07 March, 2007

Behavior-caused diabetes

Specialists in childhood diabetes are meeting at the 2nd Arab Child Health Congress, which is focusing on diabetes this year. Link

There's something fishy about this reported rate. It cannot be that high for the entire population of the UAE. High rates of diabetes are caused by low exercise and an unhealthy diet (foods loaded with fat and sugar). But more than half of those living in the UAE are doing heavy manual labor and eating well (even if it is a poor man's diet).

And yet less than three decades ago the rate of diabetes in the UAE was low. Diabetes goes hand in hand with development -- for example, diabetes is high in the US as well. As we become wealthier our lifestyles - our behavior - change.

My question then is: what subgroup of UAE adult residents are we talking about when we say, "The UAE has the highest number of diabetes cases among adults, second only to the Republic of Nauru, a small isolated island in central Pacific."


nzm said...

With the info on this page, I'd say that there are a whole lot of other countries in this region with even bigger Diabetes issues - especially if the 2030 projections come true.

Ash said...
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Ash said...

Interesting report and the figures are quite what I had suspected all along. Perhaps not the second highest but the UAE should be contesting for the top 10, at least.

In talking with patients at the major hospitals around town, over 75% of adults (locals and otherwise) are likely to tell you they have been diagnosed with Diabetes at one time or another. The rate is even higher in the local adult population (we're talking almost 90% of patients at DOHMS alone, for instance). What makes the problem worse is the poor compliance and negligence on the patient's part in taking medications regularly (or taking at all in some cases), especially in the young adult population.

Last year I wrote an article (more like an audit) for the Emirates Medical Journal proving how Diabetes (particularly type 2) in the UAE population was on the rise and in danger of reaching epidemic proportions and I concluded why the need for awareness was necessary and how it could be achieved. The aforementioned rates, therefore, are not just an estimate but were deduced from a long study spanning over a year and a half. I did get published but not many seemed to agree at the time. Now, however, after a lot of support and backing from the Endocrinology unit at Dubai Hospital, measures are being taken to increase awareness because a disease like Diabetes mellitus can be put off for a considerable number of years by adapting a healthy lifestyle even if both parents of the subject have it (of course that is not so in cases with type 1 but we're not talking about that). We have to keep in mind that despite the strong hereditary nature of the disease; environmental factors play a huge part in the expression of it. We still have a long way to go, though. And this is only the beginning.

Coming to your question, John, when you ask about the adult population referred to in the article in question, my guess is they're talking about both locals and expatriates. Whichever it is, safe to say I don't disagree with it.

Apologies if I got it wrong but you seem to suggest the labor population of this country would have a lower incidence of Diabetes. Unfortunately, that is not so. A good percentage of the labor population have already been diagnosed before they come into the UAE and more importantly, the majority of them constitute the group that ignores the need for medications and good blood sugar control. Of course, it could be due to financial reasons but that's an entirely different topic.

trailingspouse said...

That's very interesting Ash. Are westerners equally represented? My perception is that most westerners here eat pretty much what they would back home. I always assumed the high Diabetes rate here was due to people switching from their traditional diets to the western one and their bodies were not equipped to deal with it.

SevenSummits said...

first I was wondering if you are serious about this question, but it obviously seems so 
First of all, I do not want to lecture anyone and please apologize in case it seems so, but the topic in general and the future potential for increases in diabetes mellitus as well as its serious complications in the GCC region is just a timely concern. I have to admit that this does not fall into my sphere of expertise - however the concern for Public Health may somehow come close.

To answer your first question, it is obvious from the available data that these results were meant to be in respect to the "national" population of the UAE. It would in general be the norm to only use the national populace in such analysis. NZM was friendly enough to provide a link to WHO statistics which put the estimated prevalence of diabetes in the UAE at 350000. If you guys will just correlate this information with the preliminary results of the 2005 census which reveals a total population of 4,104,695 (made up locals and foreigners). Take a rough 22% and end up with 903033. Leave room for some obvious census error typical for developing countries, add two years of progressive population increase and most likely conclude a local population of somewhere around 1.2 million. So the WHO data clearly was estimated for the national population and of course a few others were counted. There is a need to be a little pragmatic and when it comes to statistic from developing countries one generally ought to be very cautious. (especially when it comes from governments or International ORGS, which means that it is usually messed about with for political reasons or totally outdated)

What I personally thought was "not serious" about your question was the fact that you mentioned the poor exploited hard working foreign laborers – as if ….. in other words you are not really assuming that anyone in the UAE would care, if these people had diabetes or not. Do you really believe that these guys are getting a serious medical treatment? And ASH, thanks for your very interesting post, but do you seriously believe that "A good percentage of the labor population has already been diagnosed before they come into the UAE"? Which type of foreigners are you talking about?

The results of the study was seriously shocking and detailed up-to-date facts and figures about diabetes can be found in "The Diabetes Atlas" (International Diabetes Federation, 2006) http://www.eatlas.idf.org/webdata/docs/Atlas 2003-Summary.pdf (PDF for download)
Interesting also the Prevalence estimates of diabetes in 2007 on a map
http://www.eatlas.idf.org/webdata/docs/Map 1.1_large.jpg

In a way the results from the UAE in second place with 20.1 %, followed by Bahrain with 14.9 % and Kuwait with 12.8 % are not that incomprehensible, when you correlate them with low exercise and an unhealthy diet. However your statement that "Diabetes goes hand in hand with development" does not hold true, since two thirds of those suffering from diabetes live in developing countries. I hope that this data is self-explanatory or at least give an impulse to some serious thought. Ash already gave us some explanations. Since only about half those having diabetes mellitus type 2 are even aware of their disease gives enough room for further concern. Here we will also have an obvious higher drift towards developing countries, since often doctors are not aware or more concerned with other diseases. (e.g. in Africa with treating Malaria, Typhoid or something as simple as hypertension – this is not at all an implication that they are not qualified, but only that they have adopted to their corresponding environment)

In comparison only between 6% to 7% percent of the population in the US (depending on source) have diabetes. Further reading and some interesting statistics on the cost of diabetes in the United States can be found on the NDIC (National Diabetes Information Clearinghouse) website. http://diabetes.niddk.nih.gov/index.htm Germany has a higher rate of around 10%.

Type 2 diabetes in the Western World is usually first treated by attempts to change physical activity, weight loss and diet (e.g. the decrease carbohydrate intake. Now I noticed from Ash's post that this does not seem to be the case in the UAE and maybe the general awareness even among doctors is not there? Does for example an Egyptian or Pakistani doctor even have the courage to come forward with such an idea towards a UAE national or will he face the risk of being deported? How about the fact that between 35 and 50 percent of men with diabetes experience ED – will this be an acceptable topic to talk about? Finally since genetics play a large role in type 2 diabetes and family history is a risk factor, will they have the ability to challenge unhealthy practices such as consanguinity? Available data suggest that genetic and congenital disorders are more common in Arab countries (High consanguinity rates 25-60% of all marriages are consanguineous) than in industrialized countries; recessively inherited disorders account for a substantial proportion of physical and mental handicap.

Generally it can be said that any conclusions about the burden of disease attributable to diabetic complications must be very guarded, and comparisons between different parts of the world should be extremely cautious, but when you take a look at general behavior of the UAE society you can see a serious tendency towards an unhealthy lifestyle. Certainly the reason can not necessarily be found in a poor diet, but mainly in the lack of awareness (especially women) and in the rising prevalence of childhood obesity. (It could be compared to "land tenure" issues – why should a nanny really care about the food that children get? These are not her children!) Emirati women are obviously busy with other interests than to take responsible care of their children.
When it comes to an unhealthy lifestyle you can also see a serious tendency to little physical activity, again especially among women. How many UAE nationals do you see walking, instead of taking a car? How many do you find exercising on the e.g. Abu Dhabi Corniche? From a close Emirati friend (an expert in the field) I also learned that the number of Emiratis suffering from elevated HDL cholesterol levels is also high. That goes hand in hand with diabetes and is serious warning sign that points towards the lack of sufficient physical activity. Personally I would start a serious awareness campaign and precise a mandatory walk for every UAE national up and down Jebel Hafeet every Saturday. :- )

Finally according to the IDF, the ultimate goal of a publication such diabetes data would be to stimulate research and concrete action by governments and all those concerned with health and wellbeing to stem the rising tide of diabetes in order to bring about better lives for all. Now the serious question will be, how many UAE nationals will actually take this quest seriously and how many "local" scientists will get involved in further research. Most of us do know the answer and since the willingness to change urgently needs to be endemic, where will this country or better region be heading to in the future?

Ash said...

trailingspouse, even if my report was strictly limited to patients presenting to the hospitals under the department of health and medical services and, for obvious reasons, did not cater to those who consult the private health sector; all nationalities were equally represented. If you asked me to further map out the rate depending on nationality, it'd be not all easy since the UAE is a pool of so many but I'm inclined to say the incidence is higher in developing countries as sevensummits already explained.

sevensummits, in reply to your comment, I'm going to have to touch on deeper political issues. First of all, let me just say I agree with you on most fronts. Now, with that out of the way let me come to the labor population in this country that I referred to in my post earlier; the same group of people we like to pretend doesn't exist. I can see where you're coming from when you talk about the general consensus on diabetes. In giving you my reasons for deciding why John's article spoke of both locals and expatriates, let's start with the fact that most government-sponsored awareness programs within the hospitals cater to both locals and foreigners, even if only in name. A big contributor to that being all major drug companies who infiltrate the hospitals week in week out putting up balloons and giving away t-shirts. They are creating awareness, yes but it doesn't even begin to explain the reason why they talk exclusively to local patients when these groups have most all nationalities (Indian, Pakistani, Filipino, Arab, the lot) so the language barrier excuse doesn't even play out. Not to mention the fact that non-local patients outnumber the local inpatient population ten to one. And a whole lot of them are made up of the laborers who've had only their construction-company dispensary doctor to talk to (who didn't exactly do a good job by prescribing an oral hypoglycemic that is now regarded as the last line of treatment and is slowly being taken off the market) before they eventually present with a life-threatening complication, also the same group of people that are flown out on the first flight available when their respective construction giant refuses to pay their medical bills. But I digress.

As far as lifestyle modification is concerned, I'll be the first to admit that most patients are never given that option alone. But there's a reason for it. Personally, even if I know my patient is not going to pay heed to my advice, I always give him the option and stress on the need for it. See, lifestyle modification is given as the sole treatment option to pre-diabetics (that is patients with an impaired glucose tolerance test) and not to those with established diabetes in whom a whole other treatment strategy is panned out; one that consists of both medications and lifestyle modification, even if the latter is rarely ever given any importance to on the patient's part. Most of our patients fall under that category where blood sugar cannot be controlled by weight loss and healthy eating alone. In medical terms, the target tissue has become completely insensitive to insulin. Type 2 is diagnosed late in the course of the disease anyway and it doesn't help that most patients with it consult a physician well into its course as routine medical checkups are pretty unheard of in this part of the world. However, if a patient does present with an impaired GTT or borderline blood sugar levels on three separate readings (or a fasting blood glucose for that matter), then medications are never prescribed as first line of treatment. Perhaps it is not so in the private health sector because most of it is just plain business, anyway.

Coming to consanguinity and genetic counseling, you see, when we talk about diabetes (type 2), consanguinity doesn't play much of a role in the expression of it because you're more than likely to get the disease sooner or later even if only one parent (or their family) has the disease. However, if we talked about Thalassemia (the incidence of which is among the highest in the world here in the gulf), I'd have to agree with you on the need to discourage consanguineous marriages, a practice that is more cultural than religious. Admittedly, a lot of local couples go for chromosomal analysis now before tying the knot which granted, is a step in the right direction but it doesn't change the fact that there's still a constant need for awareness in greater measure, as in openly discouraging it rather than only to the families of patients inside the hospitals, somewhere most outside world doesn't have a glimpse into. Five years ago my hands would've been tied a la Irish journalists but today when talking with most educated local couples I can discourage consanguinity without fear of losing my job. Times are changing.

Oh, and I think you meant LDL levels because "suffering from" elevated HDL levels would only be a good thing ;) Now, coming to the war against hypertension and dyslipidemia, well, suffice to say most of us are waiting for it to even be considered a battle albeit a losing one.

nzm said...

Thanks to all of you for this interesting discussion.

Ash: In your article/audit, you mentioned including creating awareness of diabetes and how this could be achieved.

I'd be interested in your opinions on how this could be done.

Did you specifically target the Emirati population, or was this across the board for the whole UAE population?

Do you think that the message would have to presented differently to the different nationalities within the UAE in order for it to be effective?

I'm thinking along the lines that some nationalities, depending on their cultural upbringing, might consider diabetes to be a shameful condition and something to hide, whereas others wouldn't think like that. Indeed, is this just a cultural issue, or would you find different reactions from within the same nationalities?

Sevensummits also brings up an interesting point about whether an expat doctor would be willing to risk offending a national patient with the threat of importation hanging over their head. Have you experienced situations where this has happened?

Anonymous said...

Once a treatment plan is discussed with an Emirate patient, what are the barriers for them to implement the plan?

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