Kamrul-Hasan ABM, Pappachan JM, Nagendra L, Muthukuda D, Dutta D, Bhattacharya S, Shrestha D, Dhakal GP, Sumanatilleke M, Raza SA, Kalra S. Prevalence of diabetes distress among people with type 2 diabetes in South Asia: A systematic review and meta-analysis. World J Diabetes 2025; 16(8): 109352 [DOI: 10.4239/wjd.v16.i8.109352]
Corresponding Author of This Article
Joseph M Pappachan, MD, FRCP, Professor, Faculty of Science, Manchester Metropolitan University, Oxford Road, Manchester M15 6BH, Greater Manchester, United Kingdom. drpappachan@yahoo.co.in
Research Domain of This Article
Endocrinology & Metabolism
Article-Type of This Article
Meta-Analysis
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is 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 and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Kamrul-Hasan ABM and Kalra S conceptualized the study; Kamrul-Hasan ABM, Dutta D, Bhattacharya S, Shrestha D, and Raza SA formulated the methodology; Pappachan JM, Muthukuda D, Sumanatilleke M, and Dhakal GP were involved in the literature search, study selection, and data extraction; Kamrul-Hasan ABM and Nagendra L performed statistical analysis; Kamrul-Hasan ABM, Pappachan JM, Muthukuda D, and Bhattacharya S drafted the manuscript; Nagendra L, Shrestha D, Dutta D, Dhakal GP, Sumanatilleke M, Raza SA, and Kalra S critically analyzed and revised the manuscript; All authors read and approved the final manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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 and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Joseph M Pappachan, MD, FRCP, Professor, Faculty of Science, Manchester Metropolitan University, Oxford Road, Manchester M15 6BH, Greater Manchester, United Kingdom. drpappachan@yahoo.co.in
Received: May 8, 2025 Revised: May 24, 2025 Accepted: July 15, 2025 Published online: August 15, 2025 Processing time: 98 Days and 13.8 Hours
Abstract
BACKGROUND
Diabetes distress (DD), an emotional problem arising from the challenges of living with diabetes and the relentless burden of daily self-management, is common among patients with type 2 diabetes (T2D). South Asia has a high T2D burden, and many studies have reported varying prevalence rates of DD in this area.
AIM
To estimate the pooled prevalence of DD among patients with T2D in South Asia, as it is crucial for developing effective therapeutic strategies.
METHODS
This systematic review and meta-analysis included cross-sectional studies conducted in South Asian countries involving adults with T2D and reported the prevalence of DD. The studies were identified by searching multiple electronic databases and registries from the inception of each database to January 30, 2025, using prespecified search terms. Four authors screened and extracted data independently. Meta-analyses were conducted using RStudio software with a random-effects model. The primary outcome was the pooled prevalence of DD.
RESULTS
Thirty-seven cross-sectional studies (28 from India, five from Bangladesh, and two each from Pakistan and Sri Lanka) with mostly high methodological quality involving 11500 subjects were included. The pooled prevalence of DD was 44% (95% confidence interval: 35-53, I2 = 97.4%). The prevalence of DD was highest in Pakistan (85%), followed by India and Bangladesh (42% each), and Sri Lanka (25%). Emotional burden was the most prevalent form of DD (60%), followed by treatment regimen-related distress (51%), interpersonal distress (31%), and physician-related distress (17%). Meta-regression analysis revealed no significant associations between the prevalence of DD and publication year, sample size, proportion of females, age, duration of diabetes, insulin usage, glycated hemoglobin levels, or diabetic complications.
CONCLUSION
South Asians with T2D seem to experience a relatively high burden of DD, and the emotional burden is the most common form of DD in this area. Larger studies utilizing unique tools and involving a broader participant base from the region would provide better epidemiological data for effectively planning high-quality diabetes care in South Asian countries.
Core Tip: Diabetes distress (DD), an emotional problem arising from the challenges of living with diabetes and the relentless burden of daily self-management, is common among patients with type 2 diabetes. This systematic review and meta-analysis encompassed 37 cross-sectional studies, involving a total of 11500 participants from South Asian countries. Of these, 28 studies were conducted in India, five in Bangladesh, and two each in Pakistan and Sri Lanka. The pooled prevalence of DD was 44%, with the highest in Pakistan at 85% and the lowest in Sri Lanka at 25%. Emotional burden was the most common form of DD (60%), followed by treatment regimen-related distress (51%), interpersonal distress (31%), and physician-related distress (17%).
Citation: Kamrul-Hasan ABM, Pappachan JM, Nagendra L, Muthukuda D, Dutta D, Bhattacharya S, Shrestha D, Dhakal GP, Sumanatilleke M, Raza SA, Kalra S. Prevalence of diabetes distress among people with type 2 diabetes in South Asia: A systematic review and meta-analysis. World J Diabetes 2025; 16(8): 109352
South Asia consists of eight countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka, and is home to nearly 25% of the world’s population. South Asians share genetic, environmental, sociocultural, and lifestyle factors that contribute to similar disease patterns[1]. South Asians are known for their higher susceptibility to type 2 diabetes (T2D). The prevalence of diabetes in South Asia increased from 11.29% in 2000-2004 to 22.30% in 2020-2024[2]. T2D in South Asians displays unique clinical characteristics referred to as the “South Asian phenotype”. These features include an earlier age of diabetes onset compared to White Europeans, a lower body mass index, hyperinsulinemia, increased insulin resistance, a rapid decline in β-cell function leading to low insulin reserves, reduced muscle mass, and greater visceral fat deposition[3]. A lack of knowledge and awareness, misperceptions, religious beliefs, social stigma, insufficient cultural adaptation to diabetes management, inadequate resources, limited healthcare budgets, and a lack of medical reimbursement create barriers to effective prevention and management of T2D among South Asians. South Asians with T2D often develop the disease at a younger age, resulting in early complications and premature death. These patients face not only physical issues but also numerous psychiatric comorbidities, including anxiety, depression, and psychological distress[4,5].
The term ‘diabetes distress’ (DD) refers to “an emotional response characterized by extreme apprehension, discomfort, or dejection due to the perceived inability to cope with the challenges and demands of living with diabetes”[6]. DD encompasses a wide range of emotions, including negative feelings, anger, fear, guilt, frustration, and shame, that may stem from the emotional burden of diabetes and the patient’s concerns about glycemic control, existing comorbidities, potential complications, and access to treatments[7,8]. DD is frequently observed in individuals with diabetes and their caregivers[6]. A meta-analysis published in 2017, which included 55 studies conducted across various countries and involving a total of 36998 participants, reported an overall DD prevalence of 36% among patients with T2D[7]. DD negatively impacts healthy living, self-management, self-efficacy, self-care, and following treatment recommendations, which contributes to the worsening of T2D[7,9]. It is also closely linked to cardiovascular disorders and high mortality rates[10]. DD prevalence varies across different populations. Studies have highlighted an association between greater distress and ethnicity, with non-white individuals and ethnic minority groups experiencing a higher prevalence of DD than white individuals and non-minority groups[7,11]. Considering the stigma of poor mental health in South Asian communities, along with the increased burden of T2D, distress related to diabetes may contribute to disparities in diabetes-related outcomes[12]. Numerous studies conducted in South Asian countries have revealed a highly variable prevalence of DD among individuals with T2D. However, a meta-analysis that presents the pooled prevalence of DD among these patients, providing deeper insight into the magnitude of the problem, has not yet been conducted.
Studying DD in South Asia is essential for comprehending the scope of the problem and recognizing the risk factors and disease patterns that are specific to the region. This can help enhance public health planning through the development of targeted interventions, efficient resource allocation, and the monitoring of program impacts focused on diabetes management and the prevention of complications across countries. Examining the prevalence of DD in South Asia can enhance global research efforts, guiding the development of new diagnostic tools, therapies, and interventions tailored to the region’s specific needs. With this background, we conducted this systematic review and meta-analysis (SR/MA) to explore the prevalence and contributing factors of DD in patients with T2D residing in South Asian countries.
MATERIALS AND METHODS
Ethical compliance
This SR/MA was conducted in accordance with the procedures outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist[13,14]. The SR/MA is registered with PROSPERO (CRD42025656190), and the protocol summary can be accessed online.
Search strategy
A systematic search was conducted across various databases and registries, including MEDLINE (via PubMed), Scopus, Web of Science, and the search engine Google Scholar. This search extended from the inception of each database to January 30, 2025. The search utilized the Boolean operators “AND” and “OR” for the following terms: “Diabetes distress”, “diabetes-specific distress”, “type 2 diabetes mellitus” (T2DM), “type II diabetes mellitus”, “type 2 diabetes”, “T2DM”, “T2D”, “South Asia”, “India”, “Bangladesh”, “Bhutan”, “Maldives”, “Nepal”, “Pakistan” and “Sri Lanka”. The search terms were implemented in the titles and abstracts of the documents. A detailed search strategy for PubMed is provided in the Supplementary Material. The goal was to identify published and unpublished full-length journal articles and abstracts for the conference proceedings, all in English. Additionally, the search entailed examining references in the published articles obtained for this study and in relevant journals.
Study selection
The criteria for including studies were cross-sectional studies involving adults (aged ≥ 18 years) with T2D that reported the prevalence of DD as measured by any scale for assessing DD. Case reports, case series, review articles, studies involving children or adolescents, studies involving patients with type 1 diabetes (T1D) or both T1D and T2D, studies not reporting the type of DM, and studies that did not report the primary outcome were excluded. Four review authors independently identified eligible articles based on the criteria mentioned above. Disagreements regarding the inclusion of studies were resolved by consensus.
Data extraction
Four review authors independently extracted data using standardized forms for data extraction. When multiple publications from a single study group were identified, the results were consolidated, and relevant data from each article were included in the analyses. The following data were extracted from all eligible studies and included in the review: First author, year of publication, the country where the study was conducted, study design, major inclusion and exclusion criteria, sample size, proportions of female and male subjects, mean age of the participants, duration of DM, glycated hemoglobin (HbA1c), proportions of study subjects using insulin injections, comorbidities, diabetic complications, scales used for measuring DD, and the prevalence of DD, emotional burden, regimen-related distress, interpersonal distress, and physician-related distress. Any disagreements were resolved by consensus.
Outcomes analyzed
The primary outcome of interest was the prevalence of DD. Additional outcomes included the prevalence of emotional burden and regimen-related, interpersonal, and physician-related distress. Subgroup analyses were performed based on the country where the studies were conducted.
Assessment of the quality of the included studies
The methodological quality of the included studies was independently assessed by four authors using the Joanna Briggs Institute (JBI) Critical Appraisal Tool checklist for analytical cross-sectional studies. The checklist consists of eight components, and the purpose of this appraisal is to evaluate a study’s methodological quality and assess the extent to which the study has addressed the potential for bias in its design, conduct, and analysis[15]. The ninth and tenth authors served as arbitrators to resolve discrepancies and achieve a consensus.
Statistical analysis
Statistical analyses were conducted using the RStudio software environment (R version 4.4.2, released on October 31, 2024), specifically utilizing the “meta” and “metafor” packages, which are designed for performing meta-analyses in R[16]. The random-effects model was chosen to address the anticipated heterogeneity resulting from population characteristics in the included studies. The proportions were transformed using the logit transformation, which is commonly employed when dealing with proportional data when proportions are less than 0.2 or more than 0.8. The inverse variance statistical method was applied for all instances. The pooled prevalence of DD and other secondary outcomes, along with 95% confidence intervals (CI), was calculated and presented in forest plots. Meta-regression analyses were performed using the same software to examine the relationship between the prevalence of DD and confounding variables. A significance level of P < 0.05 was used.
Assessment of heterogeneity and publication bias
The assessment of heterogeneity was initially performed by examining forest plots. Subsequently, χ2 tests were conducted using N-1 degrees of freedom and a significance level of 0.05 to assess statistical significance. The I2 test was also used in the subsequent analysis[17]. The details of understanding I2 values have been thoroughly explained elsewhere[18]. Publication bias was evaluated using funnel plots and Egger’s test in the RStudio software[16,19,20].
RESULTS
Search results
The steps of selecting studies are depicted in Figure 1. The initial search identified 736 articles, which were narrowed down to 53 after screening the titles, abstracts, and subsequent full-text reviews. Finally, 37 studies involving 11500 subjects meeting all the prespecified criteria were included in this SR/MA[21-57]. Sixteen studies were excluded; one study was conducted among South Asians residing outside of the geographical area[58], one included patients with both T1D and T2D[59], one included patients with both T1D and T2D without reporting the frequency of DD, and 13 studies did not report the frequency of DD[60-73].
Figure 1 The preferred reporting items for systematic reviews flow diagram showing the selection process of included studies.
T1D: Type 1 diabetes; T2D: Type 2 diabetes; DD: Diabetes distress.
Characteristics of included studies
All of the 37 studies in this SR/MA were cross-sectional. Five studies were conducted in Bangladesh[21-25], 28 in India[26-53], two in Pakistan[54,55] and two in Sri Lanka[56,57]. No studies from Bhutan, the Maldives, and Nepal were available. The included studies varied greatly in terms of sample size (range: 100-1406), proportions of females (range: 21.05%-77%), mean age (range: 44-60 years), mean duration of diabetes (range: 1.5-11.4 years), mean HbA1c (range: 7.7%-10.13%) proportions of subjects using insulin (range: 5.6%-64.6%), and proportions of subjects with diabetic complications (range: 40%-93.4%) and comorbidities (range: 10.5%-74.5%). For DD, most studies used the 17-item DD scale (DDS-17)[21-24,27,28,30-37,39-43,45-49,51-56]. The problem areas in diabetes scale-five-item (PAID-5) short form was used in two studies[25,50], the PAID scale-20 (PAID-20) in two studies[38,44], the general health questionnaire-12 (GHQ-12) in one study[26], the brief DD screening scale (BDDS) in one study[29] and the Sinhala version of the DDS (sDDS-15) was used in one study[57]. The reported prevalence of DD in the included studies ranged from 5% to 100%. The specifics of the included and excluded studies are shown in Table 1 and Supplementary Table 1, respectively.
Table 1 Characteristics of the included studies and participants, mean SD.
The methodological quality of the included studies, as assessed by the JBI Critical Appraisal Tool, is summarized in Supplementary Table 2. Most studies demonstrated high methodological quality, with the majority meeting the criteria for well-defined inclusion, valid exposure measurement, and appropriate statistical analysis. However, several studies lacked strategies for managing confounding factors, which may impact the internal validity of their findings. Studies published by Kamruzzaman et al[24], Sultana et al[25], and Burman et al[29] met all the assessed criteria, suggesting strong methodological rigor. Conversely, others, such as Nadig et al[36], Pinto et al[42], and Verma et al[52], showed limitations in handling confounders. Overall, many studies adhered to high methodological standards, and limitations in addressing confounding factors remain a concern in some studies. The funnel plots assessing publication bias are shown in Supplementary Figure 1. Most studies that report the prevalence of total DD, emotional burden, regimen-related, interpersonal, and physician-related distress are outside the inverted funnel. Additionally, the funnels exhibit asymmetrical shapes, with most studies showing relatively low standard errors (i.e., a narrow spread on the vertical axis) and a few exceptions, along with relatively wide ranges (on the horizontal axis) of effect sizes among those with low standard errors. Thus, the funnel plots for all the variables indicate potential publication bias. However, Egger’s test revealed significant publication bias only for physician-related distress (P = 0.0156) and not for total DD (P = 0.7492), emotional burden (P = 0.5979), regimen-related distress (P = 0.5524), and interpersonal distress (P = 0.6353) (Supplementary Table 3).
Prevalence of DD
Using a random-effects model with inverse variance, the meta-analysis of 37 studies found that the pooled prevalence of DD in South Asia was 44% (95%CI: 35%-53%), showing high heterogeneity (I2 = 97.4%, P < 0.0001) (Figure 2). In subgroup analysis according to countries, DD prevalence in Bangladesh, India, Pakistan, and Sri Lanka was 42% (95%CI: 31%-55%), 42% (95%CI: 32%-53%), 85% (95%CI: 64%-95%), and 25% (95%CI: 16%-37%) respectively; the subgroup differences were statistically significant (P = 0.0003) (Figure 2).
Figure 2 Forest plot illustrating the pooled prevalence of diabetes distress in South Asia and among subgroups based on countries.
CI: Confidence interval.
Prevalence of emotional burden
The pooled prevalence of emotional burden, reported by 23 studies, was 60% (95%CI: 49%-71%), with high heterogeneity among the studies (I2 = 96.7%, P < 0.0001) (Figure 3A). Pakistan had the highest prevalence of emotional burden [85% (95%CI: 82%-88%)], followed by Bangladesh 67% (95%CI: 58%-74%) and India 55% (95%CI: 41%-69%). A single study from Sri Lanka reported the prevalence of emotional burden at 62%. The subgroup differences among the countries for the prevalence of emotional burden were statistically significant (P < 0.0001) (Figure 3A).
Figure 3 Forest plot demonstrating the pooled prevalence of four domains of diabetes distress in South Asia and among subgroups based on countries.
A: Emotional burden; B: Regimen-related distress; C: Interpersonal distress; D: Physician-related distress. CI: Confidence interval.
Prevalence of regimen-related distress
The pooled prevalence of regimen-related distress, reported by 22 studies, was 51% (95%CI: 36%-65%), with high heterogeneity among the studies (I2 = 97.7%, P < 0.0001) (Figure 3B). Country-wise subgroup analysis revealed a prevalence of 51% (95%CI: 35%-66%) in Bangladesh, 49% (95%CI: 29%-69%) in India, and 79% (95%CI: 69%-86%) in Pakistan. The only study from Sri Lanka reported a 33% prevalence of regimen-related distress. The subgroup differences among the countries in the prevalence of regimen-related distress were statistically significant (P < 0.0001) (Figure 3B).
Prevalence of interpersonal distress
The pooled prevalence of interpersonal distress, reported by 23 studies, was 31% (95%CI: 18%-49%), with high heterogeneity among the studies (I2 = 98.1%, P < 0.0001) (Figure 3C). The prevalence of interpersonal distress was highest in Pakistan 49% (95%CI: 39%-60%), followed by India 33% (95%CI: 15%-59%), and Bangladesh 23% (95%CI: 11%-41%). A study in Sri Lanka found that 13% of individuals experience interpersonal distress. The subgroup differences among the countries for the prevalence of interpersonal distress were statistically significant (P < 0.0001) (Figure 3C).
Prevalence of physician-related distress
The pooled prevalence of physician-related distress, reported by 23 studies, was 17% (95%CI: 9%-32%), with high heterogeneity among the studies (I2 = 97.6%, P < 0.0001) (Figure 3D). Country-wise subgroup analysis revealed prevalence rates of 7% (95%CI: 1%-30%) in Bangladesh, 21% (95%CI: 9%-41%) in India, and 43% (95%CI: 28%-59%) in Pakistan. A single study from Sri Lanka reported the prevalence of physician-related distress at 1%. The subgroup differences among the countries for the prevalence of physician-related distress were statistically significant (P < 0.0001) (Figure 3D).
Meta-regression
Meta-regression analyses were conducted to examine the relationship between the prevalence of DD and various factors, including the year of publication, sample size, percentage of female subjects, mean age of participants, mean duration of diabetes, proportion of insulin users, mean HbA1c levels, and proportion of study subjects with diabetic complications. The results indicated no significant association between the prevalence of DD and these variables. Specifically, the meta-regression P values for the year of publication (P = 0.7616), sample size (P = 0.7616), proportion of females (P = 0.6946), mean age (P = 0.5941), mean diabetes duration (P = 0.4536), proportion of insulin users (P = 0.3375), mean HbA1c (P = 0.8992), and proportion of subjects with diabetic complications (P = 0.8434) were not statistically significant (Supplementary Figure 2).
DISCUSSION
The SR/MA involving 11500 subjects from 37 cross-sectional studies from the South Asian region, with mostly high methodological quality, although with high heterogeneity (I2 > 75%, P < 0.0001) among the studies, identified an overall DD prevalence of 44% (95%CI: 35%-53%). The country-wise DD prevalence was highest in Pakistan (85%), with identical figures in India and Bangladesh (both at 42%), and the lowest in Sri Lanka (25%). The pooled prevalence of emotional burden was 60% (23 studies), and that of treatment regimen-related distress (22 studies), interpersonal distress (23 studies), and physician-related distress (23 studies) were 51%, 31%, and 17%, respectively. While significant publication bias was evident only in physician-related distress (P = 0.0156), no bias was observed in total DD, emotional burden, regimen-related distress, and interpersonal distress.
There were wide variations in the baseline characteristics of the participants in the included studies of this review, such as sample sizes (n = 100-1406), percentage of female participants (21.05%-77%), mean age (44-60 years), mean duration of diabetes (1.5-11.4 years), mean HbA1c (7.7%-10.13%), use of insulin (5.6%-64.6%), and prevalence of diabetic complications (40%-93.4%) and comorbidities (10.5%-74.5%). Although most studies utilized the DDS-17 to identify DD, two studies employed the PAID-5, two others used the PAID-20, and one study each applied the GHQ-12, BDDS, and sDDS-15 scales, respectively. The reported prevalence of DD in the included studies varied from 5% to 100%, and the significant discrepancy is likely partly due to the different scales employed in these studies. These factors, along with the discrepancy in the number of included studies for each country, may explain the varying prevalence of DD in South Asian countries.
As DD significantly contributes to poor diabetes control and serious consequences, such as diabetes complications, impaired quality of life (QoL), and mortality, the high prevalence of DD in this region has important healthcare implications. We observed a higher overall DD prevalence of 44% in this study from South Asia compared to the global prevalence figures (36%) reported by Perrin et al[7] among patients with T2D. There appears to be a significant increase in the prevalence of DD (42%) among the Indian participants in the current study compared to the pooled prevalence figures from a recent meta-analysis (33%) reported from India in 2023[74]. However, the prevalence figures are better than those reported from China (53.2%), based on data from 55 studies involving 13160 participants in 2022[75]. Multiple factors, such as ethnic background, cultural traits, educational status, and economic support systems of the study populations, may have influenced the significant variations in the prevalence of DD observed across different countries. Additionally, the study methodologies employed in assessing DD could also contribute to these differences.
The high prevalence of emotional burden (60%) observed in this SR/MA, which could adversely impact health-related QoL, may be explained by prevailing misconceptions about T2D in South Asian societies, along with various socio-economic and cultural factors. Socio-demographic factors such as age, sex, education, income, marital status, religion, knowledge about diabetes, self-efficacy, comorbidities, treatment type, and behavioral patterns like exercise, adherence to therapy, and glucose monitoring, along with family support, significantly impact the emotional burden and health-related QoL in patients with T2D, according to a recent systematic review[76]. The high prevalence of other types of DD, such as treatment regimen-related distress, interpersonal distress, and physician-related distress, may also be attributed to the influence of similar factors.
Regardless of the reasons for various types of DD, it is essential to reduce DD to achieve improved diabetes management outcomes and prevent complications. Various therapeutic interventions for DD, including nurse-led psychological interventions, cognitive behavioral therapy, telehealth technologies, e-health interventions, and internet-guided self-help, were associated with significant improvements in DD and patient empowerment in managing T2D compared to usual care[77-80]. However, the results of some of these interventions on glycemic outcomes, such as improvements in HbA1c, were minimal or nonexistent. For example, the immediate and long-term effects of psychological interventions on glycemic control were not significant (MD = 0.02 and -0.27, respectively; P > 0.05)[78]. One reason for the lack of improvement in diabetes outcomes may be the brief duration of most therapeutic interventions for DD. T2D is a lifelong condition associated with various comorbidities. Therefore, extensive and long-term interventional studies for managing DD would be a crucial solution to address this significant issue.
Strengths and limitations of this SR/MA: This is the largest and most up-to-date review addressing the epidemiological aspects of DD, involving a multinational cohort in South Asia with unique cultural and ethnic diversity. Due to the widespread distribution of the South Asian population across the globe from migration, many of these epidemiological aspects of DD could also apply to patients worldwide. Most studies demonstrated high methodological quality and exhibited minimal publication bias across most types of DD, further bolstering the evidence we compiled. However, the significant heterogeneity observed in most DD parameters we assessed is a notable limitation of this SR/MA. Significant variations in the study parameters reported in individual studies included in this analysis could have adversely affected the epidemiological value of the results. Although they represent only a small proportion of the total South Asian population, the lack of any studies on DD from Nepal, Bhutan, the Maldives, and Afghanistan remains another limitation. The absence of long-term follow-up data on the effects of various therapeutic interventions for DD is another significant issue to be addressed in the future, given the serious implications of DD for those affected.
CONCLUSION
There is a relatively high (44%) prevalence of DD among patients with T2D in the South Asian population. The reported prevalence of DD seems to be highest in Pakistan (85%), while the lowest is in Sri Lanka (25%) (although data is not available from Afghanistan, the Maldives, Nepal, and Bhutan). High emotional burden is the most common form of DD, while physician-related distress accounts for the least common type. Significant variations in the study parameters and high heterogeneity of the results would restrict the generalizability and applicability of this SR/MA. Future studies should address these limitations and design appropriate interventions to improve DD for optimal disease outcomes in patients with T2D in the South Asian populations.
ACKNOWLEDGEMENTS
We thank Annlyn Vinu Thomas for providing the audio clip for the core tip of this paper.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Endocrinology and metabolism
Country of origin: United Kingdom
Peer-review report’s classification
Scientific Quality: Grade A, Grade C, Grade C
Novelty: Grade A, Grade C, Grade C
Creativity or Innovation: Grade A, Grade C, Grade C
Scientific Significance: Grade A, Grade C, Grade C
P-Reviewer: Arumugam VA; Kotyk T S-Editor: Fan M L-Editor: A P-Editor: Zhao YQ
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