripts. Figure 3 represents a meta-analysis of studies that measured the prevalence of type 2 diabetes in Nepal.
Few population-based studies conducted in Nepal so far have reported a high prevalence of type 2 diabetes in urban areas (21, 23).
The positive association we found between gender and type 2 diabetes has also been observed in Pakistan (47) and Turkey (48). At present, the government and few non-government organisations (NGOs) are conducting few awareness creation programs on the prevention of type 2 diabetes through health camps and by using the mass media in Nepal (56).
Considering the very low number of eligible articles, we took diabetes studies regardless of the place of study.
In spite of the limited publications, our review suggests that there are considerable differences in the prevalence of type 2 diabetes between rural and urban areas and between studies.
Melanoma can be highly sensitive to immunotherapy and of the six approved drugs highlighted above only dacarbazine and vemurafenib are not immunotherapies. Convening under the umbrella of SITC (June 2011), a steering committee led a panel, which sought to develop clinical treatment guidelines considering four basic issues for each immunotherapy agent in current clinical practice: patient selection, toxicity management, assessment of response, and therapy sequencing and combinations. A few panellists (5%) individualize treatment of patients with high-risk stage II melanoma based on the particular situation. Polyunsaturated fats are found in plant-based oils such as olive, soybean, corn and sun flower, as well as salmon, mackerel and other fatty fish.
Microvascular complications become apparent over time, depending on how well glucose levels can be controlled. Additionally, we performed a manual search for other articles and references of published articles.
Of the two forms of diabetes, type 2 diabetes is widespread globally, accounting for over 90% of all diabetes cases (2).
We explored the search terms to include all possible synonyms and spellings obtained in the search strategy. A low P value or large chi-squared statistic (relative to its degree of freedom) suggests heterogeneity and variation in effect estimates beyond chance. Significant differences in type 2 diabetes prevalence were observed between urban and rural parts of Nepal. One study reported urban residency, having a higher socio-economic status and a higher BMI as risk factors for diabetes (25). Figure 4 represents the funnel plot for visualising publication bias amongst the 10 studies used for meta-analysis.
However, this pooled result is consistent with other literature examining the prevalence of type 2 diabetes in different parts of the world.
One possible reason behind this might be due to low educational level of women as a result of which they might pay less attention to their dietary intake habits and physical activities. However, diabetes and other NCDs are still not the priority area of the government and there is a paucity of programs to detect, manage, and prevent diabetes and NCDs in the country (57).
We could not consider key variables that have shown to influence the prevalence of diabetes in this study such as BMI, family history, physical activity, and diet intake. Consequently, there is a need to prioritise diabetes on the public health care agenda in Nepal through the promotion of preventive measures such as dietary pattern, exercises, and periodic check-up.
All the authors contributed in drafting the manuscript, literature review, and interpretation of the findings.
The Institute of Medicine clinical practice guidelines were used as a basis for this consensus development. There was level B data for a clinical benefit with surgical resection of completely resectable lesions and first-line surgical resection was a minority opinion (9%) of the consensus panel. This consensus statement is not intended to substitute for the individual professional judgement of the treating physician.
None of the panel members recommends treatment with pegylated-interferon-α2b for patients with high-risk stage II disease.
However, beyond that, the effects of dietary fat and carbohydrates on blood sugar and insulin sensitivity have been debated, he says. A systematic review carried out in 2012 confirmed a rapid increase in prevalence over the last two decades in the South Asian region (3). Individually these studies cannot provide sufficient information about the overall prevalence of type 2 diabetes in the country due to the non-representativeness of the study populations. We did not use pre-diabetes as a MeSH term since this search term was only introduced in 2002 and definitions of pre-diabetes cannot be found from studies predating 2002.
When there was more than one report relating to the same study sample, the most up-to-date and relevant study was included. A score of one was given for fulfilling conditions in each domain, 0.5 for partial fulfilment, and 0 otherwise. I2 is the proportion of total variation provided by between-study variation, and I2 values of 0, 25, 50, and 75% represent no, low, moderate, and high heterogeneity, respectively (32). One study reported physical activity and primary education as risk factors for diabetes (8). One statistic puts female literacy rate at around 47% as compared to 71% for men in Nepal (45). Moreover, the level of knowledge, attitude, and good practice as a means to control and prevent diabetes is very low among Nepali people (20). More than two-thirds of studies included were of poor methodological quality in terms of sample size, variable selection, and sampling techniques, which might have resulted in some bias. A systematic literature search was performed for high-impact studies in English between 1992 and 2012 and was supplemented as appropriate by the panel. Although therapeutic benefits can be durable, only a subset of patients respond.7, 8 In addition, unique adverse effects of immunotherapy, many of which relate to the induction of autoimmunity and pro-inflammatory-like states,10 might limit eligibility or become challenges in clinical management. Full consensus recommendations can be found on the SITC website.14 Owing to disparities in drug approval and availability in some countries, this panel focused solely on drugs approved by the FDA for the treatment of patients in the USA. Patients with high-risk stage II melanoma who are treated with interferon-α2b should have a good performance status without evidence of significant depression or psychiatric history or underlying autoimmune disease.
The prevalence of type 2 diabetes in South Asia in 2011, according to the International Diabetes Federation (IDF), is shown in Fig.
It is anticipated that bringing together the currently available evidence on the prevalence of type 2 diabetes in Nepal will improve statistical power and provide more accurate estimations to inform policy makers at the local and national level to control the emerging burden of the disease.
All studies were original and contained a minimum of information necessary to calculate pooled analysis of prevalence (number of subjects and number of diabetes events).


The maximum possible score was 11 and a study scoring seven or more was classified as a high-quality study and low-quality study otherwise. We could not conduct a meta-analysis and calculate pooled ORs of these studies since only one study reported the same risk factor. Moreover, owing to patriarchal mindset, women are normally expected to pay more attention to the health of the men and children in the family, and in the process they might ignore their own well-being (49). Unless urgent and specific focus is on preventing, treating, and controlling of diabetes, the burden of diabetes will be severe in low-resource setting such as Nepal. This consensus report focuses on issues related to patient selection, toxicity management, clinical end points and sequencing or combination of therapy.
An advance copy of this manuscript was submitted to the FDA for comment before submission for publication.Consensus panel and conflicts of interestPotential panel members were solicited from SITC members and non-member melanoma multidisciplinary experts, clinicians and populations in the USA expected to be affected by the development of any recommendations, including patients, patient advocates and nurses.
Before conducting the review, Imamura says, the researchers had hypothesized that unsaturated fats were preferable to saturated fats or refined carbohydrates.
On binding to its receptor, insulin induces activation of the insulin-receptor kinase (IRK) through autophosphorylation. Thus, the purpose of this review is to document the studies estimating the prevalence of and associated risk factors of type 2 diabetes in Nepal through a systematic review and meta-analysis.
The full text of studies meeting inclusion criteria was retrieved and screened to determine eligibility by two reviewers (BG, RS). Three studies reported their sampling methods (10, 23, 25): one used simple random sampling (25), one used cluster sampling (23), and the third used probability proportionate to size (10). The general shift of people from rural to urban areas for education, employment, and a better life may have contributed to an increasing burden of type 2 diabetes. A wealth of studies has documented an association between diabetes and BMI (50), family history (51), physical inactivity (52), and area of residence (53).
Acquiring information regarding awareness level about diabetes is the first step in formulating prevention programs for diabetes (51).
The literature review and consensus panel voting and discussion were used to generate recommendations for the use of immunotherapy in patients with melanoma, and to assess and rate the strength of the supporting evidence. IL-2 can be considered in those patients who have a good PS and otherwise qualify for IL-2 administration as per local institutional guidelines.
To provide guidance to practicing clinicians caring for patients with melanoma, SITC established a Melanoma Clinical Immunotherapy Guidelines panel (Supplementary Box 1 online). Panel members were screened for conflicts of interest using the SITC disclosure form, which mandates full financial and other disclosures including relationships with commercial entities that might reasonably be expected to have direct regulatory or commercial impact resulting from the publication of this statement. Patients with high-risk melanoma who are enrolled in a clinical trial follow the course of treatment and treatment cessation dictated by the trial protocol.Literature review and analysisLimited data exist on the role of immunotherapy for low-risk stage II melanoma, but there have been several randomized clinical trials focusing on patients with high-risk stage II disease.
Recruitment of insulin-receptor substrate (IRS) proteins induces activation of phosphatidylinositol 3-kinase (PI3K) through binding the p85 subunit and activating the catalytic p110 subunit. Factors such as family history, urban residence, advanced age, higher Body Mass Index (BMI), poor lifestyle, and hypertension were found to be major drivers behind the increasing prevalence of diabetes in South Asia (3).
Two researchers (BG, RS) independently searched the database with these search terms to ensure that none of the relevant studies were missed.
Three studies fulfilled the highest quality criteria (10, 23, 25), while the majority of the articles did not include the limitations of the studies. It is also possible that people with diabetes may move to urban areas after diagnosis to be closer to hospitals, perhaps staying with urban family members.
We could not perform a meta-analysis for these risk factors due to the limited number of studies in Nepal.
Therefore, a national strategy is required to address the disease burden and one of the strategies would be to involve a large number of community health care workers to communicate with the general public at large which can serve as an antecedent for future prevention and management efforts of type 2 diabetes in low-resource settings (58).
There are limited data available on interferon-α2b as treatment for stage II disease. The panel consisted of melanoma experts, including physicians, nurses and patient advocates and considered issues related to patient selection, toxicity management, treatment cessation guidelines and current recommendations for treatment sequencing with the goal of preparing a consensus statement on clinical use of tumour immunotherapy for patients with melanoma. Disclosures of potential conflicts of interest are noted in this manuscript and in detail online.
PI3K activation induces downstream effectors, such as phosphatidylinositol-dependent kinase 1 (PDK1) and protein kinase B (PKB; also known as AKT), leading to translocation of glucose transporter 4 (GLUT4) and glucose uptake in muscle, and inactivation of glycogen-synthase kinase 3 (GSK3).
The detailed inclusion and exclusion criteria as well as extraction process of the articles are shown in Fig.
Various socio-economic characteristics and lifestyle behaviours of rural and urban regions may have attributed to these observed differences between regions. More studies are needed to explore the association between diabetes and its risk factors in Nepalese settings. Furthermore, information on the prevention and control of diabetes must be incorporated into general health promotion programs, from the government, NGOs and international non-government organisations (INGOs).
Two of the studies were hospital-based (19, 20), we considered removing those as they are not typical general population studies.
Expert recommendations for how to incorporate these agents into the therapeutic approach to melanoma are provided in this consensus statement.
IR activation can also activate the c-Cbl-associated protein (CAP) and mitogen-activated protein kinase (MAPK) pathways (not shown). We identified a number of studies from World Health Organization (WHO) publications (one study) (10), grey literature (two studies) (11, 12), university institutional website (one study) (13), and reference lists of retrieved articles (three studies) (14–16). The reported high prevalence of diabetes exemplifies the shift from a burden of disease ruled by mortality from infectious causes to chronic ones (40). Specific lifestyle interventions tailored to meet the cultural, religious, and socio-economic needs of the target communities are urgently needed. Tumour immunotherapy is a useful therapeutic strategy in the management of patients with melanoma and evidence-based consensus recommendations for clinical integration are provided and will be updated as warranted.
Additional questionnaires were distributed after the meeting to collect further information. But her team also thinks those foods may help the muscles take up the glucose, she says.Putting Results to WorkHere's how to put the results to work.
This increase could be attributed to various lifestyle changes associated with urbanisation and deterioration of the ecological environment (41). These two hospital-based studies may have biased the urban–rural difference as hospitals in Nepal are based in urban areas but provide care for both urban and rural patients.
In most cases individual clinical trials should be considered pending patient eligibility and interest. The final consensus statement was made available to the entire SITC membership for open comment and these comments were considered for the final manuscript and are available in Supplementary Box 2 online.Literature reviewA search of the scientific literature (using the MEDLINE database) was conducted focusing on current therapeutic approaches in humans. Remember that the new study found that switching just 5% of energy from carbs and saturated fat to healthier fats made a difference, Imamura says.
Activation of STAT3 through JAK2 phosphorylation induces translocation of STAT3 to the nucleus. One email request was also sent to a corresponding author to obtain raw data (15), but the attempt was unsuccessful.
STAT3 induces gene responses that reduce transcription of acetyl-coenzyme-A carboxylase (ACC), reducing malonyl CoA and fatty-acid synthesis, while increasing fatty-acid oxidation. Since the reported prevalence rate was unusually high, the article was excluded from the analysis, which we believe was the appropriate action.
The bibliography was supplemented with additional literature identified by the panel, as appropriate. Endoplasmic-reticulum-bound or cytosolic PTP1B dephosphorylates membrane-bound or endocytosed insulin receptors and leptin receptors, causing their deactivation. Complete tumour staging information should be assessed, including pathological features of the primary tumour and any involved lymph nodes, whole-body imaging, serum lactate dehydrogenase (LDH) levels and performance status assessment. Other PTP1B substrates, such as IRS1 and PTP1B, can downregulate IRK activity through a complex formed with growth-factor-receptor-bound protein 2 (GRB2).
Level A represented strong supporting evidence-based data as derived from appropriately powered prospective, randomized clinical trials and meta-analyses. Level B represented moderate supporting data as derived from uncontrolled, prospective clinical trials. Level C represented weak supporting data as derived from retrospective reviews and case reports.



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