1. National Diabetes Program Kuwait Dr. Monira Al Arouj Assistant Director, Dasman Diabetes center, Kuwait

3. Kuwait Area: 17,820 sq. km. (6,880 sq. miles) Population (2005 census ): 2.3 million, including about 1.5 million non-nationals Natural resources: Oil, natural gas, fish

4. Diabetes in Kuwait Type 2 Increasing prevalence; –1970-1980 : 7% (MOH) –1980-1990 : 12% –1996-1998 : overall prevalence 15.7% IGT 7.0 % Abdella etal, Diabetes Res. & Clinical Pract.42 (1998) 187 - 196

5. Age and sex specific prevalence rate of DM in 3003 Kuwaiti aged above 20 year Abdella etal, Diabetes Res. & Clinical Pract.42 (1998) 187 - 196 Prevalence % Female Prevalence % Male Age group 5.75.8 20 -3 9 18.718.1 40 - 49 37.838.8Over 60 15.715.8Total

6. Characteristics of 3003 Kuwaiti adults aged 20 and above IGT (%)Type 2 DM (%)Non diabetic (%)Characteristics 58.2 25.3 67.5* 20.1* 58.9 24.0 Exercise Inactive Occasional 38.5 61.5* 43.5 56.5* 50.1 49.9* Family history No Yes 80.2 19.8 74.8 25.2 90.0 10.0 Hypertension Normal Ht 11.0 25.3* 63.7* 14.5 30.5* 55.0* 21.6 38.5* 39.5* BMI Normal 25 G1 25-30 G2 >30

7. Type 2 DM in children and adolescents Increase in the incidence of type 2 DM in children and adolescents parallel to increase in obesity In 2004,among 155 diagnosed with DM in the age group below 18 years, 46 had type 2 (30%) Kuwait Nutrition Surveillance System, 2004

8. Type 1 Diabetes - Kuwait 1983 (Taha etal) 3.9/ 100000 age 0 -14 year 1991 type 1 diabetes registry was started (DIAMOND) –1994 : 12.8/100000 –2000 : 18.0/100000 –2002 : 20.1/100000 Shaltout etal, Diabet Med. 2002 Jun;19(6):522-5

10. Diabetes Services in Kuwait Primary Care Level –Diabetes mini clinics (34) –Drs, nurses, dietitians, lab & pharmacy Secondary Care Level –Diabetes units in hospitals (3/6) Tertiary Care Level (specialized center)

11. Health Areas Al Asima HawalliFarwaniya Al Ahmedi Al Jahra Total Population (2004) 423,998614,187632,858454,345290,2392.415, 627 Registered Diabetic Patients 38,47133,36333,04125,94915,852146,676 Number of mini clinics 76107434 Number of Drs. (Diabetologists) PHC 182017131179 Primary Care Level

12. Diabetes Services in Kuwait The mini diabetes clinics provide all the services & Insulins OHAs Free of charge This system was not functioning properly for many years, for different reasons !!!

13. Diabetes Services Barriers Attitude barrier - decision makers - professionals Lack of Multidisciplinary team Approach Lack of diabetic educators Lack of standardized educational programs Lack of screening programs for complications

14. What has been done? Increase policy makers awareness Kuwait Diabetes Society 1996 National Diabetes Program (NDP) 2000 Tertiary Diabetes Center (by NGO) 2006

15. Governmental awareness Continuous campaigning to demonstrate the effectiveness of education, training and awareness in reducing the burden of diabetes. Ministers, MPs, Media, Other NGOs

16. National Diabetes Program (NDP 2000) Political will Chaired by under- secretary MOH Members: - Diabetologists - PHC - Nurse, health educator - Dietitian - Ophthalmologist -Surgeon - Education and awareness dep. In MOH Sub-committees with: - Ministry of information - Ministry of education (school) - Kuwait diabetes society (DKS)

17. National Strategies Action targeted across the continuum of care Action targeted at the primary prevention of diabetes Action targeted early detection of diabetes Action targeted the care of people with diabetes

18. Programs 1.Organization and improvement of diabetes care delivery system: PHC (mini diabetes clinics) Secondary care (Diabetes units in hospitals) Foot care program Eye screening program Children Care 2.Training and education programs for diabetes care team 2.Diabetes care programs in PHC 4. Programs for patients education and increase public awareness 5. Prevention programs

19. Diabetic Retinopathy screening Until the end of 1987 NO screening activities, at any level, were performed.

20. The Screening for Diabetic Retinopathy, Capital Health Region First step - Evaluate data from variety of sources (ophthalmic care services, diabetes clinic and hospitals) - To know the basal situation (pilot study) Second step - build on the existing strength

21. Diabetic Fundus Clinic - Amiri Hospital Started 1987 Run by diabetologists Methodology: Ophthalmoscopy Fundus photography Ophthalmology opinion and referral, when needed Patients from Capital area (3 mini diabetes clinics in PHC)

22. Results of the First Year 1050 patients 536 (50.1%) --- different grades of DR 287 (53%) --- had Ophthl. Treatment 1008 (96%) --- first eye check

23. Diabetic Retinopathy Screening Services A training program for doctors in diabetic clinics, was started 1993. training at Diabetes Unit and Ophthalmology Dep. Training on how to detect sight threatening DR by ophthalmoscope screening done at diabetes mini clinics using ophthalmoscopes only

24. Result

25. NDP 2000 Diabetic Retinopathy Screening services for the whole country 2002 Committee: –Diabetologists –Ophthalmologisits –Administration Screening clinic in the mini diabetes clinics (34)

26. General Principles Diabetes Registry Call & recall system Training of diabetologists and PHC doctors Education for patients and public Create the link with Ophthalmology for easy referral and treatment Identify the recourses (MOH, public funds)

27. What has been achieved? Registry, call and re-call system (mini diabetes clinic) Training and development of screening service (PHC Drs) in ophthalmology center and diabetes unit in hospitals Digital Cameras in 20 of the diabetes clinic Referral for ophthalmologists (treatment center) Periodic assessment by Ophthalmologist

28. Total Health areas Al AsimaHawalli Farwaniya Al AhmediAl Jahra5 Pop. 2004 423,998614,187632,858454,345290,2392.415,627 Register Diabetics 38,47133,36333,04125,94915,852146,676 Mini Clinics 76107434 # D. Drs. PHC 182017131179 # of Cameras 4454320

29. What do we need? Remote image capture system Transmission to central reading center for interpretation Training and development of grading center

30. Conclusion There is no well structured program for diabetic retinopathy, however there is established clinical services for screening in most of the primary care diabetes clinics and hospitals (digital cameras, training) We are in process of developing an accepted protocol of action between the screening services and the treating center We are in process of establishing the tele- ophthalmology services

31. The Diabetic Foot A neglected complication of diabetes in Kuwait until 1994 A retrospective study of 86 in-patient cases in 1989, showed: high amputation rate (55%) long hospital stay (66 days) `A foot care clinic and team was formed

32. Foot care program First diabetic foot clinic Amiri hospital 1994 Team diabetologist surgeon nurses foot wear specialist Podiatrist (2000) Lab, X-ray, Vasc. Lab referrals from capital area clinics Daily

33. The Diabetic foot Clinic-Amiri Hospital Patients from Capital Area

34. NDP 2000 Diabetic foot care program 5 diabetic foot clinic (one in each general hospital) 2 podiatrists Continuous nurses training to do the job of podiatrists International diabetic foot conferences Diabetic foot workshops

35. NDP What have been achieved 1.Organization and improvement of diabetes care delivery system: –34 mini diabetes clinics in PHC –3 diabetes units in 3 general hospital (secondary level) –Children care in 3 hospital –Eye screening program –Foot care program ( 5 foot clinics)

36. What else have been achieved ? 2. Training and education programs for diabetes care team (MOH, Faculty of medicine, KDS) For Doctors Diploma in diabetes (UCD), 27 candidates Continuous CME courses for all health care professions by MOH, faculty of medicine and KDS (diabetes clubs monthly) Regular training for pediatricians in diabetes care in pediatric diabetes unit Fellowship in diabetes ( 2 years post graduate fellowship) 2006 by MOH and faculty of medicine For nurses Educate the educator courses, workshops for one week by help of IDF and WHO and others

37. 3. Patients education (Kuwait Diabetes society) Children club - Twice/ month, for child and the family with the diabetic team (25-30 families/ week)

38. Patients education (regular at KDS) Diwania (Adult club) - twice monthly, (40-50 pt/ w) - HbA1c, foot care, fundus exam, dietary advice - Group education or one by one Pregnancy advice - once weekly for diabetic control Diet advice - Twice weekly Glucometers & strips: 50-60% discount Sponsor a child with diabetes

39. 4. Increase public awareness (KDS) Local media : press release, radio and TV Daily messages in newspapers School (obesity and fast food) Marathons ( yearly ) KDS website (www.kds- kw.org)www.kds- kw.org Educational materials Participations in other social activities

40. SMS messages

41. Diabetes Care Program Main Objective Improve the quality of diabetes care in the PHC Improve the quality of diabetes care in the PHC

42. Main Interventions Monitoring and Evaluation Surveys Implementation of standards Development and distribution of Clinical practice guidelines Determination and distribution of Standards of care Training courses Kuwait Diabetes Care Programme Participation in patients’ education Suggestion of drugs to be available

43. Main Interventions Monitoring and Evaluation Surveys Implementation of standards Development and distribution of Clinical practice guidelines Determination and distribution of Standards of care Training courses Kuwait Diabetes Care Programme Participation in patients’ education Suggestion of drugs to be available

44. Development and distribution of Clinical practice guidelines First edition of clinical practice guidelines for diabetes care was developed and distributed to all physicians working at the PHC in 2001First edition of clinical practice guidelines for diabetes care was developed and distributed to all physicians working at the PHC in 2001.

45. Monitoring and Evaluation System to audit the diabetes care services provided at the primary health care level. to determine the adherence to the standards. to evaluate the effectiveness of DCP

46. Diabetes Care Programme: Standards of care improvement 20041999 31.6 %2.4%Fundus exam 40.4 %0.4 %Foot exam 26.4 %4.4 %Microalbumine 60.8 %10.4 %HbA1c 80 %16.4 %Lipid Profile 27.2 %2.8%Smoking assessment

47. Dasman Diabetes Centre Prevention programs Training of health care providers Patient education Increase public awareness Research

48. Promising Initiatives GGSD - Annual workshops for health care providers - Biannual conference in each GCC country Gulf committee for the National Diabetes Planning in the GCC region to adopt the same strategies and sharing experience

49. GCC Declaration on Diabetes 16 May 2007 All ministers of health in the Gulf cooperation council states signed a declaration which recognizes diabetes as a chronic debilitating and costly disease, associated with sever complication that poses sever risks for families, member states and entire world. Give all the commitments for putting plans and strategies that reduces the burden of diabetes Copy was send to IDF president and will be distributed to all members

50. GCC strategic plan for diabetes prevention Goals Primary prevention Secondary prevention Improvement of medical services in all level Empowerment of methods of surveillance and follow up Support researches Empowerment of patients and their families role in the control of diabetes

51. Each country should have operational action plans in a time bound program Each goal have specific objectives, strategies, implementation stages and several standard and indicators to assess the success

52. Conclusion Diabetes is a major healthy problem in Kuwait Some promising achievements Lots of efforts are needed With clear objectives & vision and a dedicated team more and more can be achieved

53. Thank you

55. Future plans Prevention programs - Early detection of diabetes and its risk factors - Community-based healthy lifestyle programs, aiming for prevention of type 2 DM More Diabetic educators and qualified dietitians Foot care specialists (podiatrists) Research

56. Thank you

58. NDP Objectives 1.Increase public awareness of the seriousness of diabetes, its risk factors, complications. 2. Improve understanding of diabetes and its control and promote self-management behaviours among diabetics. 3. Improve health care providers’ understanding of diabetes and its control and promote an integrated approach to care. 4. Promote health care policies that improve quality of and access to diabetes care. 5. Set strategies for early detection and prevention of diabetes and its complications

60. Patients education (regular at KDS) Diwania (Adult Club) - twice monthly - HbA1c, foot care, fundus exam, dietary advice - Group education or one by one Pregnancy advice - once weekly for diabetic control Diet advice - Twice weekly Glucometers & strips: 50-60% discount