Diseases of Lifestyle
Diabetes & primary care

Middle East Health looks at the current state of diabetes in the region and speaks to Dr Maha Taysir Barakat, the medical & research director at Imperial College London Diabetes Centre in Abu Dhabi, to find out what primary care practitioners, often the first line of defence against disease for many people, can do to help alleviate the rising prevalence.

“Diabetes is currently the fastest growing debilitating disease in the world,” says Dr Maha Taysir Barakat, consultant endocrinologist, medical & research director, Imperial College London Diabetes Centre (ICLDC), Abu Dhabi.

According to the World Health Organisation (WHO) more than 180 million people worldwide live with diabetes. The WHO says this figure is set to double by 2030.

The international Diabetes Federation (IDF) says diabetes is expected to cause 3.8 million deaths worldwide this year, about 6% of total global mortality, roughly the same as that from HIV/AIDS.

In the six Gulf Cooperation Council (GCC) States, figures from the IDF Diabetes Atlas for 2003 show some 1.8 million people have diabetes and that this figure is estimated to double to 3.6 million by 2025.

In the wider Eastern Mediterranean and Middle East (EMME) region – a large region extending from Morocco in the west to Pakistan in the east – the IDF estimates that as of this year 24.5 million people have diabetes and that by 2025 this figure will also double to 44.5 million.

“In the UAE it is estimated that one out of five people aged 20 to 79 lives with this disease, while a similar percent of population is at risk of developing it,” Dr Barakat said.

“This year, the UAE ranked second highest worldwide for diabetes prevalence, followed by Saudi Arabia, Bahrain, and Kuwait, according to the International Diabetes Federation.”

As well as the devastating impact on individuals and their families who live with and manage the disease on a daily basis, the cost of diabetes management and treatment is placing an increasingly large burden on the economies of countries in the region and has recently become a key driving force for governments to initiate action to remedy the situation.

Dr Oussama Khatib, WHO Eastern Mediterranean Region regional advisor for communicable diseases, speaking to Middle East Health earlier this year emphasised this issue.

“The high cost of taking care of diabetes patients, which has been shown in various studies in a range of countries from the United States to Jordan, should act as a warning to governments in the region that a concerted initiative needs to be developed to create awareness of the risk factors.

Full screening programmes should be developed to catch the disease early and also to help those who remain undiagnosed,” he said.

In that interview, (published in Middle East Health in May 2007) he pointed out that a recent study showed that the economic burden of diabetes exceeded 10% of the total budget of the ministries of health in the GCC.

The Saudi Arabian Government is reportedly spending some SR5 billion (about US$1.3 bn) annually to treat diabetes and related diseases in the kingdom, according to a report in Saudi Arabia’s Arab News newspaper.

The government in Saudi Arabia has embarked upon a kingdomwide campaign to raise awareness about the dangers, causes and treatments for diabetes. Part of this initiative will see the establishment of a satellite TV channel devoted to educating people about diabetes Arab News quoted Dr Khaled Al-Zahrani, deputy minister of health for preventive medicine in Saudi Arabia, as saying the ministry would appoint 20 goodwill ambassadors to carry out the campaign in all the 22 health regions in the kingdom.

Other initiatives in Saudi include the strengthening of its primary healthcare centres throughout the kingdom. The Ministry of Health announced recently that they were seeking an additional 13,000 family doctors to staff these centres and reduce the current doctor-patient ratio from 1:4,000 to 1:400.

Referring to the UAE, Stephen Baker, general manager, ICLDC, noted at a recent Healthcare Management Forum in Abu Dhabi, that forecasts indicate that the cost of healthcare is fast outstripping the rate of inflation and that if left unchecked would consume an increasingly large proportion of the UAE’s GDP.

Although not referring exclusively to diabetes he pointed out that most of these diseases – diabetes, hypertension, cancer, osteoporosis, obesity and cardiovascular disease – are preventable or at least can be mitigated with early diagnosis.

“Research shows that the only way to avoid spending unnecessary money on healthcare is by preventing sickness and disease in the first place.

“If you are diagnosed early, without question, the cost to prevent is far less than the cost to cure, if at all, a cure is possible,” Baker said. Saudi Arabia has not been alone in developing initiatives to combat the increasing prevalence of diabetes.

The UAE too has orchestrated a number of programmes, the latest of which is a plan to make a free annual medical checkup compulsory for all UAE nationals. The Ministry of Health added that the plan would be extended to expatriates at a later date.

Dr Mariam Mattar, assistant undersecretary for Public Health and Primary Health Care at the UAE MoH said: “People of all ages, including children, will be required to undergo the annual health check-up at a Primary Healthcare Centre.”

The annual medical check-up is part of a wider UAE MoH plan to upgrade primary healthcare facilities throughout the Emirates.

Similar initiatives are underway in other GCC countries. Qatar announced recently that the National Health Authority will set up a specialised diabetes centre, which is due to open in 2008.

And in Bahrain the Gulf Diabetes Specialist Center has, for the past four years, had a close affiliation with world renowned Joslin Diabetes Centre in Boston, United States.

Primary health care

Primary health practitioners are, in many instances, the first line of defence for those at risk of getting diabetes. With a clear understanding of the root causes of diabetes they are in a good position to play a decisive role in early diagnosis and prevention of the disease.

“Non-insulin-dependent Type 2 diabetes is by far the most prevalent,” Dr Barakat explains, adding that “some 85% to 95% of diabetics have this type, compared to insulin-dependent Type 1 diabetes.”

“However,” Dr Barakat says, “if one follows up Type 2 diabetes over 5 years, 10 years, 20 years or longer, all Type 2 diabetics will eventually require insulin at some stage.” This is because the pancreas, although it works normally initially, has to work increasingly harder and becomes steadily weaker over time as it battles insulin resistance by the body.

“It is important that doctors are aware of this and try to preserve pancreatic function for Type 2 diabetics for as long as possible,” Dr Barakat emphasises.

She says that when confronted with a Type 2 diabetes patient there are two critical aspects that spring immediately to mind: firstly how can pancreatic function be preserved and, secondly, what can be done to prevent this person having a heart attack. “Diabetes significantly increases the risk of heart disease and stroke,” says Dr Barakat.

“People with Type 2 diabetes are more than twice as likely to have a heart attack or stroke as people who do not have diabetes.” There are other serious complications of diabetes, Dr Barakat says. “Diabetes brings with it several serious complications related to the heart, eyes, blood vessels, kidneys, feet and nerves.

“Diabetic retinopathy, a key cause of blindness, occurs as a result of longterm accumulated damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment,” Dr Barakat explains.

“Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of diabetes sufferers. Although many different complications can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands. Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.

“Diabetes is among the leading causes of kidney failure with some 10-20% of people with diabetes dying from this complication. “The overall risk of premature death among people with diabetes is at least double the risk of their peers without diabetes.”

Lifestyle Across the region the rapid escalation of Type 2 diabetes has been brought on largely by increasing affluence, which in turn has resulted in an increasingly sedentary lifestyle as well as a move to more Western dietary habits and the consumption of more high-fat fast food.

The end result – obesity. Abdominal obesity, in particular, is considered a key risk factor for diabetes. However, as well as falling victim to the risks inherent in an unhealthy lifestyle, it is presumed certain population groups are genetically disposed to developing Type 2 diabetes.

Dr Barakat explains: “The reason we make this presumption is that there are two groups of people living here [the UAE] – the expats and the nationals. Some of the expats were born here, so the environment is the same for both these groups, yet there is a significantly higher prevalence rate of Type 2 diabetes among the national population.

This points to them having a genetic predisposition to the disease, which is pushed on by an unhealthy lifestyle.” The ICLDC is currently carrying out research into this aspect of diabetes.

Asked if primary care practitioners were sufficiently aware of the scope of diabetes in the region, Dr Barakat replies: “I think primary health caregivers are increasingly aware of the scope of the diabetes problem. In the UAE the MoH is playing an important role in raising their awareness by sending them guidelines and protocols. “That is one way of helping them. The other is by providing lectures and seminars on the subject for Continuing Medical Education (CME).”

Dr Barakat remarked that the health authority in Abu Dhabi has taken the important step of making CME mandatory in order for doctors to annually renew their medical licences. A similar position has been adopted by the health authority in Dubai. Saudi Arabia has also implemented similar legislation.

The ICLDC runs regular CME accredited lectures and workshops by visiting experts. A calendar of events is available on their website: www.icldc.com

 Dr Barakat emphasises that it is important that doctors revise their knowledge. “How you practised 20 years ago is very different from how we practise now. “It’s completely changed. The methods have changed.

The inferences have changed. The regime has changed. Insulin used to be given once daily, it is now five times daily. “Primary care has improved in one sphere – the threshold for testing for diabetes is lower than it used to be.

“Primary care is important and we do rely on it as there are more diabetes cases than we can deal with at centres such as this [the ICLDC].”

Community Dr Barakat adds that although primary care is important in detecting diabetes and or pre-diabetes, it is important that we spread the message in the community.

Doctors can play a role in this when treating diabetics by telling them that, as well as correcting their unhealthy lifestyle habits, they must tell their family and friends to do so as well, Dr Barakat explained.

She said that when doctors diagnose patients as being prediabetic it is important that they recommend a dietician to assist them with correcting their eating habits.

“These patients are at risk of developing diabetes and heart disease. It is important that they are given assistance with correcting their lifestyle [diet and exercise]. And it is important that they are followed up annually,” Dr Barakat said.

The ICLDC has a lifestyle clinic where patients can attend a four-week course to learn the correct lifestyle for good health. “In fact the best results come from intense supervised exercise. If patients are left on their own they become lazy generally,” Dr Barakat explained.

Dr Barakat alluded to a study in Germany where a number of diabetic patients were institutionalised for three weeks with an intense supervised exercise and dietary programme.

Several of these patients actually reversed their diabetes to show no signs of it at the end of the programme. She said it is important that diabetes is handled in a multi-disciplinary way. “However, I can understand the position of some primary care centres, which don’t have this capacity.

“At the same time as we improve primary care standards, we should also be creating awareness in the community to empower the patients. This is very important.” She said that patients can be empowered through knowledge.

They should know that diet and exercise is important for their health. They should know what symptoms to look for and when to visit a doctor. They should be proactive to catch disease early and not wait until it is too late to prevent the disease.

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