Diabetes -
Time to reverse the trend

Diabetes has reached epidemic proportions in the Middle East and as prevalence continues to increase it will place a heavy burden on regional governments unless urgent action is taken to reverse the trend. Middle East Health reports from two landmark meetings held recently in Dubai that looked at the current situation and strategies to combat the disease.

The number of people aged 20 to 79 years with diabetes in the Eastern Mediterranean and Middle East (EMME) region will nearly double from the 24.5 million this year to 44.5 million in 2025. Moreover, the number of people with impaired glucose tolerance (IGT) or pre-diabetes will increase from 22.4 million to 38.6 million during the same period.

These staggering figures provided by The International Diabetes Federation (IDF) were highlighted by diabetes experts in two symposia in Dubai recently to emphasise the enormous burden that diabetes is set to place on healthcare systems across the region, unless a concerted effort by governments and the private sector is taken to reverse this runaway trend.

The experts from across EMME came together to discuss diabetes at two separate events in Dubai earlier this year. One of these experts was Dr Oussama Khatib, WHO regional advisor for non-communicable diseases. Read Middle East Health’s exclusive interview with Dr Khatib on page 50.

The first of these symposia held in February and sponsored by pharmaceutical company Sanofi Aventis, saw the launch of a campaign entitled “DEVOTED” or “Developing actions for better Outcomes in Diabetes care” and focused on how effective modern treatment strategies and ongoing support can significantly improve the daily life for people with diabetes and diabetes complications.

The following issues were highlighted at the symposium.

- The prevalence of adult diabetes is projected to rise markedly in both developed and developing countries

- Diabetes is now considered by the World Health Organisation (WHO) as an “epidemic”, and represents a huge burden for societies worldwide

- The WHO and the International Diabetes Federation (IDF) estimate that the number of diabetic patients in the world is currently between 194 and 246 million, and that this figure should rise to between 333 and 380 million individuals by 2025

Diabetes prevalence in some countries of the Eastern Mediterranean and Middle East Region (EMME) is among the highest in the world (9.4% in 2007, according to the Diabetes Atlas). This region extends from Pakistan in the east to Morocco in the west, and the population is a mosaic of several ethnic groups. The age distribution pattern of the population is pyramidal with about 50% of the population below the age of 20 years.

Over the past three decades major social and economic changes have occurred in many of these countries. These include progressive urbanisation, decreasing infant mortality and increasing life expectancy.

Rapid economic development among the more wealthy oil-producing nations has been associated with extraordinary social change resulting in the adoption of an increasingly Western lifestyle which is reflected in changes in diet and nutrition, a move to a more sedentary lifestyle with an increasing prevalence of smoking and obesity. These socioeconomic changes are believed responsible for an explosion of diabetes across the region.

According to recent studies, six countries in the region – United Arab Emirates, Bahrain, Kuwait, Saudi Arabia, Egypt and Oman – are among the world’s 10 highest with regards to diabetes prevalence, and a similar situation applies for IGT prevalence in these countries. As with many other countries with high diabetes prevalence, the onset of type 2 diabetes is becoming increasingly prevalent in adolescents.


Spotlight on children

The second event in Dubai to focus on diabetes was the Arab Children Health Congress (ACHC), held in March. At this event regional and global healthcare leaders, as well as several children with diabetes, came together to discuss the issue and develop a series of key strategy recommendations on tackling the disease in the region.

Congress delegates said the strategic plan would be put to ministries of health in the region with the aim of affecting change in regional health policies. The plan focuses on improvements at the regional, national and school levels.

Recommendations at the regional and national levels focused on adopting rules and regulations aimed at implementing preventative measures and protecting the rights of children with diabetes, while recommendations for the school looked at ways in which to strengthen the capacity of schools and the capabilities of personnel in caring for children with diabetes through a number of clearly defined initiatives.

Her Royal Highness Princess Haya Bint Al Hussein who launched the ACHC in an effort to create a platform for challenged Arab children to discuss health issues and to raise public awareness, said: “I am extremely proud of the outcome of this year’s congress. The shared experiences of children with diabetes coupled with the knowledge and expertise of the healthcare professionals at the Congress have resulted in a clear set of recommendations on how to tackle the diabetes issue effectively. I am convinced that we can now move forward and see some positive results. Our children are our future and I strongly believe that through the initiatives put forward by the Congress, we will be able to ensure a brighter future for all.”

In addition to the recommendations, the panel also elected the new ACHC ambassador representing children with diabetes. Omani national Habiba Malik Al Tawqi, who was diagnosed with diabetes at the age of two, assumes her new role as the 2007 ambassador for the Congress. Habiba has had both her legs amputated and has had kidney transplant as a result of diabetes related complications. Her experiences will allow her to shed light on living with diabetes.

Arab Children Health Congress 2007 Key Recommendations

Regional Level:
Ensure that all items of the United Nations resolution on diabetes be implemented in government, private and NGO sectors
Develop a strategy to prevent the disease and enhance the health of children with diabetes
Develop and adopt rules and regulations to ensure the rights and safety of children with diabetes
Establish a regional website on prevention and controlling diabetes among children
Establish a network of expertise, professionals, researchers and community members to support and advocate for the wellbeing of children with diabetes

National Level:
Integrate and unify programmes and activities related to children with diabetes
Establish policies and regulations to protect children with diabetes at school, day care centres, hospitals, clinics and community
Draft a bill of rights of children with diabetes and work towards approval at ministerial level by the Ministry of Health and the Ministry of Education
i. Provide resources for blood tests
ii. Provide access for at least three visits per year to a diabetes clinic where HBA1C test is done
iii. Provide required syringes and insulin
iv. Ensure financial coverage of basic healthcare needs of children with diabetes
Develop concrete policies to ensure informative labelling of food products
Establish a comprehensive healthcare centre dedicated to children with diabetes
Provide an adequate number of trained nurses at all levels of healthcare services for children with diabetes
Ensure that manufacturing companies of diabetes related products play an active role in supporting diabetic children’s camps, educational materials and conferences on diabetic children
Develop an awareness programme to support and enhance the health and well being of children with diabetes that utilises tools such as diabetic medical ID
Develop clinical protocols that standardise the care for children with diabetes throughout governmental and private healthcare sectors
Provide annual training and education programmes for healthcare providers
Conduct research and establish database on obesity, other risk factors and status of children with diabetes
Develop monitoring and evaluation mechanisms to supervise and evaluate all interventions related to children with diabetes

School Level
Strengthen the capacity of schools and capabilities of personnel in caring for children with diabetes through

Development and implementation individual healthcare plan for children with diabetes including an emergency healthcare plan at schools
Provision of all necessary equipment and tools at school clinics to support children with diabetes and ensure their safety
Ensure adequate number of trained nurses and councillors at schools for children with diabetes
Promote healthy eating habits within the school environment through the provision of health food options and the banning of junk foods
Develop and activate physical education programmes that promote exercise and physical activities

Types of diabetes and treatment options

The most common types of diabetes are called type 1 and type 2 diabetes, accounting for 5%-10% and 90%-95% of cases worldwide, respectively, according to the IDF. The mechanisms leading to hyperglycaemia are different in each type.

Type 1 diabetes results from beta-cell destruction, usually leading to absolute insulin deficiency. Consequently, people with type 1 diabetes must inject insulin to survive. Type I diabetes most commonly occurs during childhood.

Type 2 diabetes results from a progressive insulin secretion defect on the back of insulin resistance. During the development of type 2 diabetes, cells gradually lose sensitivity to the effects of insulin – insulin resistance.

The resulting high blood glucose causes the pancreas to secrete more insulin, bringing the blood glucose back under control. The cycle of worsening insulin resistance and increased insulin secretion eventually reaches a point at which the amount of insulin secreted can no longer overcome the insulin resistance, and the hyperglycaemia of type 2 diabetes ensues. In type 2 diabetes, insulin deficiency is relative because insulin is still produced, though not in sufficient quantities.

Type 2 diabetes – also known as adult – onset diabetes – is usually diagnosed after the age of 40, although many of those diagnosed people may have had the disease for several years without realising it. However, the disease is increasingly being diagnosed in children and adolescents, which is largely explained by the increasing prevalence of obesity in this sector of the population.

Treatment

Diabetes treatments are aimed at lowering high glucose levels in the blood, in order to delay complications.

Insulins are given as a substitute (type 1 diabetes) or a supplement (type 2 diabetes) to natural insulin secretion. Modern insulins closely resemble human insulin but have been modified to target glucose at different times of the day:

- Basal insulins are effective at all times, targeting fasting glucose (the background level of glucose, i.e. during sleep and between meals) as well as post-prandial glucose (the glucose surge that occurs after meals)  

- Bolus insulins target post-prandial glucose only

People with type 1 diabetes must inject insulin, usually using a basal-bolus regimen, which consists of mealtimes boluses of rapidacting insulin and longacting basal insulin injection.

An oral inhalation insulin delivery mechanism, which does away with then need for injections, has recently been approved by various medical regulatory authorities and marketed worldwide.

The treatment of type 2 diabetes is in line with the progressive nature of the disease. Insulin resistance and insulin insufficiency steadily worsen over time and, as a result, the average blood glucose level rises unrelentlessly. Type 2 diabetes treatments consist of diet and exercise measures, oral antidiabetics, insulin and combinations thereof. The average level of blood glucose (HbA1c) should be monitored at least every 3 months to ensure that the current treatment is still working.

International guidelines stipulate HbA1c targets of 6.5% (IDF) and 7.0% (American Diabetes Association). Over time, most people with type 2 diabetes will need insulin to control the blood glucose. The IDF has recommended that insulin treatment be commenced in patients whose HbA1c is over 7.5% despite the use of optimal oral therapy.


Study shows CVD rises in proportion

A new study shows that as rates of diabetes have risen in the United States, the proportion of cardiovascular disease (CVD) linked to diabetes has also increased.

These findings emphasise the need for increased efforts to prevent diabetes and to aggressively treat and control CVD risk factors among those with diabetes, according to the investigators from the long-standing Framingham Heart Study.

The researchers compared risk factors for CVD and cardiovascular “events” such as heart attacks in Framingham study participants from two different time periods. The first group was examined between 1952 and 1974 and the more recent group was examined between 1975 and 1998.

A total of 9,540 individuals age 45 to 64 were evaluated. The risk attributable to diabetes was 5.2% in the earlier time period, compared to 7.8% in the later period. Most of the increased risk was observed among men. The scientists also reported that the prevalence of diabetes among those with CVD almost doubled between the earlier and later time periods and there was also an increase in the prevalence of obesity.

“Increasing cardiovascular disease burden due to diabetes: The Framingham Study” is published in the 27 March issue of Circulation and can be accessed online here: http://circ.ahajournals.org


Insulin free with stem cell therapy

A therapy that includes stem cell transplantation induced extended insulin independence in patients with type 1 diabetes mellitus, according to a preliminary study in the April 11 issue of JAMA.

Type 1 diabetes mellitus (DM) results from a cellmediated autoimmune attack against pancreatic beta cells. Beta-cell preservation has been shown to be an important target in the management of type 1 DM and in the prevention of its related complications. Researchers in Brazil and the US conducted a study to examine the effect of highdose immunosuppression followed by autologous nonmyeloablative hematopoietic stem cell transplantation (AHST) to preserve beta-cell function in 15 newly diagnosed patients with type 1 DM. AHST, which uses a patient's own blood stem cells, involves the removal and treatment of the stem cells, and their return to the patient by intravenous injection.

During a 7 to 36-month follow-up, 14 patients became insulin-free (one for 35 months, four for at least 21 months, seven for at least six months; and two with late response were insulinfree for one and five months, respectively). Among those, one patient resumed insulin use one year after AHST. The only severe adverse effects were pneumonia in one patient and endocrine dysfunction.


European Society of Cardiology publishes new guidelines

The European Society of Cardiology (ESC) has released their “Guidelines on diabetes, pre-diabetes and cardiovascular diseases”. The 2007 Guidelines were published in the European Heart Journal (doi:10.1093/ euroheartj/ehl261).

The guidelines provide a guide for management and offers recommendations for individual patients with diabetes based on a thorough review of the literature by a team of experts in the field.

The authors point out that it “is high time that diabetologists and cardiologists join forces to improve quality management in diagnosis and care for the millions of patients who have both cardiovascular and metabolic diseases.

The cardio-diabetologic approach not only is of the utmost importance for the sake of those patients, but also instrumental for further progress in the fields of cardiology and diabetology.” It is for this reason that the comprehensive 2007 Guidelines have been developed to incorporate “diabetes and cardiovascular diseases”.

The 2007 Guidelines can be downloaded from www.escardio.org


                                  
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