1. Diabetes mellitus organization of care the experience of Syria Bassam ABDULMASSIH MD Endocrinologist Istanbul Friday,April 27 2007

2. Syria

5. Epidemiology of DM in Damascus 1999 ( 24y – 64y)

6. male femaleall Age group Percentage of subject having glycemia >140mg\%ml

7. NCD in Syria in Syria a survey was conducted and it was a part of series of similar surveys conducted in different country in the word backed up by the WHO. in Syria a survey was conducted and it was a part of series of similar surveys conducted in different country in the word backed up by the WHO. the objectives of the study are to measure NCD risk factors and to evaluate the distribution of these diseases in the Syrian population. the objectives of the study are to measure NCD risk factors and to evaluate the distribution of these diseases in the Syrian population. a total of 9184 individuals between 15-64 years old, males and females, were chosen randomly and were collected from 1002 clusters from all communities according to their population. a total of 9184 individuals between 15-64 years old, males and females, were chosen randomly and were collected from 1002 clusters from all communities according to their population.

8. NCD in Syria (continue) half of those individuals gave a sample of blood for analysis.. half of those individuals gave a sample of blood for analysis.. the survey was carried out during 2003-2004 and the result was published in 2005 by the report (NCD distribution and risk factors in the SAR lama hamish MD and all2005) the survey was carried out during 2003-2004 and the result was published in 2005 by the report (NCD distribution and risk factors in the SAR lama hamish MD and all2005)

9. smoking Alcohol consumption Obesity Physical activity Nutritional habits HypertensionDiabetesHyperlipidemia NCD in Syria

10. The average of glycemia Syria France EAU Iran Lebanon Fasting blood sugar Mg \%ml FmFm

11. Result -in the 4742 individuals fasting blood test was done 22.9% of males and 22.9% of males and 18% of females and 18% of females and 19.8% of the whole population had a FPG >110mg%ml. 19.8% of the whole population had a FPG >110mg%ml. - the percentage of dysglycemia is different according to the age group, - the percentage of dysglycemia is different according to the age group,

12. Result (2) in the group aged 15-19y 13.8% of males and 7.6% of females were hyperglycemic. in the group aged 15-19y 13.8% of males and 7.6% of females were hyperglycemic. It increased gradually to reach 40.4% in male and 45.1% in female between 60-64y. It increased gradually to reach 40.4% in male and 45.1% in female between 60-64y. from the questionnaire 4.8% of the population answered by yes that they are diabetics.(4.7% male,4.9% female) from the questionnaire 4.8% of the population answered by yes that they are diabetics.(4.7% male,4.9% female) this percentage is different according to the age group (0.2% in the group 15-19y –increased up to 22.2% between 60-64y). this percentage is different according to the age group (0.2% in the group 15-19y –increased up to 22.2% between 60-64y).

13. Epidemiology of DM 15.6% of the individuals that were not aware to have diabetes, showed FPG >110 mg\dl (there is no data about the percentage of those who are between 110- 125 mdl and those who are >126mg\dl) 15.6% of the individuals that were not aware to have diabetes, showed FPG >110 mg\dl (there is no data about the percentage of those who are between 110- 125 mdl and those who are >126mg\dl) in the diabetic population, to the question (did you monitor your blood glucose the last year ?) 85% answer yes (93% in the urban area 71.3% in the rural area) so 15% of diabetics in Syria don't have any follow up for there diabetes and specially in the rural area (28.7%) in the diabetic population, to the question (did you monitor your blood glucose the last year ?) 85% answer yes (93% in the urban area 71.3% in the rural area) so 15% of diabetics in Syria don't have any follow up for there diabetes and specially in the rural area (28.7%)

14. the treatment in the question about the treatment the survey showed that the majority of patient (79.6%) were treated orally in the question about the treatment the survey showed that the majority of patient (79.6%) were treated orally specially in the rural area the use of insulin is limited comparing with the urban population (the use of insulin is 4 time more in urban than in rural area?!!) specially in the rural area the use of insulin is limited comparing with the urban population (the use of insulin is 4 time more in urban than in rural area?!!)

15. Glycemic control in diabetic patients the average of FPG was 179.4mg\dl (the majority had uncontrolled glycemia), (Hb a1c was not tested) the average of FPG was 179.4mg\dl (the majority had uncontrolled glycemia), (Hb a1c was not tested) plasma glucose tested in the diabetic population showed that 20.4% of them had a FPG plasma glucose tested in the diabetic population showed that 20.4% of them had a FPG of <110mg\dl of <110mg\dl

16. Conclusions the percentage of dysglycemia is elevated and in the next decades we will assist a greater number of diabetics. the percentage of dysglycemia is elevated and in the next decades we will assist a greater number of diabetics. in the rural area we need more continuous medical education to stimulate doctors to have better follow up for our diabetic patients in the rural area we need more continuous medical education to stimulate doctors to have better follow up for our diabetic patients

18. Diabetes care in Syria National program (ministry of health) National program (ministry of health) this program offers all services this program offers all services free-of-charge. free-of-charge. Other public health services. Other public health services. Private sector. Private sector.

19. National diabetes program Started in 1987 Started in 1987 The first diabetic clinic opened in Deirelzor. The first diabetic clinic opened in Deirelzor. Actually there is 105 clinics that cover all regions Actually there is 105 clinics that cover all regions There is a central clinic in each department (14). There is a central clinic in each department (14). The patients are referred to them yearly. The patients are referred to them yearly.

20. Central clinic clinic

21. Distribution of the diabetic clinics Damascus : 10 Damascus sub. : 18 Damascus : 10 Damascus sub. : 18 Aleppo : 10 latakie : 6 Aleppo : 10 latakie : 6 Tartous : 5 raka : 4 Tartous : 5 raka : 4 Daraa : 10 soueda : 6 Daraa : 10 soueda : 6 Hasake : 4 deirelzor : 4 Hasake : 4 deirelzor : 4 Homs : 13 hama : 10 Homs : 13 hama : 10 Idleb : 4 konetra : 5 Idleb : 4 konetra : 5

22. Number of patients registered in each department :

23. Central clinic Diabetic consultation Diabetic consultation Eye clinic : fluorescence and laser treatment. Eye clinic : fluorescence and laser treatment. Cardiologic clinic equipped with EKG and echo. Cardiologic clinic equipped with EKG and echo. Diabetic foot clinic. Diabetic foot clinic. laboratory. laboratory. Education. Education. Social clinic. Social clinic. In some cases the patient is referred to the hospital for further evaluation In some cases the patient is referred to the hospital for further evaluation

24. Several programs are included in the diabetes program Education program Education program Diabetic foot program Diabetic foot program Blindness reduction program. Blindness reduction program. Children care program. Children care program. Nutrition program. Nutrition program.

25. Education program Started in 1997 Started in 1997 Courses for patient. Courses for patient. Duration : 6weeks Duration : 6weeks Individual education Individual education Collective education Collective education

26. Diabetic foot program Started in 1999 Started in 1999 To teach doctors the basis of foot care. To teach doctors the basis of foot care. Actually there are 26 doctors trained and are working in 12 diabetic foot clinics in different provinces Actually there are 26 doctors trained and are working in 12 diabetic foot clinics in different provinces

27. Diabetic children care program Started in 2000. Started in 2000. Summer camps in different regions Summer camps in different regions Educational courses to children using drawing and puppet theater. Educational courses to children using drawing and puppet theater. Excursion and participation in social activity. Excursion and participation in social activity.

28. Reduction of blindness program Started in 2001 Started in 2001 Follow up of each patient every 6 month. Follow up of each patient every 6 month. Fluorescent fundography. Fluorescent fundography. Laser treatment if needed Laser treatment if needed

29. Nutritional program Started in 2004. Started in 2004. 4 courses for nurses. 4 courses for nurses.

31. What do we need? Majority of physician are part time. Majority of physician are part time. The outcome in each center is related to the physician …. The outcome in each center is related to the physician …. More resources to afford all lab. Test in a regular basis. More resources to afford all lab. Test in a regular basis. Invest in the prevention of DM. Invest in the prevention of DM.