TRACK (by NEHEP) Implementation: A Bangladesh Scenario

With the increasing burden of non-communicable diseases in low-income and middle-income countries (LMICs), biological risk factors, such as hyperglycemia, are a major public health concern in Bangladesh. Optimization of diabetes management by positive lifestyle changes is urgently required for prevention of comorbidities and complications, which in turn will reduce the cost. Diabetes had 2 times more days of inpatient treatment, 1.3 times more outpatient visits, and nearly 10 times more medications than nondiabetes patients, as reported by British Medical Journal. And surprisingly, 80% of people with this so called “Rich Man’s Disease” live in lowand middle-income countries. According to a recent study of American Medical Association, China and India collectively are home of nearly 110 million diabetic patients. The prevalence of diabetes in this region is projected to increase by 71% by 2035. Bangladesh was ranked as the 8th highest diabetic populous country in the time period of 2010-2011. In Bangladesh, the estimated prevalence of diabetes among adults was 9.7% in 2011 and the number is projected to be 13.7 million by 2045. The cost of diabetes care is considerably high in Bangladesh, and it is primarily driven by the medicine and hospitalization costs. According to Bangladesh Bureau of Statistics, in 2017 the annual average cost per T2DM was $864.7, which is 52% of per capita GDP of Bangladesh and 9.8 times higher than the general health care cost. Medicine is the highest source of direct cost (around 85%) for patients without hospitalization. The private and public financing of diabetes treatment will be severely constrained in near future, representing a health threat for the Bangladeshi population.


Introduction
Bangladesh is among the top 10 countries with the highest rates of projected age-standardized mortality among selected LMICs due to chronic diseases, particularly for CVDs and diabetes [1]. The age adjusted death rate 40 per 100,000 of population ranks Bangladesh 57 in the world, says WHO [2]. Diabetes is one of the four major types of non-communicable diseases that make the largest contribution to morbidity and mortality worldwide.
The International Diabetes Federation (IDF) estimated that, worldwide, approximately 425 million people had diabetes in 2017, projected to be 629 million by 2045. Again, worldwide $727 billion was spent in 2017 for treating and preventing diabetes, projected to be US$776 billion by 2045 [2]. In Bangladesh, specifically, the IDF projects the prevalence of diabetes will increase to more than 50% in the next 15 years [4]. About 129,000 deaths were attributed to diabetes in Bangladesh in 2015, as reported by leading research organization ICDDR, B [5]. According to the WHO-Diabetes country profile of Bangladesh in 2016, the physical inactivity was prevailing among 25.1% of population [6]. Around 85% population of age group 25-65 never checks for diabetes [7]. A recent study by British Medical Journal says, 1 in 10 Bangladeshi adults aged ≥18 years have hyperglycemia (among urban residents) [4]. Even in rural Bangladeshi community, undiagnosed diabetes was high, 7.2% found in a 2016 [8] and 10% in 2019. Roughly 20%-30% of adults in rural areas of Bangladesh have abnormal fasting glucose or impaired glucose tolerance, with the prevalence of diabetes (mostly type 2 diabetes) expected to reach 24%-34% by 2030 [9]. And IDF says, there are 7.1 million people with undetected diabetes in Bangladesh and this number will be double by 2025 [10]. Das et.al, 2019 reported prevalence of dyslipidemia was over 70% to both male and female subjects, which indicates the urgency of lifestyle intervention strategies to prevent and manage this important health problem and risk factor [11]. Among 8400 stroke patients from different hospitals in Bangladesh over a period of sixteen years, diabetic patients were nearly 25% [12]. Prevention strategies should focus on increasing physical activity, weight loss, smoking cessation, and stricter control of hypertension and glycemic level [13].

A. The TRACK Concept
National Eye Health Education Program (NEHEP) developed a tool using the word "TRACK" to help you remember how to stay on track with diabetes. To keep blood sugar level on target and avoid problems with eyes, kidneys, heart and feet, patients should eat right and be active, and may need to take medication. This helps them make choices in eating and being active so body can perform at its best. By regularly monitoring, patients get it on track and prevent long-term health problems [14,15]. TRACK was developed for diabetic retinopathy prevention but in real life it prevents all other diabetic complication by disease progression. The criteria, in short are regular health checkup and compliance of treatment guidelines along with some lifestyle modifications.

Research
conducted a year-round comprehensive literature search, which included technical newsletters, newspapers journals, and many other sources. The present study was started at the beginning of 2019. PubMed, ALTAVISTA, Embase, Scopus, Web of Science, and the Cochrane Central Register were thoroughly searched. The keywords were used to search for different publishers' journals such as Elsevier, Springer, Willey Online Library, and Wolters Kluwer which were extensively followed. Medicine and technical experts, pharmaceutical company representatives, hospital nurses, and journalists were given their valuable suggestions. Projections were based on TRACK criteria of regular health checkup by diabetic and non-diabetic Bangladeshi population. There are many studies regarding diabetes in Bangladeshi population. This is the first study so far, where TRACK criteria (suggested by NEHEP of National Institute of Health, England) fulfillment is studied in Bangladesh.

A. Compliance Issue
Poor adherence is a well-documented obstacle in therapeutic control of diabetes. For an effective control and prevention of diabetes, 87% of Bangladeshis were noncompliant, compared to 71% of Indians and 52% Europeans [16]. Out-of-pocket expenditure, emotional status, frequency of counseling, patient's family priorities, availability of medication (mainly insulin) are the factors greatly influence patient compliance to treatment guidelines. In 2016, the median monthly cost of diabetes maintenance was close to $10, approximately 10% of the median monthly income [17]. According to a 2018 BBC record, insulin availability found supplies were low in six countries -Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka [18]. Also, huge gap between the number of diabetic patients and doctors are well-known. The Diabetic Association of Bangladesh (DAB) record shows, except Dhaka and Chittagong, there are no tertiary facilities in Bangladesh to preventing blindness due to diabetic retinopathy [19]. Children with diabetes are still managed by adult physicians or occasionally by adult diabetologists, except in institutions like BIRDEM, and Dhaka Shishu Hospital. Children and adolescents have special needs at different stages e.g., nutrition, schooling, growth, puberty etc. Improving detection, awareness, and treatment strategies is urgently needed to prevent the growing burden associated with diabetes [20].

B. Overweight Issue
Overweight or obese children have a higher risk of becoming obese in adulthood and are at higher risk of associated chronic diseases [21]. Al Muktadir et.al, 2019 revealed that around 22% to 27% Bangladeshi youth were recorded as obese with different stages of obesity [22]. Another study says nearly 40% Bangladeshi youth, taking fast foods were recognized as overweight where 32% were noted as obese with different phases of obesity and overall prevalence of fast food consumption was about 53.8% [23]. In a newspaper interview, Professor AK Azad Khan, President, Diabetic Association of Bangladesh said 40% school going children of Dhaka city were either obese or overweight [24]. "Children with type 2 diabetes is rising "alarmingly" in Bangladesh. A 300% raise in the last five years", according to the Changing Diabetes in Children Program of the BIRDEM hospital [25]. A community level study shows 35% of mothers perceived that childhood overweight/obesity could be a health problem and nearly 70% were not aware of any health consequences of childhood obesity [26]. Another study shows 97.4% students consume fast food contain Monosodium Glutamate which causes obesity and other body discomforts [27]. In a similar study among students of 4 private universities of Dhaka, 98% of the students were well informed about the negative effects associated with excessive fast food consumption, they were still profoundly addicted to it [28]. Prevalence rates of overweight and obesity are higher in urban peoples compared to rural peoples living in Bangladesh. Hoque et.al, 2015 reported higher average annual rate of reduction of underweight was found among wealthier, highly educated, urban-living women, while a higher average annual rate of increase of overweight was found among poorer, uneducated, rural-living women [29]. Tanwi et.al, 2019 reported prevalence of overweight and obesity was 34% among urban Bangladeshi women [30], increased by 17.5% between 1996 and 2011 [31]. Another study reveals that a nearly 30% married women in Bangladesh are overweight [32]. Women's employment status was only associated with overweight or obesity for urban residents. Working urban women had a lower probability of being overweight. Sociodemographic factors including age, education, wealth index, marital status, watching TV and employment status were associated with the increased trend of overweight and obesity [33]. The highest prevalence of overweight and obesity were observed in those women with the highest education level and wealth, larger family size, living in urban areas and not being in paid employment [34].

C. Lifestyle Issues
According to the WHO-Diabetes country profile of Bangladesh in 2016, the physical inactivity was prevailing more than 25% of population. Bangladeshi women more at health risk than men due to inactivity. Two big reasons to diabetes among Bangladeshi people are carbohydrate-dependent food pattern and sedentary lifestyle [35][36][37]. While males can go outside, socialize and take part in outdoor activities such as cricket or football or cycling, females are often confined to domestic chores and not allowed to go outside freely. Parents are likely to restrict or discourage their daughters from outdoor activities such as recreational walking or bicycling. Young females are vulnerable to crime while travelling and so are more likely to avoid walking. Uddin et.al, 2019 reported that 80% young adults in Dhaka City, did not meet the WHO recommended level of physical activity (150 minutes of moderate-to vigorous-intensity activity per week) for optimal health, with higher rates of insufficient activity among females than males [38]. Unplanned urbanization in the capital is clear, where people have very limited scope for physical activities. Even in the rural areas people now take rickshaw/vans or other rides to go to marketplaces. Evidence shows that prevalence of physical inactivity 35% to 38% in Bangladeshi adults aged 25 years and older [39]. Adults engage in high levels of sedentary behavior during waking hours, said another study [40]. Prevalence of self-reported depression was respectively 47.7% in Bangladesh. Lower frequency of vigorous physical activity was significantly associated with higher rates of depression diagnosed [41]. People with depressive disorders have a 65% greater risk of developing diabetes than the general population, which is a double-trouble according to the WHO [42].

D. Regular Health Checkup
Despite the high levels of diabetes and intermediate hyperglycemia, awareness and control of the condition is low in rural Bangladesh. In Bangladesh, one in three people over the age of 35  Bangladesh has been identified as a highachieving country for several tobacco control measures, including tobacco taxation, health warning labels and anti-tobacco mass-media campaigns. The high level of achievement for Bangladesh in cigarette taxation is, however, contradicted by an increase in per capita cigarette consumption [59]. Urban male smokers in Bangladesh consume more cigarettes than bidis and smoke more per day than rural smokers. More than half of Bangladeshi men over the age of 25 years smoke cigarettes or bidis, small handmade cigarettes containing about one fourth the amount of tobacco found in cigarettes [60]. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37% [61]. Although, government is taking initiatives from administration, more than one fourth (25.5%) of the police personnel in Bangladesh are currently smokers and this should be intervened [62].  [80]. Several studies highlighted formaldehyde-induced neurodegeneration, diabetes risk and diabetesassociated cognitive impairments [81][82][83][84]. Even more unfortunate is the fact that nefarious practice of food adulteration increases exponentially during the month of Ramadan in Bangladesh, according to a study of European Journal of Sustainable Development Research, 2019 [85]. The number of patients suffering from cancer, diabetes, and kidney diseases is on the rise due to food adulteration [86][87][88][89]. (e) Child Marriage: According to UNICEF, Bangladesh has the fourth highest prevalence rate of child marriage in the world, and the second highest number of absolute child brides -4.5 million. Around 30% of girls in Bangladesh married before the age of 15 and nearly 80% got married before the age of 18 [90][91][92]. The prevalence of nutritional deficiency was relatively higher among rural, illiterate and early married women and among those with a low standard of living [93]. Child marriage, low-birthweight, mother nutrition and diabetes closely related to each other [46], [93][94][95][96]. (f) Low Health Literacy (LHL): In low-income countries such as Bangladesh, the less than optimum use of services could be due to LHL. Emphasis on health literacy has been inadequate. And also, health service delivery is pluralistic with a mix of public, private and informally trained healthcare providers [97]. Non-compliance with medication 87% Factors found to be associated with non-adherence to antidiabetic medication include financial difficulties, forgetfulness, younger age, level of education, existing diabetes complications and difficulties in taking the medications alone [121]. Patients' non-adherence to diabetes medication is associated with poor glycemic control and suboptimal benefits from their prescribed medication, which can lead to worsening of medical condition, development of comorbidities, reduced quality of life, elevated health care costs, and increased mortality [122].

More than 70%
Approximately 44% of the diabetes burden, is attributable to overweight or obesity [102]. Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years [123]. Students in private schools are at a greater risk of being overweight/obese relative to students in government schools [124]. Poor quality of the early maternal-child relationship to be associated with higher prevalence of adolescent obesity [125]. In Bangladesh, a thin child is likely to be perceived by others as coming from a poor family. Mothers of skinny children are, in many cases, held guilty for not taking proper care of their children; thinness is often judged as proof of the mother's negligence of responsibility. Because of a lack of knowledge, these mothers frequently consider their offspring's thinness as analogous to parenting failure. As a result, parents are willing to see their children carrying excess weight [26]. During a 30-year follow-up, the risk of CVD was 54.8% in normal-weight women versus 78.8% among obese women with diabetes and 78.6% versus 86.9% among normal and obese men with diabetes, respectively [126]. In general, on average men were found to spend three-fold more time doing physical activity than women in both urban and rural areas Overall consumption of fast food consumption among youth and children Around 54% High intake of sweetened beverages increases cardiometabolic risk factors, obesity, T2DM, hypertension, and metabolic syndrome. It negatively affects brain health by damaging regions relevant to memory tasks and by diminishing brain-derived neurotrophic factor levels [128].
Prevalence of selfreported depression 47% Depression occurrence is two to three times higher in people with diabetes mellitus [129]. In people with diabetes the comorbidity with depression is associated with micro-and macrovascular complications and increased mortality [130]. However, people with depressive disorders have a 65% greater risk of developing diabetes than the general population [131].

Smokers (male) 37%
Up to 65% of cardiovascular mortality is attributable to interaction between smoking and diabetes. Research suggests that diabetic people who smoke have poorer diabetes control, greater insulin needs, increased insulin resistance and increased risk of hypoglycemia [132].

GDM 15%
The most common risk factors include obesity and overweight, high maternal age, family history of T2D, previous history of GDM, polycystic ovary syndrome, persistent glucosuria, recurrent abortions, previous history of a large baby (birth weight ≥ 4000 g), history of stillbirth, history of chronic hypertension or blood pressure associated with pregnancy. Among these risk factors, women with overweight, obesity and morbid obesity are related to an increased risk of developing GDM at a rate of two, four and eight times, respectively [133].

50%
Extensive studies on food adulteration confirm that ~50% of the food is either adulterated or contaminated with toxic compounds. WHO reveals that unsafe foods can be significant reasons of many chronic and non-chronic diseases including but not limited to diarrhea, different types of cancer, heart diseases, various kidney diseases, and birth defects [134].
Child marriage 30% Illnesses associated with nutrient deficiencies have significantly reduced the productivity of women in less developed countries [135]. Evidence shows that women with undernutrition before and during pregnancy have increased risk of metabolic disorders (i.e., gestational diabetes mellitus) and are at increased risk of complications during labor and birth [136].
Undernourished women 33% Underweight among children aged less than five years 40% Low health literacy (among urban people)

60%
It was significantly positively associated with understanding of diabetes care, self-efficacy, communication with doctors, and medication adherence, with compliance to treatment being a major issue. Health literacy increases patients' self-efficacy and knowledge about diabetes and thereby improves selfmanagement of diabetes [137]. Individuals with poorly controlled diabetes and low HL believed that they were optimally controlling their blood glucose, although they did not take measures to improve their glycemic control [97].

Conclusion
The prevalence of type 2 diabetes showed an increasing trend in both urban and rural population in Bangladesh. People with no education, lower socio-economic status, and those who lived in disadvantaged regions in terms of education and economic profile are found lacking of diagnosis, treatment, and control of diabetes.