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1
Diabetes in the
Nabil Isseh MDKalamoon UniversitySyria
middle east
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THANK YOU
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Thank youThank you
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Thank you
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conflict of Interest Declaration
No other conflicts to report
UEDA Luxor 2011 conferenceand I dislike pharaohs I like Tahreer Square
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What is themiddle east
?
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East from where?Middle of what?
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East from where?Middle of what?
middle east
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The Middle East 1850
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The Middle East 1930
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The Arab World
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Diabetes was a rare disease
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“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
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Diabetes is the epidemic of the new century
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PROJECTIONS FOR THE NUMBER OF PEOPLE WITH DIABETES (20-79 AGE GROUP), EASTERN MEDITERRANEAN AND MIDDLE EAST REGION, 2007-2025 (MILLIONS)
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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
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But what is the cause of this epidemic?
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The new century Epidemic
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The new century Epidemic
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The rates of diabetes and obesity are rising in the Arab world
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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
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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
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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
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Why are the ratesof diabetes and
obesity rising in the Arab world
?
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What’s Unique about the Arab
world?
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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
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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%
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Cummunicable diseasesTrachomaMalariaSchistosomiasisSmallpox
Trachoma
Diseases pattern in the kingdom of Saudi Arabia over 100 years
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Non-comunicable diseasesDiabetes MellitusObesityHypertensionHyperlipidemia
Diseases pattern in the kingdom of Saudi Arabia over 100 years
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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*.
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Millions of years 50 years
Thrifty genes
البخيلة المقتصدة الجينات
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السـفربرلك مجاعة
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1915
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November 4, 2009
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51
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November 4, 2009
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55
172 million in 1981 331 million in 2007385 million in 2015
Arab Population
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80
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34M31 M
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34
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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
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Diabetes and Poverty
Diabetes and Poverty … Which one will kill the patient first ?
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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
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Occupation and War
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1798
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The British Army stationed in Damascus after the fall of the Ottoman Empire in
October 1918.
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the 2003 invasion of
Iraq
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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
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The NEW ENGLAND JOURNAL of MEDICINE
The Weapons That Kill Civilians — Deaths of
Children and Noncombatants
in Iraq, 2003–2008
April 16, 2009
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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
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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
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Mortality after
the 2003 invasion of Iraq
Published online October 11, 2006
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Restrictions on the movement of Palestinians, curfews and frequent shutdowns have had a devastating effect on health services in general
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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
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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.
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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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THANK YOU FOR TRYING TO STAY AWAKE
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1945
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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
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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:
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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
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مرافقها درم فنق هركولةيمشي كما الهوينى تمشي
الوحل الوجي
العرب( 629م-530األعشى ) صناجة م
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Why do Arabs have high prevalence of type 2 Diabetes?
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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
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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
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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)
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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
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What is the Most Common Cause of Death in People with
Diabetes?
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Dyslipidemia is common in the
Arab world
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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
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Smoking is a common and accepted way
of daily life
1997 11 : 14Nutr Health
20 – 50 %
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THANK YOU FOR TRYING
TO STAY AWAKE
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THANK YOU