Diabetes as a Global Health Problem The IDF meets the Challenge By Prof. Morsi Arab IDF Chairman MENA Region Prof. Morsi Arab IDF Chairman MENA Region

MENA

Reported Incidence of Type1 Diabetes at the MENA Region per population under 15 yrs ( Diabetes Atlas 2006) Afghanistan1.2 Algeria8.6 Bahrain2.5 Egypt8.0 Iran3.7 Iraq3.7 Jordan3.2 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 Sudan10.1 Tunisia 7.3 Emirates 2.5 Yemen 2.5

ِ At The MENA Region Prevalence of Diabetes is 9.2 % (age ) 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 years is related to diabetes

MENA

The pyramidal structure of the Egyptian population >

Age Group

Western desert Eastern desert Saini Nubia

DIABETES IS PART OF THE WIDER HEALTH PROBLEM : THE METABOLIC SYNDROME % of the world adult population have the metabolic syndrome ( MTS), and these are : - 5 times at risk to develop diabetes type 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) definition According 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 :  150 mg/dL (1.7 mmol/L ) or specific treatment for this lipid abnormality. Raised triglycerides  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 Reduced HDL Cholesterol Systolic BP 130 or diastolic BP 85 mmHg Or treatment of previously diagnosed hypertension Raised blood pressure ( FPG) 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes Raised fasting plasma glucose

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 mg/dl = 15.6 % Marked hyperglycemia -200 = 31.3 % Severe hyperglycemia -220 = 12.5 % Very severe hyperglycemia > 220 = 20.8 %

120 mg/dl Hyperglycemia Fasting

Post Prandial Hyperglycemia - Controlled < 160 mg/dl = 13.5 % - Accepted mg/dl = 7.9 % Total = 21.4 % - Uncontrolled ( >180 mg/dl ) = 78.6 % * Moderate -220 mg/dl = 17.4 % * Severe mg/dl = 16.0 % * Very Severe > 260 mg/dl = 45.2 %

180 mg/dl Hyperglycemia

Diastolic Blood Pressure 80 mm Hg

Systolic Blood Pressure 130 mm Hg 0.50%

Lipid Control Serum Cholesterol 200 mg

Lipid Control Serum Triglycerides 150 mg

( C ) > 30 ( B ) ( A ) < 24 Obesity as BMI group 30.6 % *20.5 % *8.7 % Syst. B.P. > 150 mm Hg 41.5 % *32.9 % *17.1 % Diast. B.P. > 80 mm Hg 50.4 % *24.5 % *19.7 % S. Cholest. > 200 mg/dL 54.9 % *22.6 %23.5 % S. Triglycerides >150mg/dL 80.0 %73.8 %72.3 % Fasting Bl.Gluc.>120mg/dL N.B. (%) percentage of patients above the acceptable levels, (*) Significant Obesity as a Risk Factor for Hyperglycemia, Hypertension and Hyperlipidemia

Cardiac Complications

Retinopathy (in 1173 patients ) - Free 68.9 % - Back ground 22.6 % - Proliferative 9.5 %

Retinopathy in correlation with Duration of DM

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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

Fertility and Abortions Abortions : 21.5% Fertility : 3.6 ch/m

The Socio economic Burden

Middle East Countries- economic status per capitum incomes : High Kuwait Emirates Qatar Bahrain Oman Saudi Arabia Libya Low Syria Jordan Tunisia Morocco Egypt Yemen Sudan Middle (Iraq) Iran >5,000 US $ < 2,000 US $

> > 200 Bahrain 1047 Lebanon 1050 Qatar 1198 Oman 614 Tunisia 637 Jordan 711 Iran 744 Kuwait 806 Saudi Arabia 891 Emirates 929 Alger 273 Morocco 285 Egypt 286 Libya 384 Afghanistan 56 Iraq 72 Pakistan 99 Sudan 103 Yemen 110 Syria 185 MENA Countries according to The Mean Health Expenditure per person with diabetes in ID (international Dollar) : Diabetes Atlas, 3rd Ed.

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

What are The IDF Goals ? 1. Global Advocacy 2. To raise Global Awareness 3. Promote appropriate Diabetes Care & Prevention 4. Encourage finding a Cure

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 Physician Nurse Dietitian Foot Care Pharmacist Laboratory Medical Group Work- school Friends MEDIA Ministry of Health Governmen t Parliament Syndicate 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 Team The 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 Care 2- 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