Diabetes as a Global Diabetes as a Global Health ProblemHealth Problem

The IDF meets the The IDF meets the ChallengeChallenge

ByBy

Prof. Morsi ArabProf. Morsi Arab

IDF Chairman MENA RegionIDF Chairman MENA Region

MENA

Reported Incidence of Type1 Diabetes at the MENA Region per 100.000 population under 15 yrs ( Diabetes Atlas 2006)

• Afghanistan 1.2• Algeria 8.6 • Bahrain 2.5• Egypt 8.0• Iran 3.7• Iraq 3.7• Jordan 3.2• Kuwait 22.3• Lebanon 3.2• Libya 9.0• Morocco 8.6• Palestine 3.2• Oman 2.5• Pakistan 0.5• Qatar 11.4• Saudi Arabia 12.3• Sudan 10.1• Tunisia 7.3 • Emirates 2.5• Yemen 2.5

�ِAt The MENA Region

Prevalence of Diabetes is 9.2 % (age 20 -79)Prevalence of IGT …….is 8.1%

24.5 millions with Diabetes & 22.4 with IGT

out of the top 10 highest diabetes prevalence rate countries 6 are MENA countries

Estimated death due to DM as % of all deaths is 11.5% ) 11.1% in Europe and 11.8 % in MENA (

Diabetes Mortality

World wide = 3.2 millions die from complications

associated with diabetes

In the ME : ( with high prev. of diab.)

one in 4 deaths in adults 35-64 years

is related to diabetes

MENA

30.5

20.5

14.3

13

9.3

6.3

6.1

0 5 10 15 20 25 30 35 %

age

gro

up

sThe pyramidal structure of the

Egyptian population

>60

-60

-50

-40

-30

-20

-10

Prevelance of DM in whole Egypt in Different Age Groups

0.62 0.80

3.08

8.25

12.04

15.06

0

2

4

6

8

10

12

14

16

% p

op

ula

tio

n

Age Group 10 20 30 40 50 60

0

5

10

15

20

25P

erc

en

t

20 30 40 50 60 >60

Age

Diabetes Prevelance & Age Groups

Western desert

Eastern desert

Saini

Nubia

14.7% 14.3%

5.6%

8.5%

2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

U UN RN RA RD

Prevelance of DM among age group ( 40 - ) in different communities

DIABETES IS PART OF THE WIDER HEALTH PROBLEM : THE METABOLIC SYNDROME

20-25 % of the world adult population have the metabolic syndrome ( MTS) , and these are:

- 5 times at risk to develop diabetes type 2

- 3 times likely to have a heart attack

or stroke

- twice likely to die

“Obesity” is always involved , or associated with all elements of the

Metabolic Syndrome:

But Which type of Obesity?

“Abdominal Obesity “ as measured by waist

circumference is more indicative of the

Metabolic Syndrome profile than increased BMI

The new international Diabetes Federation (IDF) definitionAccording to the new IDF definition , for a person to be defined as having the

metabolic syndrome he/she must have: Central Obesity ( defined as waist circumference * with ethnicity specific values )

plus any two of the following four factors:

Raised triglycerides

150 mg/dL (1.7 mmol/L )

or specific treatment for this lipid abnormality.

Reduced HDL Cholesterol

40 mg/dl ( 1.03 mmol/L ) in males

50 mg/dL (1.29 mmol/L) in females

or specific treatment for this lipid abnormality

Raised blood pressure

Systolic BP 130 or diastolic BP 85 mmHg

Or treatment of previously diagnosed hypertension

Raised fasting plasma glucose

)FPG (100 mg/dL (5.6 mmol/L)

or previously diagnosed type 2 diabetes

Diabetes Mellitus and its state of control and complications in the

MENA Region

Fasting Hyperglycemia

- Controlled (> 120 mg/dl ) = 19.8%

- Uncontrolled = 80.2 %

----------------------------------

Hyperglycemic 121-150 mg/dl = 15.6%

Marked hyperglycemia -200 = 31.3%

Severe hyperglycemia -220 = 12.5%

Very severe hyperglycemia > 220 = 20.8 %

19.80%

15.60%

31.30%

12.50%

20.80%

> 220

200-220

151-200

121-150

-120

120 mg/dl

Hyperglycemia Fasting

Post Prandial Hyperglycemia

-Controlled > 160 mg/dl = 13.5% -Accepted 161-180 mg/dl = 7.9 %

Total = 21.4%

-Uncontrolled ( >180 mg/dl ) = 78.6% *Moderate -220 mg/dl = 17.4%

* Severe - 260 mg/dl = 16.0% * Very Severe > 260 mg/dl = 45.2%

Post Prandial

13.50%

7.90%

17.40%

16%

45.20%

> 260 220-260180-220160-180<160

180 mg/dl

Hyperglycemia

Diastolic Blood Pressure

64.60%

18.10%

12.10%

4.50%

0.70%

> 120

110

100

90

> 80

80 mm Hg

Systolic Blood Pressure

53.70%

22.30%

20.70%

2.80%

>200200180150< 130

130 mm Hg

0.50%

56.40%

33.20%

10.40%

>250

201-250

-200

Lipid Control

Serum Cholesterol

200 mg

Lipid ControlSerum Triglycerides

50.40%

33.30%

9.10%

7.20%

> 250

201-250

151-200

-150

Column1

150 mg

Obesity as BMI group )A (

>24

)B(

24-30

)C (

>30

Syst. B.P. > 150 mm Hg 8.7% 20.5* % 30.6* %

Diast. B.P. > 80 mm Hg 17.1% 32.9* % 41.5* %

S. Cholest. > 200 mg/dL19.7% 24.5* % 50.4* %

S. Triglycerides >150mg/dL

23.5% 22.6% 54.9* %

Fasting Bl.Gluc.>120mg/dL

72.3% 73.8% 80.0%

N.B. (%) percentage of patients above the acceptable levels , (*) Significant

Obesity as a Risk Factor for Hyperglycemia , Hypertension and Hyperlipidemia

15.00%

7.90%

21.80%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Angina ECG+ve H.F-Arryth

Cardiac Complications

Retinopathy (in 1173 patients ) - Free 68.9 % - Back ground 22.6 %

- Proliferative 9.5%

Retinopathy

22.6 %

9.5%

68.9 %

Free

B.ground

Prolif.

Retinopathy in correlation with Duration of DM

0%

20%

40%

60%

80%

100%

1 3 6 9 12 15 >15

Free Non-Prol. Prol.

Ankle reflex and Duration of DM

0

10

20

30

40

50

60

70

80

>1 -3 -6 -9 -12 -15 -18 -21 -24 >24

Duration /year

%

l

22.00%

9.70%

6.80%

3.00%

1.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Fungus Isch Ulcers Ampt. Deform.

Frequency of Foot Complications

Prevalence of foot complications

1 -Fungus infection = 22.0%

2 -Foot ulcers = 6.8%

3 -Evident Ischaemic changes = 9.7%

4 -Amputations = 3.0%

5 -Deformities = 1.0%

Diabetes Keto Acidosis (DKA)

- Occurrence of DKA episodes in = 12.2 %.

--------------------------------------------------------------------

- The mean age in patients who developed DKA = 42.5 years

- The mean age in patients who never developed DKA = 53.1 years

Hypoglycemia- Occurrence of Hypoglycemic episodes in = 20.5%

------------------------------------------------------------------------ - The mean age of patients who developed hypoglycemic episodes at any time = 50.8 years

- The mean age of patients who did not experience hypoglyceamic episodes = 52.1 years

labour Abortion

Fertility and Abortions

Abortions : 21.5%

Fertility : 3.6 ch/m

The Socio economic Burden

Middle East Countries- economic statusper capitum incomes:

High Kuwait EmiratesQatarBahrainOmanSaudi ArabiaLibya

Low SyriaJordanTunisiaMoroccoEgyptYemenSudan

Middle

(Iraq)Iran

>5,000 US $

> 2,000 US $

Mean Health Expenditure /person with diabetes in different regions

180 233514 625 684

11881561

0

500

1000

1500

2000ID

>200200-600600 -1000 >1000

Afghanistan 56

Iraq 72

Pakistan 99

Sudan 103

Yemen 110

Syria 185

Alger 273

Morocco 285

Egypt 286

Libya 384

Oman 614

Tunisia 637

Jordan 711

Iran 744

Kuwait 806

Saudi Arabia 891

Emirates 929

Bahrain 1047

Lebanon 1050

Qatar 1198

MENA Countries according to The Mean Health Expenditure per person with diabetes in ID (international Dollar) : Diabetes Atlas, 3rd Ed.

100%120.80%

354% 346%

0%

50%

100%

150%

200%

250%

300%

350%

400%

DM +CVD +R.F. +Diab. Foot

Hospital Treatment 2001 Cost /Day

(Egyptian Study )

55% Medicine & Supp.

45% Basic( Food : 5%

H.C.Team 11%

Others: 29%)

Distribution of Hospital Cost

8.85%

EGYPT

1.9%

QATAR

3.1%

SAUDI ARABIA

Year Cost / percapit. Burden for Human Insulin (40 u /d)

EGYPT

29.9%

Cost Burden of Oral Treatment related to Percapitum

QATAR

4.2%

8.4%

SAUDI ARABIA

To promote diabetes care, prevention and a cure worldwide

What are The IDF Goals? 1 .Global Advocacy

2 .To raise Global Awareness

3 .Promote appropriate Diabetes Care & Prevention

4 .Encourage finding a Cure

http://www.unitefordiabetes.org/

Objective 4 attained!

For improving Diabetes Care and Prevention , Education of Health Care Providers should consider expertise in both: I- Clinical Diabetes , and

II- Educations skills

The Way to a National Diabetes Program

Minimal requirements : 1- Insulin and medications availability ( affordable) 2- Primary centers for diagnosis and care 3- wide distribution of services allover the country 4- Basic requirements to manage complications 5- Education : knowledge & skills to patients – Public orientation 6- National basic studies in epidemiology and socioeconomics . 7- Care for Diabetes in School children 8- Care for diabetes in pregnancy

Potential Adverse Factors 1- Economic :Poor Financial Res. /per capit. / Government expenditure/ House-hold expend. with High Prev. of diab.

2- Demographic Extensive areas with poor communications . High population density

3- Social : Illiteracy- Misconceptions – adverse habits and traditions.

Patient

IDF

NGO

Family

Pharmaceutical industries

WHO

Society

PhysicianNurseDietitianFoot CarePharmacistLaboratory

Medical Group

Work- schoolFriends

MEDIA

Ministry of Health

Government

ParliamentSyndicate

National Institute

In Developing a National Diabetes Programme :

1- Consider the specific needs in the country and available resources to decide priorities 2 - Define the role to be played by each one of the constituents of the community , and Identify Champions for projects .3- Seek partnerships with :

WHO , Twining ,WDF , Rotary , etc..

Obligations of Different Parties

The Government ( Ministry of Health)

1- Increase Investments in Health/Diabetes 2- provide Minimal Diabetes Care in Clinics & Hospitals 3- Insure Insulin & Medications Availability 4- provide Education :Patient, Health Care Team and Public

5- Coordinate with Health Care Syndicates 6- Coordinate with NGOs 7- attract International Aid programmes 8- promote National Research ( epidemiol.-socioeconomic)

Parliament (Legislation)

1- Budget planning to improve diabetes Care 2- Taxation Exemption for insulin & medical requirements 3- Put rules and regulations for NGO activities 4- Maintain and guard Patients’ Human Rights ( anti discrimination, working , children, women , elderly …etc) 5- Health Insurance Laws

The Non-Governmental Organizations (NGOs )

1- Advocacy 2- Education Programs for : -Patients and Families -Health Care Team -Community at large

3 - Rules & Regulations - legally recognized - non profitable - accountable and transparent - coordinated & complementary to government - no unhealthy competition, extravagance , business controlled ( by industries )

The Health Care TeamThe Physician 1- is Leader of the HC team 2- is the Final reference for his patient’s education 3- keep harmony with others in the HC team 4- requires continuous training courses and updates 5- acquire education skills

Nurses 1- Training courses , by whom ? 2- Knowledge + skills & attitude 3- skills in education 4- keep Team work 5- Continuous education , scientific meetings and workshops

Diabetes Care for Special Groups School Children - Registration at national level - Individual records in schools - basic equipments to manage emergencies - Education courses to school attendants. - protecting special rights : play- recreation - treatment .non discrimination …etc

Mothers with Diabetes of Pregnancy

- Screening for diabetes of pregnancy - Protocols for management of GD - Care for the N.B. - After-labour follow-up of mothers

The National Diabetes Registry - essential as source of information for planning public services - Central location - paper or computer recordings - contains individual patient data - complemented by local & peripheral registries (in schools - work – Health insurance, etc ) - network connections for exchange information

Diabetes Screening Programmes - Specifically to high risk groups - By central planning and organization - ensure unified criteria for diagnosis

- Screening for early detection of complications :

- Sending study groups to remote areas.

International Relations

The International Diabetes Federation

1- get moral support from IDF to National Associations & programs 2- use as source of information & educational material 3- Benefit from IDF Task forces’ activities and programs 4- Benefit from WDD events

The WHO

1- Government / collaborative programmes for promotion of diabetes Care2- NGO : collaboration in promoting diabetes care through training & education programmes

The Patient Obligations 1- Take active role: seek to be educated 2- follow proper life style 3- comply 4- not to accept misconceptions and deceptive propaganda

Thank You

Bibliotheca Alexandrina on WDD