DIABETES, AN EMERGING EPIDEMIC: BURDEN AND OPPORTUNITIES IN BANGLADESH
By:
Dr. Abdur Rafi Chief Research Officer Dhaka Cast Ltd.
Table of contents
- 1. Executive summary
- 2. Diabetes: an emerging global epidemic
- 3. Diabetic burden in Bangladesh
- 4. Economic burden of diabetes
- 5. Uncontrolled diabetes: a major issue in Bangladesh
- 6. Burden of diabetic complications in Bangladesh
- 7. Lack of awareness and social support: a hindrance for glycemic control
- 8. Digital health: a new era in diabetes management
- 9. Conclusion
- 10. References
Executive summary
Diabetes is a burning global health concern affecting more than 463 million people worldwide. 1 in 5
diabetic patient lives in the lower and middle income countries of South-East Asian region and almost
half of the diabetic patients of this region remain undiagnosed, which have made the situation more
critical. In Bangladesh currently there are almost 8.4 million diabetic and 3.8 million pre-diabetic patients
which is suspected to be double by 2045.
This country, being one of the world’s lowest spending countries in health sector, is struggling to cope
with this epidemic due to inadequate infrastructure for diabetes care. The average annual cost of diabetes
care in Bangladesh is USD 865 (BDT 75000), of which more than two-third come from the out-of-pocket
expenditure of the patients. The medicine cost accounted for the largest share of overall cost followed by
the hospitalization cost.
Almost two-third of the diabetic patients of Bangladesh has poor glycemic control. Infrequent follow-up
check-ups, use of insulin incorrectly, low level of education, residing in a rural area, unhealthy eating
habits, history of cardiac complications, etc. are the major influencing factors of uncontrolled diabetes in
this country. This inadequate glycemic control results in multi-organ and multi-systemic complications of
diabetes. Every 3 out of 5 diabetes patients of Bangladesh are suffering from some sort of complications.
Diabetic nephropathy (renal impairment due to diabetes) is the most prevalent complication among these
patients followed by cardiac complications and eye complications (diabetic retinopathies or blindness).
The picture of knowledge and awareness about the disease is very poor among the patients of Bangladesh.
Majority of the patients reported very low diabetic self-care ability and self-care adherence, which has a
negative influence on their glycemic control. There is a significant positive correlation between support
received from family and friends and good glycemic control. Therefore, future interventions for diabetes
control and prevention should also involve family members and/or primary caregivers in order to improve
their motivation and behavioral skills to offer greater support to the diabetes patients.
A couple of years ago, healthcare giants started tapping into the power of technology and moved on to
developing smartphone apps. As an emerging technology, mobile phone applications and other online
diabetes management platforms are showing promising results in diabetes management. Bangladesh is not
lagged behind in the field of digital diabetes management. Diabetic care startups like Dhaka Cast are
providing a 360 degree solution for a diabetic patient under an umbrella. Dhaka Cast is one of the very
first digital diabetic care platforms of the country who are offering online and at home service for diabetic
patients including specialist consultation, regular health check-ups, nurse and caregiver support as well as
providing quality insulin and other medications.
Though the sustainable development goals (SDG) undertaken by the UN set a target to reduce the
prevalence of non-communicable diseases by one-third by 2030, the number of diabetes patients is
increasing in Bangladesh with the socio-economic development of the country. It is high time we thought
about a sustainable solution. Digital technology based handy solutions at doorsteps of the patients may
take the upper hand for better diabetes management. Public-private partnerships to support these
initiatives are important to combat this rising problem
Diabetes: an emerging global epidemic
Diabetes is one of the most prevalent non-communicable diseases globally and, currently, the disease is a major public health issue, especially in developing countries because of its chronic nature, rapidly increasing prevalence, related complications, and the requirement of long-term care. The higher
prevalence of diabetes is related to an increased prevalence of obesity, population ageing, population
growth, urbanization and physical inactivity.
The International Diabetes Federation (IDF)1
estimated that, worldwide, approximately 463 million
people had diabetes in 2019; the number is projected to be 578 million by 2030 and 700 million by 2045.
More than 4% of total deaths of the world are attributed to this single disease. According to the report, 1
in 5 diabetic patient lives in the lower and middle income countries of South-East Asian region and
almost half of the diabetic patients of this region remain undiagnosed, which have made the situation
more critical.
Diabetic burden in Bangladesh
Diabetes is one of the most prevalent non-communicable diseases globally and, currently, the disease is a major public health issue, especially in developing countries because of its chronic nature, rapidly increasing prevalence, related complications, and the requirement of long-term care. The higher
prevalence of diabetes is related to an increased prevalence of obesity, population ageing, population
growth, urbanization and physical inactivity.
The International Diabetes Federation (IDF)1
estimated that, worldwide, approximately 463 million
people had diabetes in 2019; the number is projected to be 578 million by 2030 and 700 million by 2045.
More than 4% of total deaths of the world are attributed to this single disease. According to the report, 1
in 5 diabetic patient lives in the lower and middle income countries of South-East Asian region and
almost half of the diabetic patients of this region remain undiagnosed, which have made the situation
more critical.

Fig 1: Number of people affected by diabetes in Bangladesh during 2019 (Source: IDF report 2019)

Fig 2: Trend of diabetes patients in Bangladesh from 2010 to 2045 (Source: IDF report 2019:
Bangladesh.)
Economic burden of diabetes
For treating diabetes and its related complications, an estimated USD 1123 billion was spent globally in 2019. The cost has been projected to be USD 1308 billion by 20451 . More than 87% of the diabetes related deaths occur in low and middle-income countries, though only 35% of total diabetes-related health
expenditure is spent here. Moreover, compared to people living in high-income countries, people in these
countries have a lack of access to health insurance or publicly available medical services. Thus, they pay
a larger share of out-of-pocket health expenditures.
Bangladesh, like many developing countries is struggling to cope with this epidemic due to inadequate
infrastructure for diabetes care. It is one of the world’s lowest spending countries in health sector and
most of the people are deprived from health insurance, making the health service mostly unaffordable.
According to the Bangladesh National Health Accounts, in 2010, Bangladesh spent USD 2.3 billion on
health (or USD 16.2 per person per year) and 64% of this cost came from out of pocket payments.
However, according to the World Health Organization (WHO), in 2014, Bangladesh spent USD 88 per
person per year on health. It has been observed that, on average, a household spent 7.5% of its total
income on receiving health care, with the poorest 20% of the households spending approximately 13.5%
of their income on it. The per capita gross domestic product (GDP) of Bangladesh was USD 1677 in
2018, and nearly one-third of the population in the country was below the poverty line. Hence, the out of
pocket health care expenditure posed a notable economic burden on the Bangladeshi population.
The average annual cost of diabetes care in Bangladesh is USD 865, of which the direct cost is 90% with a mean of USD 782 and the indirect cost (loss of productivity by the patient and/or accompanying person)
is 10% with a mean of USD 83. Without hospitalization, the average annual cost is USD 410, which
increased to USD 1705 with hospitalization. The medicine cost accounted for the largest share (61%) of
overall direct cost followed by the hospitalization cost (28%). Medicine cost was also the highest source
of direct cost (84%) for patients without hospitalization. For patients with hospitalization, medicine cost contributed 51% of direct cost followed by a hospitalization cost of 40%. The average annual indirect cost was approximately four times higher for patients with hospitalization (USD 159) compared to that of
patients without hospitalization (USD 42)
3

Fig 3: Breakdown of diabetes related medical cost in Bangladesh (Source: Afroz, A. et al. Type 2
diabetes mellitus in Bangladesh: A prevalence based cost-of-illness study. BMC Health Serv. Res. 19,
601, 2019)


Fig 4: Variations of cost of disease among diabetes patients of Bangladesh (Source: Afroz, A. et al. Type
2 diabetes mellitus in Bangladesh: A prevalence based cost-of-illness study. BMC Health Serv. Res. 19,
601, 2019)
Uncontrolled diabetes: a major issue in Bangladesh
A recent country-wide study conducted in the hospitals are all affiliated with the Diabetic Association of
Bangladesh (BADAS)4
reported that only 18% of the diabetic patients had a good glycemic control, 20%
had fair control, 62% had poor glycemic control. Almost 55% had very poor control, making them highly
vulnerable to fatal diabetic complications. The following factors presented an increased risk for both
inadequate and very poor glycemic controls:
- infrequent follow-up check-ups
- use of insulin incorrectly
- low level of education
- residing in a rural area
- unhealthy eating habits
- history of cardiac complications
A research led by Dr. Abdur Rafi, chief research officer of Dhaka Cast Ltd. who are working to help
diabetic patients of Bangladesh since last year, conducted in Rajshahi Metropolitan area5
reported that
more than two-third of the patients of that region had uncontrolled diabetes. Most of them were suffering
from the disease for a long time (more than five years) and were out of follow-up. Moreover, a number of
patients lack of proper knowledge about their disease and using alternative and unscientific medicines like
homeopathy, which is hindering their glycemic control.
Burden of diabetic complications in Bangladesh
Diabetes is a multi-organ and multi-systemic disease. Persistent hyperglycemia causes damage to macro
and microvasculature of different organs of the body and causes a range of morbid complications
including coronary artery disease, renal impairment, stroke and blindness. Every 3 out of 5 diabetes
patients of Bangladesh are suffering from some sort of complications 6
. Diabetic nephropathy (renal
impairment due to diabetes) is the most prevalent complication among these patients followed by cardiac
complications and eye complications (diabetic retinopathies or blindness).
According to the report, elderly patients (more than 61 years of age), those who live in urban areas,
maintain unhealthy diet and are physically inactive are more vulnerable to both macro and micro-vascular
complications. Moreover, patients who are suffering from diabetes for more than ten years, have
inadequate medication adherence and suffering from comorbidities like hypertension and dyslipidemia
are mostly suffering from these complications6
.

Fig 5: Prevalence of diabetic complications in Bangladesh (Source: Afroz, A., Zhang, W., Wei Loh, A. J.,
Jie Lee, D. X. & Billah, B. Macro- and micro-vascular complications and their determinants among
people with type 2 diabetes in Bangladesh. Diabetes Metab. Syndr. Clin. Res. Rev. 13, 2939–2946, 2019)
Lack of awareness and social support: a hindrance for glycemic control
Multi-disciplinary approach including lifestyle modification and therapeutic measures is needed for
adequate glycemic control of diabetic patients. For this patients’ knowledge, perception, attitude and care
seeking behavior as well as their family and social support is important. Despite the fact, the picture of
knowledge and awareness about the disease is very poor among the patients of Bangladesh. A population
based survey including more than 12000 patients7
reported that only one in three adults were able to
report causes, symptoms, complications, preventive measures of the disease. More than 78% of known
diabetic patients reported that they did not monitor their blood glucose levels on at least a monthly basis.
Majority of the patients of Bangladesh scored very low in diabetic self-care ability and self-care
adherence scale, which has a negative influence on their glycemic control8
. There is a significant positive
correlation between support received from family and friends and good glycemic control. Family
members are the care-giver for most of the diabetic patients of Bangladesh, though their knowledge and
expertise about the diabetic care is questionable. Only a minority of the patients have professional expert
caregivers. Most alarming fact is that approximately 14% of the patients said that they had no caregiver
for their diabetes8
. ‘We found, as expected, that most of the patients got highest help for their diabetes
self-care management from their spouse or family members. Therefore, future interventions for diabetes
control and prevention should also involve family members and/or primary caregivers in order to improve
their motivation and behavioral skills to offer greater support to the diabetes patients’, said Dr. Shajedur
Rahman Shawon, an epidemiologist of the Nuffield Department of Population Health, University of
Oxford, who led the study team.
Digital health: a new era in diabetes management
A couple of years ago, healthcare giants started tapping into the power of technology and moved on to
developing smartphone apps. As an emerging technology, mobile phone applications and other online
diabetes management platforms are showing promising results in diabetes management. A recent metaanalysis of studies on effectiveness of fourteen mobile apps designed for patients with diabetes for
monitoring and remote consultations by their physicians as well as for improving patients’ selfmanagement by providing personalized feedback on self-monitoring data, such as blood glucose, food
and medication intake, and physical activity reported that using these technology significantly reduces
blood glucose level and shorten the consultation time and helps in achieving better glycemic control9
. To
grab the huge market opportunity, digital health companies are fighting back with innovative solutions.
The growing number of connected devices, tests and apps recently launched are not only changing the
way doctors treat diabetes, but also pump millions of dollars into a once stagnant market. In 2017, total
revenue for the digital diabetes market tripled to USD 98 million and these services are predicted to take
off even more in the next years; up to USD 742 million by 202210
.
Bangladesh is not lagged behind in the field of digital diabetes management. Diabetic care startups like
Dhaka Cast are providing a 360 degree solution for a diabetic patient under an umbrella. Dhaka Cast is
one of the very first digital diabetic care platforms of the country who are offering online and at home
service for diabetic patients including specialist consultation, regular health check-ups, nurse and
caregiver support as well as providing quality insulin and other medications.
Conclusion
Though the sustainable development goals (SDG) undertaken by the UN set a target to reduce the
prevalence of non-communicable diseases by one-third by 2030, the number of diabetes patients is
increasing in Bangladesh with the socio-economic development of the country. It causes a huge burden on
the developing economy of the country. It is high time we thought about a sustainable solution. Digital
technology based handy solutions at doorsteps of the patients may take the upper hand for better diabetes
management. Public-private partnerships to support these initiatives are important to combat this rising
problem.
References
- IDF Diabetes Atlas 9th edition 2019. https://www.diabetesatlas.org/en/.
- IDF report 2019: Bangladesh. https://idf.org/our-network/regions-members/south-eastasia/members/93-bangladesh.html.
- Afroz, A. et al. Type 2 diabetes mellitus in Bangladesh: A prevalence based cost-of-illness study.
BMC Health Serv. Res. 19, 601 (2019). - Afroz, A. et al. Glycaemic Control for People with Type 2 Diabetes Mellitus in Bangladesh – An
urgent need for optimization of management plan. Sci. Rep. 9, (2019). - Rafi, M. A. et al. A hospital-based study on complementary and alternative medicine use among
diabetes patients in Rajshahi, Bangladesh. BMC Complement. Med. Ther. 20, (2020). - Afroz, A., Zhang, W., Wei Loh, A. J., Jie Lee, D. X. & Billah, B. Macro- and micro-vascular
complications and their determinants among people with type 2 diabetes in Bangladesh. Diabetes
Metab. Syndr. Clin. Res. Rev. 13, 2939–2946 (2019). - Ahmed, N. et al. Diabetes knowledge and care practices among adults in rural Bangladesh: A
cross-sectional survey. BMJ Glob. Heal. 3, 891 (2018). - Shawon, M. S. R. et al. Attitude towards diabetes and social and family support among type 2
diabetes patients attending a tertiary-care hospital in Bangladesh: A cross-sectional study. BMC
Res. Notes 9, 286 (2016). - Hou, C., Carter, B., Hewitt, J., Francisa, T. & Mayor, S. Do mobile phone applications improve
glycemic control (HbA<>1c<>) in the self-management of diabetes? A systematic review, metaanalysis, and GRADE of 14 randomized trials. Diabetes Care vol. 39 2089–2095 (2016). - Digital diabetes market will reach $742M by 2022. What drives this growth? – Healthcare Weekly.
https://healthcareweekly.com/digital-diabetes-market-will-reach-742m-by-2022/.