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The vital signs are an integral part of clinical methods. In diabetes, determination of plasma glucose can be taken as the fifth vital sign. The sixth vital sign is well being, which can easily be measured by two item questionnaires designed to assess distress, depression and coping skills. This sign is essential for the screening and follow up of persons living with diabetes, as it provides an idea of quality of care, helps plan therapeutic interventions, and serves as a surrogate for prognosis or outcome. Inclusion of the sixth vital sign reflects the relevance of the bio-psychosocial model of health to diabetes care.

This communication focuses on an important, yet neglected, aspect of medicine, which has an impact on diabetes care as well. Betel quid (paan) chewing is a commonly encountered, socioculturally accepted, "culture-bound" addictive disorder. Betel quid chewing has unwanted psychotropic, carcinogenic and dysmetabolic effects. Thus, it should be discouraged as strongly as tobacco use. This communication calls for raised awareness among physicians and community leaders regarding this addictive disorder, and highlight the need for research on this topic.

Both diabetes and drug addiction are common phenomena across the world. Drug abuse impacts glycaemic control in multiple ways. It becomes imperative, therefore, to share guidance on drug deaddiction in persons with diabetes. The South Asian subcontinent is home to specific forms and patterns of drug abuse. Detailed study is needed to ensure good clinical practice regarding the same. This communication provides a simple and pragmatic framework to address this issue, while calling for concerted action on drug deaddiction in South Asia.

Diabetes and psychiatric disorders share a bi-directional relationship, with both affecting each other adversely. Just as achieving glycaemic control is important, so is ensuring that the person enjoys a good quality of life. All individuals with diabetes must be screened regularly for co-morbidity, especially depressive and anxiety disorders. Multiple evidence based psychotropic pharmacological interventions are available for management of these psychiatric disorders. Additionally, non-pharmacological interventions play a key role in comprehensive management of such patients.

Though the importance of psychological factors in the natural history, and the management of diabetes, cannot be overstated, these factors are sometimes not discussed adequately in current literature. Lack of trained manpower, time, and other resources, tends to detract diabetes care professionals from paying attention to this field. This review discusses simple, practical ways of psychological assessment and psychological management, in a manner relevant not only to Pakistan, but to other resource challenged settings as well. The paper underscores the fact that improvements in our understanding of psychological aspects of diabetes should be considered worthy of inclusion in the column: recent advances in endocrinology.