ueda2011 diabetes in arb-d.nabil

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Diabetes in the

Nabil Isseh MDKalamoon UniversitySyria

middle east

THANK YOU

Thank youThank you

Thank you

conflict of Interest Declaration

No other conflicts to report

UEDA Luxor 2011 conferenceand I dislike pharaohs I like Tahreer Square

What is themiddle east

?

East from where?Middle of what?

East from where?Middle of what?

middle east

The Middle East 1850

The Middle East 1930

The Arab World

Diabetes was a rare disease

“I, too, have not seen it in the West, nor did any of my teachers under whom I studied mention that they had seen diabetes. However, here in Egypt, in the course of approximately ten years, I have seen more than twenty people who suffer from this illness.”

“Diabetes mellitus was seldom seen in “cold” Europe, whereas it was frequently encountered in “warm” Africa.”

(1135-1204AD)

Diabetes was a rare disease

MAIMONIDES

Diabetes is the epidemic of the new century

PROJECTIONS FOR THE NUMBER OF PEOPLE WITH DIABETES (20-79 AGE GROUP), EASTERN MEDITERRANEAN AND MIDDLE EAST REGION, 2007-2025 (MILLIONS)

Eben Kholdoon:

Recognized this problem when he talked about Urban and rural medicine

طب الحضر وطب البادية

”وأما أهل البدو فمأكولهم قليلفي

الغالب والجوع غلب عليهم لقلة الحبوب، حتى صار لهم

عادة ... أما أهويتهم فقليلة العفن، لقلة الرطوبات

والعفونات ... ثم إن فيهم من الرياضة موجودة

كثيرة الحركة في ركض الخيل أو الصيد أو طلب الحاجات

أو مهنة أنفسهم في حاجاتهم ... فتكون أمزجتهم أصلح

وأبعد عن األمراض، فتقل حاجتهم إلى الطب“

” ووقوع هذه األمراض في أهل الحضر

واألمصار أكثر، لخصب عيشهم،

، وقلة وكثرة مأكلهم

اقتصارهم على نوع واحد من األغذية، وعدم توقيتهم لتناولها“

مقدمة ابن خلدون صفحة 384-385

But what is the cause of this epidemic?

The new century Epidemic

The rates of diabetes and obesity are rising in the Arab world

The Prevalence of diabetes and other chronic diseases in Arab Countries

Epilepsy

Tberculosis

Hepatitis

Doudenal ulcer

Asthma

Hpertension

Hyperlipidiaedemia

Diabetes

0 5 10 15 20 25 30

Prevalence %

Prevalence %

WHO, 2000

Prevalence of Diabetes (20-79 age group) 2007-2025

2007 2025• Nauru 30.7% 32.3% • United Arab Emirates 19.5% 21.9%• Saudi Arabia 16.7% 18.4%• Bahrein 15.2% 17.0%• Kuwait 14.4% 16.4%• Oman 13.1% 14.7%• Tonga 12.9% 15.2%• Mauritius 11.1% 13.4%• Egypt 11.0% 13.4%• Mexico 10.6% 11.4%

IDF Diabetes Atlas 2006

Top 10

Prevalence of overweight and obesity among some countries of the Eastern Mediterranean Region

Country Overweight / obesity (%)Male

Overweight / obesity (%)Females

Bahrain 56.4 79.0

Egypt 43.8 41.0

Islamic Republic of Iran 57.0 67.7

Jordan 46.0 43.7

Lebanon 60.0 53.0

Libya Arab Jamahiriya 42.5 74.9

Morocco 37.2 21.7

Oman 40.5 43.5

Pakistan 10.5 34.6

Saudi Arabia 64.0 70.0

Tunisia 13.1 41.9

United Arab Emirates 25.5 39.9

Eastern Mediterranean Health Journal - 2004

Why are the ratesof diabetes and

obesity rising in the Arab world

?

What’s Unique about the Arab

world?

The Arab World1. The site of ancient civilizations2. The birthplace of three of the world’s major

religions3. Strategic location4. Oil5. Conflict and war6. Occupation

Moro...

7

Alge...

8

Tuni...

4

Maur...

3 Libya...

14

Egyp...

13

Yeme...

7

Saudi...

24

UAE

26

Qatar

15

Bah

19

Jorda...

16

Syri...

913

Suda...

3

I

5

16

Diabetes Mellitus Prevalence in the Middle east countries

<10%

10-20%

>20%

Cummunicable diseasesTrachomaMalariaSchistosomiasisSmallpox

Trachoma

Diseases pattern in the kingdom of Saudi Arabia over 100 years

Non-comunicable diseasesDiabetes MellitusObesityHypertensionHyperlipidemia

Diseases pattern in the kingdom of Saudi Arabia over 100 years

1970 1975 1980 1985 1990 1995 2000 2005 20100

5

10

15

20

25

Diabetes Prevalence in Saudi ArabiaFrom 1975 to 2004

Years

Prev

alen

ce R

ate

Al-Nuaim

Fatani et al

Anokute et al El-Hazmi et al

El-Hazmi et al

Al-Nozha

Bacchus et al4Abu-Aisha abst*.

Millions of years 50 years

Thrifty genes

البخيلة المقتصدة الجينات

السـفربرلك مجاعة

November 4, 2009

55

172 million in 1981 331 million in 2007385 million in 2015

Arab Population

34M31 M

Diet change in SAUDI ARABIA:

There has been an increase in the total calorie in-take from 1900 to 3000 cal.

This increase is associated with low fiber diet.

1900

3000

3600

0

1000

2000

3000

4000

1970 1990 USA

33

123

0

40

80

120

160

1970 1990

Total fat intake

Dietary change

Diabetes and Poverty

Diabetes and Poverty … Which one will kill the patient first ?

Mortality and Poverty

Mortality Adult Below National Diabetes Country before literacy poverty poverty Prevalence

40 years rate line line Rate

% of cohort % of >15 yrs 2 US$/day (%)

Bahrain 4.7 12.4 - - 10*Djibouti 42.3 35.4 - 45.1 -Egypt 10.3 44.7 52.7 22.9 9.3*Iran 9.3 23.7 - - 8*Jordan 7.9 10.3 7.4 11.7 14.0*Kuwait 3.0 18.0 - - -Lebanon 5.0 14.0 - - -Oman 6.8 28.3 - - 10.0*Pakistan 20.1 56.8 84.6 34.0 14.0*Qatar 4.8 18.8 - - -Saudi Arabia 6.4 23.7 - - 24.3*

Sudan 27.3 42.2 - - 3.4*Tunisia 7.8 29.1 10.0 14.1 3.8*UAE 5.4 23.7 - - -Yemen 20.0 53.7 45.2 19.1 -

UNDP, Human development report 2002 *The Epidemiology of Diabetes Mellitus, Ekoe2001

Occupation and War

The British Army stationed in Damascus after the fall of the Ottoman Empire in

October 1918.

the 2003 invasion of

Iraq

The new England journal of medicine

special article

Violence-Related Mortality in Iraq

from 2002 to 2006

Iraq Family Health Survey Study Group*

January 31, 2008

The NEW ENGLAND JOURNAL of MEDICINE

The Weapons That Kill Civilians — Deaths of

Children and Noncombatants

in Iraq, 2003–2008

April 16, 2009

Two bloody decadesconflicts in the Arab world since 1990

Conflict Arab deaths

Invasion of Iraq (since 2003) 110,000War of Kuwait (1990-1991) 30,000Second Palestinian Intifada (2000-2005) 5,500Gaza war (2009) 1,400Lebanon war (2006) 1,200

The Human Costof the War in Iraq

A Mortality Study, 2002-2006

A new household survey of Iraq has foundthat approximately 600,000 people have

been killed in the violence of the war that beganwith the U.S. invasion in March 2003.

Bloomberg School of Public HealthJohns Hopkins UniversityBaltimore, MarylandSchool of MedicineAl Mustansiriya UniversityBaghdad, Iraqin cooperation with theCenter for International StudiesMassachusetts Institute of TechnologyCambridge, Massachusetts

Mortality after

the 2003 invasion of Iraq

Published online October 11, 2006

Restrictions on the movement of Palestinians, curfews and frequent shutdowns have had a devastating effect on health services in general

Economic and social repercussions of the Israeli occupation

on the living conditions of the Palestinian people in the

Occupied Palestinian Territory, including Jerusalem, and of

the Arab population in the occupied Syrian Golan

The Israeli closure system remains a primary cause of poverty and humanitarian crisis in the occupied Palestinian territory, and restricts Palestinian access to natural resources.

The Wall• West Bank’s wall:

to be at least 650 KM long

Hight:8 Meters• Berlin Wall: 155

KM long Average Hight:3.6

Meters

Berlin Wall

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Type 2 diabetes in Arab Countries

1. Prevalence is relatively high ( 13-25 % in subjects > 30 y)

2. Prevalence is rising steadily

3. In many surveys, proportion of patients with previously undiagnosed DM was relatively high

4. Many patients present with co-morbidities and complications

5. The role of obesity is consistently clear

Cultural Aspects of Diabetes Care in the Arab Population

1- Body image2- Diet 3- Hospitality and social etiquette4- Hijab5- Alcohol6- Contraception 7- Fasting Ramadan8- Hajj to Mecca

Diabetes in the Arab world Lakhdar A, Gill G2005:

Fatness is good for youLet me have men about me that

are fat;Yond Cassius has a lean and

hungry look;He thinks too much: such men

are dangerous.

W. Shakespear; Julius Ceaser

مرافقها درم فنق هركولةيمشي كما الهوينى تمشي

الوحل الوجي

العرب( 629م-530األعشى ) صناجة م

Why do Arabs have high prevalence of type 2 Diabetes?

Prevalence of Obesity vs Diabetes in Europe: selected countries

0

5

10

15

20

25

UK Gr Hu Sp Ge Fi Tu Sw Fr No

BMI>30

Diabetes

Obesity: NationMaster.com: Diabetes: IDF

Diabetes in Syria

1- Random sample of 1168 subject > 25 years2- Prevalence of Diabetes was 15.6 %3- Impaired fasting glucose was 8.6 %4- Many people with Diabetes are unaware5- The majority had A1c > 7 %

Aleppo study of prevalence of DM and CV Risk Factors. Diabetes Research Unit, Aleppo University 2006. Submitted data

PREVALENCE OF DM ON EGYPT

DM type2 in Egypt

4.30%

9.30%

10.20%

0%

2%

4%

6%

8%

10%

12%

Arab / 1992 Herman / 1995 (>20) Herman / 2000 (>20)

Diabetes Mellitus in Saudi Arabia

A survey of 17,232 Saudi subjects aged 30-70 y

RESULTS:

Age-adjusted prevalence: 21.9 %

In urban areas: 25.5 % rural areas: 19.5 %

Percentage of previously undiagnosed diabetics: 27.9 % Al-Nozha M et al, Saudi Med J 2004; 25: 1603-10

What is the Most Common Cause of Death in People with

Diabetes?

Dyslipidemia is common in the

Arab world

Population attributable risks associated with smoking, hypertension, diabetes, abdominal

obesity and lipids by geographic region Region risk factors

Smoking % Hypertension % Diabetes% Abdominal obesity%

Lipids%

Western Europe

29.3 21.9 15.0 63.4 44.6

Middle East 45.5 9.2 15.5 25.9 70.5

Southeast Asia and Japan

36.2 38.4 21.0 58.0 67.7

North America

26.1 19.0 8.0 59.5 50.5

Yusuf S et al. Lancet. 2004;364:937-52.

INTERHEART

Smoking is a common and accepted way

of daily life

1997 11 : 14Nutr Health

20 – 50 %

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ueda2011 diabetes in arb-d.nabil

Health & Medicine

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