The diabetes challenge in the Islamic Republic of Iran

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1 The diabetes challenge in the Islamic Republic of Iran ALIREZA GHAEMMAGHAMI Iran Alireza has type 1 diabetes IRAN BB_ENG_ FINAL.indd 1 17/11/15 15:10

2 IRAN BB_ENG_ FINAL.indd 1 17/11/15 15:10

3 2 THE DIABETES CHALLENGE IN IRAN Contents 3 Executive summary 4 Diabetes a global and local healthcare challenge 7 About diabetes 10 Changing the future of diabetes in Iran 12 Diabetes is a rapidly escalating healthcare KEY MESSAGES DIABETES IS A SIGNIFICANT BURDEN ON IRANIAN SOCIETY The number of people with diabetes in Iran is estimated by the IDF to be 4.6 million in This will double in the next 25 years 1 diabetes constitutes a significant and growing burden on the Iranian people, the healthcare system and government expenditure. challenge in Iran and throughout the region 14 Prevention, early detection and effective treatment can make a difference 16 Strengthening the healthcare system 18 Good capacity-building practices to strengthen diabetes care in Iran 21 Moving from words to action EDUCATION AND AWARENESS RAISING IS KEY TO PRIMARY AND SECONDARY PREVENTION AS WELL AS BUILDING CAPACITY 2 Prevention through public education and awareness raising remains the strongest approach for curbing the disease and the associated healthcare costs in Iran. Medical education is essential to build capacity to deal with the growing burden of diabetes. Patient education can improve control of diabetes and treatment outcomes. 22 Glossary EFFECTIVE DIABETES CARE AND MANAGEMENT REDUCE HEALTHCARE COSTS AND IMPROVE QUALITY OF LIFE 2 Diagnosing and treating diabetes early is vital in order to prevent costly complications. Once diagnosed, control of diabetes through better treatment and care can reduce healthcare costs and improve quality of life. Evidence shows that not adhering to medications results in higher healthcare costs, longer hospital stays, and increased illness and death This diabetes briefing book is based on the latest evidence available at the time of being produced. The book aims to provide an overview of the diabetes challenge in Iran and serve as a tool for dialogue on defining future strategies and efforts to address the diabetes challenge. LONG-TERM POLICY EFFORTS ARE NEEDED TO ADDRESS THE ESCALATING DIABETES CHALLENGE IN IRAN Comprehensive policy and multistakeholder efforts involving government, healthcare professionals, patients and industry enhance the organisation, quality and reach of diabetes prevention and care. It is feasible and desirable for all countries to have a national diabetes programme, and successful models are already in place in some countries. 2 In Iran, local evidence-based clinical guidelines for the treatment of diabetes have been updated 4 the next step will be to develop and execute the Iranian Diabetes Manifesto to further improve diabetes care. IRAN BB_ENG_ FINAL.indd 2 17/11/15 15:10

4 THE DIABETES CHALLENGE IN IRAN 3 Executive summary DIABETES IS A GROWING EPIDEMIC THAT REQUIRES CONCERTED AND DELIBERATE EFFORTS FROM STAKEHOLDERS ACROSS IRAN AND THE GLOBE. BY 2040, IT IS PREDICTED THAT THERE WILL BE OVER 9 MILLION PEOPLE WITH DIABETES IN IRAN. 1 NOW IS THE TIME TO ACT TO BETTER UNDERSTAND THE CAUSES OF DIABETES AND PUT IN PLACE SUSTAINABLE POLICIES TO REDUCE ITS IMPACT. The International Diabetes Federation (IDF) estimates that 415 million adults worldwide have type 2 diabetes in The incidence of diabetes has already escalated to pandemic proportions, and by 2040 the figure is expected to increase to 642 million. 1 The growth of diabetes in Iran is predicted to be even greater than the global trend. Today, there are an estimated 4.6 million people with diabetes in Iran, which is 8.5% of the population. 1 By 2040 there will be twice as many people with diabetes in Iran as there are today: a potential 9.2 million. 1 Rapid lifestyle changes due to urbanisation, among other factors, are leading to increased numbers of people who are overweight and have obesity significantly fuelling the global and Iranian diabetes burden. Diabetes is a progressive chronic disease that can cause serious complications, such as cardiovascular disease, neuropathy and retinopathy all of which are costly to treat. 2 Lifestyle intervention and early and effective treatment can significantly reduce the rate of complications and improve quality of life. 5 In 2014, the Islamic Republic of Iran enacted a series of reforms known as the Health Sector Evolution Plan. The aims of these reforms included increasing the population coverage of basic health insurance, improving quality of care in Ministry of Health and Medical Educationaffiliated hospitals, reducing out-of-pocket payments for inpatient services and improving the quality of primary healthcare. 6 Many of these reforms have directly impacted people with diabetes, who are now able to access new treatment options. However, costs associated with treatment and care of diabetes will put a strain on the system as the number of people with diabetes increases. Therefore, addressing the modifiable risk factors through initiatives aimed at primary prevention, early diagnosis and avoidance of complications with innovative medicines is imperative if the healthcare system is to be sustainable and ensure healthcare provision for all. The Iranian Diabetes Leadership Forum 2015 is an opportunity for all stakeholders government, the healthcare profession, industry and the millions of people with diabetes in Iran to come together to develop long-lasting solutions to the burden of diabetes. SAMAN BERAHMANI Iran Saman has type 1 diabetes 1. IDF. International Diabetes Federation. IDF Diabetes Atlas, 7th ed. Brussels, Belgium: International Diabetes Federation; IDF. International Diabetes Federation. Global Diabetes Plan Brussels, Belgium: International Diabetes Federation; Rasmussen JN, Chong A, et al. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA. 2007;297(2): Nasli-Estafahani E, Peimani, M., Rambod, C., Omidvar, M., and Larijani, B. Developing a Clinical Diabetes Guideline in Diabetes Research Network in Iran. Iranian Journal of Public Health IDF. International Diabetes Federation. IDF Diabetes Atlas, 6th ed. Brussels, Belgium: International Diabetes Federation; Moradi-Lakeh M, Vosoogh-Moghaddam A. Health Sector Evolution Plan in Iran; Equity and Sustainability Concerns. International Journal of Health Policy and Management. 2015;4(10):637. IRAN BB_ENG_ FINAL.indd 3 17/11/15 15:10

5 4 THE DIABETES CHALLENGE IN IRAN Diabetes a global and local healthcare challenge THE DIABETES SITUATION WORLDWIDE The International Diabetes Federation (IDF) estimates that 415 million adults worldwide have type 2 diabetes. 1 The incidence of diabetes has already escalated to pandemic proportions, and by 2040 the figure is expected to increase to 642 million. 1 Ageing populations, urbanisation and changing lifestyles are rapidly accelerating the spread of diabetes along with other chronic diseases. The financial burden of diabetes is challenging for nations and individuals alike. This has created an environment in which national and global action has become a priority. THE DIABETES SITUATION IN IRAN Over the course of seven years, based on national population estimates, the prevalence of diabetes among adults increased by slightly more than a third (35%), or 1 million adults. 2 However, other studies suggest that over the past few years the prevalence of diabetes has actually doubled. 3 There are now an estimated 4.6 million people with diabetes in Iran, which is 8.5% of the population. 1 Living in urban areas, a family history of diabetes, hypertension and ageing are significantly associated with developing diabetes. 4 The number of people with diabetes is growing every year. By 2040 there will be twice as many people with diabetes in Iran as there are today: a potential 9.2 million million ADULTS HAVE DIABETES WORLDWIDE 1 THIS IS EQUIVALENT TO 8.8% OF THE ADULT POPULATION % OF WHOM DO NOT KNOW THEY HAVE IT million ADULTS HAVE DIABETES IN IRAN 1 THIS IS EQUIVALENT TO 8.5% OF THE ADULT POPULATION 1 40% OF WHOM DO NOT KNOW THEY HAVE IT million 9.2 million ADULTS WILL HAVE DIABETES WORLDWIDE BY ADULTS WILL HAVE DIABETES IN IRAN BY TRENDS IN THE PREVALENCE OF DIABETES IN IRAN INDICATE THAT THE DIABETES BURDEN MAY BE EVEN GREATER THAN ESTIMATED BY THE IDF Data from the Survey of Risk Factors of Non-communicable Diseases 2005, 2007 and 2011 were gathered on the nationwide prevalence of impaired fasting glucose (IFG) and diabetes in Iran to establish trends over the seven-year period. 2 These data indicate that the prevalence of diabetes in Iran may be even higher than what is currently being reported. The data reveals that the total diabetes prevalence may be as high as 11.4%, including both diagnosed and undiagnosed diabetes. 2 In addition, it shows that there was a 35% increase in the number of people with diabetes between 2005 and The estimated number of people with diabetes in Iran was already more than 4 million people in DIABETES PREVALENCE MAY BE AS HIGH AS 11.4% 2 IRAN BB_ENG_ FINAL.indd 4 17/11/15 15:10

6 THE DIABETES CHALLENGE IN IRAN 5 A STORY OF MISSED OPPORTUNITIES ONLY A SMALL PERCENTAGE OF PEOPLE WITH DIABETES ARE ABLE TO SUCCESSFULLY MANAGE THEIR CONDITION AND CONSEQUENTLY AVOID COMPLICATIONS. 5 The Rule of Halves 5 tells the story of missed opportunities along the care pathway and the effectiveness of current attempts to address the diabetes challenge. Although actual rates of diagnosis, treatment, targets and outcomes vary in different countries, the Rule of Halves suggests that half of all people with diabetes are not diagnosed. Of those who are diagnosed, only half receive treatment, of whom only half achieve treatment targets. What the rule means is that only a tiny proportion manage to live full lives free of complications. IRAN AND THE RULE OF HALVES 1,5* In Iran, 4.6 million people are currently estimated to have diabetes, of them only 60% are diagnosed (2.7 million). Applying the Rule of Halves, it is possible to hypothesise that of those people diagnosed with diabetes, approximately 50% (1.4 million) receive treatment, of whom half (675,000) achieve treatment targets. Potentially, just over 6% (337,500) of all people with diabetes in Iran achieve desired outcomes and avoid diabetes-related complications. FIGURE 1 THE RULE OF HALVES IN IRAN 5* Of the estimated 4.6 million people with diabetes 1 About 60% are diagnosed 1 Of whom about 50% receive care Of whom about 50% achieve treatment targets Of whom about 50% achieve desired outcomes * The Rule of Halves, a general model, estimates the global diabetes situation. Actual rates of diagnosis, treatment, targets and outcomes vary in different countries. 1. International Diabetes Federation. IDF Diabetes Atlas update poster, 7th ed. Brussels, Belgium: International Diabetes Federation; Esteghamati A, Etemad K, et al. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: Diabetes Res Clin Pract. 2014;103(2): Ravaghi H, Sajadi HS, et al. Evaluation of an urban phase of the specialized care program for diabetes in Iran: providers perspectives. Int J Prev Med. 2014;5(8): Keshavarz S GK, Pezeshki M, Zeinalzadeh S A, Toloun, H. Epidemiological Study of Diabetes and its Risk Factors in East Azerbaijan, Iran. Journal of Pioneering Medical Sciences Hart JT. Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. Br J Gen Pract. 1992;42(356): IRAN BB_ENG_ FINAL.indd 5 17/11/15 15:10

7 THE DIABETES CHALLENGE IN IRAN HASSAN DEHGHAN Iran Hassan has type 2 diabetes IRAN BB_ENG_ FINAL.indd 6 17/11/15 15:10

8 THE DIABETES CHALLENGE IN IRAN 7 About diabetes DIABETES IS CHARACTERISED BY HIGH BLOOD SUGAR LEVELS, RESULTING FROM THE BODY FAILING TO PRODUCE ENOUGH INSULIN AND/OR BEING UNABLE TO USE IT. Insulin allows cells to absorb, use and store sugar, and reduces blood sugar levels after a meal. Lack of insulin means glucose levels remain consistently high, resulting in diabetes. Consistently high levels of sugar in the blood lead to diabetes-related complications. 1 TYPES OF DIABETES 1 Type 1 diabetes is an autoimmune disease, where the body s immune system attacks and destroys healthy body tissue. In type 1 diabetes, the immune system destroys the insulin-producing cells of the pancreas. This type of diabetes accounts for 3 5% of diabetes globally. It is most common in children and young people, but can develop later in life as latent autoimmune diabetes in adults (LADA). People with type 1 diabetes are dependent on insulin injections for survival. Type 2 diabetes occurs due to an inability to produce enough insulin and insulin resistance by various organs. It is the most common type of diabetes, accounting for over 95% of all diabetes cases. It most often occurs in middle-aged and older people, but is becoming more common in overweight children, adolescents and young adults. Gestational diabetes mellitus (GDM) is a glucose intolerance which occurs during pregnancy. It currently affects at least one in 25 pregnancies globally, but this rate is expected to triple in the near future. 2 If undiagnosed or inadequately treated, GDM can lead to larger than normal babies, higher rates of infant deaths and foetal abnormalities. In addition, both women with GDM and children born from GDM pregnancies are at increased risk of developing type 2 diabetes later in life. 2 DIABETES AND ITS COMPLICATIONS Diabetes is a progressive chronic disease that can cause serious complications, such as heart attack, stroke, kidney failure, blindness and amputation. Often, diabetes is first diagnosed when irreversible complications manifest. Poorly controlled diabetes can lead to the onset of diabetes-related complications. 2 Apart from the treatment costs directly associated with the management and care of diabetes and diabetes-related complications, there are also a number of indirect costs. Currently, over 1.9 million Iranian adults remain undiagnosed and unaware of their condition. 3 All these people are at high risk of developing major complications related to type 2 diabetes in the coming decades. 4 Due to complications, people with diabetes have nearly a twofold higher risk of premature death compared to people without diabetes. 5 In Iran, approximately 100 people die from diabetes-related causes every day, resulting in more than 37,000 adult deaths in Maintaining glycaemic control can prevent and reduce complications The majority of diabetes-related healthcare costs are related to the treatment of long-term complications brought on by poor glycaemic control. Maintaining blood glucose, blood pressure and cholesterol levels close to normal can help delay or prevent diabetes complications. 6 Therefore, preventing and reducing complications is the best way to manage costs. The landmark UK Prospective Diabetes Study (UKPDS) demonstrated that a 1% decrease in HbA 1c is associated with a 21% decrease in the risk of developing complications. 6 Effective treatment with multiple drugs and lifestyle modification can lead to sustained benefits in terms of reduced complications and mortality as well as significantly improve quality of life and reduce the healthcare cost burden. 6 FIGURE 2 A DECREASE IN HbA 1C LEVELS REDUCES THE RISK OF DIABETES-RELATED COMPLICATIONS 7 Myocardial infarction (heart attack) -14% risk HbA 1c -1% Microvascular complications (disease of the small blood vessels eyes, nerves and kidneys) -37% risk Deaths related to diabetes -21% risk HBA 1C A WAY TO MEASURE WHETHER TREATMENT TARGETS HAVE BEEN ACHIEVED 8 Healthcare professionals can assess a person s average blood sugar over time by measuring glycated haemoglobin, also called HbA 1c. HbA 1c is used as an indicator of how well diabetes is controlled. People with diabetes achieve treatment targets when HbA 1c is maintained at 7% or below. A level higher than 7% is associated with an increased risk of complications. IRAN BB_ENG_ FINAL.indd 7 17/11/15 15:11

9 8 THE DIABETES CHALLENGE IN IRAN Hypoglycaemia an everyday challenge for people with diabetes Extreme low blood sugar events (hypoglycaemia) happen when blood sugar levels fall to abnormally low levels (lower than 70 mg/dl). 9 It is a common complication for people with diabetes receiving insulin treatment. Most people who receive insulin have experienced extreme low blood sugar episodes. 10 When one occurs, it is a medical emergency that needs to be quickly identified and treated in order to prevent organ and brain damage. 10 Prevention of extreme low blood sugar is important as it helps avoid such events and lowers costs. More than 50% of hypoglycaemic episodes can be predicted by self-monitoring of blood glucose and by a risk factor assessment. 11 In addition, innovative diabetes treatments such as modern insulin where fewer injections are required or where the dose can be adjusted according to meals can help address the challenges of extreme low blood sugar events. FIGURE 3 IF UNCONTROLLED, DIABETES CAN LEAD TO A NUMBER OF SEVERE COMPLICATIONS BLINDNESS Damage to the retina through diabetes is a leading cause of blindness in adults of working age. 1 Effective treatment can reduce deterioration of the retina by more than a third. 1 A recent study showed that damage to the retina was present in 41% of all people with type 2 diabetes tested. 12 KIDNEY FAILURE Studies have shown that, globally, kidney disease resulting from diabetes is a leading cause of end-stage renal disease (ESRD). 1 This is also the case in Iran. A significant increase in the number of people with ESRD in Iran was observed over a 10-year period. 15 The percentage of ESRD patients grew from 16% in 1997 to 31% in 2006 the increase is attributed to diabetes. 16 AMPUTATION Diabetes is the leading cause of nontraumatic lower limb amputations. 1 Effective education on how to care for feet and early treatment can significantly reduce the number of amputations. 17 More than 5% of the 234 people with diabetes enrolled in one study in Iran had foot ulcers, which are prone to infection and can lead to amputation. 12 CARDIOVASCULAR DISEASE High blood pressure, high blood cholesterol, overweight, obesity and type 2 diabetes are among the major risk factors for cardiovascular disease. 1 Type 2 diabetes increases the risk of heart attack by up to five times compared to that of people without the disease. People with diabetes are four times more likely to have a stroke compared to those without diabetes, 13 but this risk can be reduced by 44% through tight blood pressure control. 7,14 DEPRESSION People with diabetes are more likely to suffer from depression than those without diabetes. 17,18 Depression affects both the quality of life of the individual and of their family, and can impact the success rate of treatment. 19,20 A high prevalence rate of distress was found among people with diabetes in Iran. 35% of those interviewed in one study had disease-related distress. This highlights the need to identify distress as well as other mental health conditions in people with diabetes. 21 IRAN BB_ENG_ FINAL.indd 8 17/11/15 15:11

10 THE DIABETES CHALLENGE IN IRAN 9 PARISA TAKI Iran Parisa has type 1 diabetes 1. International Diabetes Federation. IDF Diabetes Atlas, 6th ed. Brussels, Belgium: International Diabetes Federation; International Diabetes Federation. Global Diabetes Plan Brussels, Belgium: International Diabetes Federation; International Diabetes Federation. IDF Diabetes Atlas, 7th ed. Brussels, Belgium: International Diabetes Federation; Esteghamati A, Etemad K, et al. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: Diabetes Res Clin Pract. 2014;103(2): Emerging Risk Factors C, Seshasai SR, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011;364(9): Stratton IM. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. Bmj. 2000;321(7258): Group UPDS. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ : British Medical Journal Inzucchi SE, Bergenstal RM, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care. 2012;35(6): American Diabetes Association. Diabetes Basics. common-terms/common-terms-f-k.html. Accessed October 16,, Shafiee G, Mohajeri-Tehrani M, et al. The importance of hypoglycemia in diabetic patients. J Diabetes Metab Disord. 2012;11(1):17. IRAN BB_ENG_ FINAL.indd International Diabetes Federation. Global Guidelines for Type 2 Diabetes. Brussels, Belgium: International Diabetes Federation; Shaghaghi A, Ahmadi A, et al. Iranian patients require more pertinent care to prevent type 2 diabetes complications. Adv Prev Med. 2014;2014: Haffner SM, Lehto S, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. New England journal of medicine. 1998; Shera AS, Jawad, F., Maqsood, A., Jamal, S., Azfar, M., & Ahmed, U. Prevalence of chronic complications and associated factors in type 2 diabetes. Prevalence Mousavi SS, Soleimani, A., & Mousavi, M. B.. Epidemiology of end-stage renal disease in Iran: A review article. Saudi Journal of Kidney Diseases and Transplantation Aghighi M, Mahdavi-Mazdeh M, et al. Changing epidemiology of end-stage renal disease in last 10 years in Iran. Iran J Kidney Dis. 2009;3(4): International Diabetes Federation. IDF Diabetes Atlas, 5th ed. Brussels, Belgium: International Diabetes Federation; de Groot M, Anderson R, et al. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001;63(4): National Institute for Mental Health UDoHaHS. Depression and Diabetes. nimh.nih.gov/health/publications/depression-and-diabetes/index.shtml. Accessed 22 April, Diabetes.co.uk. Diabetes and Depression Baradaran HR, Mirghorbani SM, et al. Diabetes distress and its association with depression in patients with type 2 diabetes in Iran. Int J Prev Med. 2013;4(5): /11/15 15:11

11 10 THE DIABETES CHALLENGE IN IRAN Changing the future of diabetes in Iran WIDESPREAD URBANISATION, SOCIOECONOMIC GROWTH AND A NUMBER OF POOR LIFESTYLE HABITS, SUCH AS AN UNHEALTHY DIET, LACK OF EXERCISE AND BEING OVERWEIGHT OR HAVING OBESITY, ARE DRIVING THE INCREASE IN DIABETES. Some risk factors for type 2 diabetes are linked to factors that cannot be changed, including age, gender and ethnicity. However, lifestyle choices such as physical inactivity, poor nutrition and obesity are modifiable and greatly impact the risk of developing diabetes. In fact, up to 80% of all cases of type 2 diabetes can be prevented through managing risks and choosing a healthier lifestyle.1 Many of the risk factors for diabetes are shared with other noncommunicable diseases, making type 2 diabetes an important and logical entry point for prevention and control of a number of illnesses. RISK FACTORS FOR TYPE 2 DIABETES IN IRAN Genetics and diabetes A study from the diabetes referral clinic of the Tehran University of Medical Sciences looked at the factors that predict retina disease resulting from diabetes.2 It found that diabetes and diabetes-related complications were the result of an interaction between a person s genes and their environment. A family history of the disease is a strong indicator for future risk of diabetes or diabetic retina disease. Gestational diabetes (GDM) Programming received by an unborn baby through being exposed to GDM while in the womb and low birth weight have both been linked to type 2 diabetes.3 GDM increases the risk for both mother and child of developing type 2 diabetes. GDM also increases the risk of birth defects and can lead to premature labour and caesarean delivery.4,5 One in 20 pregnant Iranian women will develop GDM, with significantly increased odds of adverse maternal and foetal outcome.6 Universal GDM screening for pregnant women in Iran should be considered.6 Overweight and obesity Overweight and obesity have a strong association with type 2 diabetes and other chronic diseases.7 Together, overweight and obesity probably account for about 80 90% of type 2 diabetes cases and are also important obstacles to the successful longterm management of the disease.8,9 The World Health Organization (WHO) in 2014 show that more than 1.9 billion people, or 39% of all adults over the age of 18, are overweight worldwide. Of these, nearly 600 million people have obesity.10 Obesity and overweight are common in Iran, and there are signs that both are increasing. There are also clear signs of an increase in excess weight among young children.11 Childhood obesity increases the susceptibility to noncommunicable diseases such as diabetes later in life.11 Studies of obesity in Iran have shown that people with obesity are more than 3.5 times and overweight people 1.7 times more likely to develop type 2 diabetes than people of normal weight.12,13 The prevalence of obesity in Iran increased from 13.6% in 1999 to 22.3% in IRAN BB_ENG_ FINAL.indd 10 17/11/15 15:11

12 THE DIABETES CHALLENGE IN IRAN 11 Age and gender Diabetes affects people of all ages, although the rate of type 2 diabetes does increase with age globally. However, the 2005 National Survey of Risk Factors of Non-Communicable Diseases (SURFNCD) of Iran showed that most individuals with diabetes are between the ages of 45 and More recent national population estimates in Iran from 2011 for impaired fasting glycaemia (IFG) or prediabetes found that as many as 5.8 million, or 14.6%, were diagnosed with IFG. 14 The prevalence of IFG increased significantly with advancing age, and adults in the oldest age category (age 56 70) were twice as likely to have IFG as those in the youngest age category (age 25 34). Similar trends were observed among those undiagnosed and those with type 2 diabetes. Of the people with type 2 diabetes surveyed, those who were in the oldest age category were almost nine times more likely to have diabetes than their younger counterparts (29.2% of those aged versus 3.3% of those aged 25 34). 14 The same study reported that the prevalence of type 2 diabetes was about 30% higher in women than in men (12.9% versus 9.9%). 14 On the other hand, the International Diabetes Federation (IDF) states that diabetes is more common in men, while impaired glucose tolerance (IGT) is more often found in women. 1 FIGURE 4 OVERWEIGHT AND OBESITY IN IRAN 16 OVERWEIGHT (BMI 25) 49.7% of all men 63.9% of all women MEASUREMENT OF OBESITY OBESITY (BMI 30) 10.5% of all men 22.5% of all women Obesity is commonly measured using body mass index (BMI), which is an estimate of an individual s body fat in relation to their weight and height. FIGURE 5 INCREASE IN LIFE EXPECTANCY IN IRAN AND THE MENA REGION BETWEEN 2000 AND IRAN MENA REGION Life expectancy at birth has increased significantly in recent years in Iran, rising from 70 years in 2000 to more than 74 years in This is an indicator that Iran needs to invest more in healthcare to care for its growing older population. 1. International Diabetes Federation. Global Diabetes Plan Brussels, Belgium: International Diabetes Federation; Maghbooli Z, Pasalar P, et al. Predictive factors of diabetic complications: a possible link between family history of diabetes and diabetic retinopathy. J Diabetes Metab Disord. 2014;13: Kim C, Newton K, Knopp R. Gestational Diabetes and the Incidence of Type 2 Diabetes A systematic review. Diabetes care Reece E. The fetal and maternal consequences of gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2010;23(3): Jonsdottir S. Hyperglycemia and Adverse Pregnancy Outcomes. MCN: The American Journal of Maternal/Child Nursing Hossein-Nezhad A, Maghbooli Z, et al. Prevalence of Gestational Diabetes Mellitus and Pregnancy Outcomes in Iranian Women. Taiwanese Journal of Obstetrics and Gynecology. 2007;46(3): Malnick SD, Knobler H. The medical complications of obesity. QJM. 2006;99(9): Han T, Richmond P, et al. Waist circumference reduction and cardiovascular benefits during weight loss in women. International journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity. 1997;21(2): Astrup A, Finer N. Redefining type 2 diabetes: diabesity or obesity dependent diabetes mellitus? Obesity Reviews. 2000;1(2): World Health Organization. Obesity and Overweight Fact Sheet N ; who.int/mediacentre/factsheets/fs311/en/. Accessed 27 July Kelishadi R, Haghdoost A, et al. Trend in the prevalence of obesity and overweight among Iranian children and adolescents: a systematic review and meta-analysis. Nutrition. 2014;30(4): Hosseinpanah F, Rambod M, et al. Population attributable risk for diabetes associated with excess weight in Tehranian adults: a population-based cohort study. BMC Public Health. 2007;7: Harati H, Hadaegh F, et al. Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran. BMC Public Health. 2009;9: Esteghamati A, Etemad K, Koohpayehzadeh J, et al. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: Diabetes Res Clin Pract. 2014;103(2): Esteghamati A, Gouya MM, Abbasi M, et al. Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non- Communicable Diseases of Iran. Diabetes Care. 2008;31(1): Ayatollahi S, Ghoreshizadeh Z. Prevalence of obesity and overweight among adults in Iran. Obes Rev. 2010;11(5): World Bank Data. Life expectancy at birth. Accessed 15 May IRAN BB_ENG_ FINAL.indd 11 17/11/15 15:11

13 12 THE DIABETES CHALLENGE IN IRAN Diabetes is a rapidly escalating healthcare challenge in Iran IT IS PREDICTED THAT IRAN WILL HAVE NEARLY TWICE AS MANY PEOPLE WITH DIABETES IN 25 YEARS TIME. 1 DIABETES IN IRAN Type 2 diabetes is among the most common chronic illnesses in Iran. More than 4.6 million people in Iran are currently estimated to have diabetes, and only 60% are aware of their condition. 1 Diabetes is often diagnosed once complications occur and medical advice is sought from a doctor. Uncontrolled diabetes or high blood sugar levels over a long period of time inevitably result in both debilitating and costly complications. Each year the prevalence of diabetes increases as well as its social and economic impact. A further 3.8 million people are estimated to have impaired glucose tolerance (IGT) 1, a well-known precursor of diabetes, putting them at increased risk of developing diabetes in the near future. 3.8 million PEOPLE HAVE IMPAIRED GLUCOSE TOLERANCE IN IRAN 1 In Iran, more than 310,000 individuals, or 1% of the Iranian population over the age of 20, develop type 2 diabetes every year. 2 It is estimated that, by 2040, 13% of adults in Iran will have diabetes ,000 DEVELOP TYPE 2 DIABETES EACH YEAR IN IRAN 2 EVER-INCREASING COSTS FOR THE HEALTHCARE SYSTEM In 2009, the total national cost of type 2 diabetes for Iran was estimated at 3.8 billion US dollars. This includes direct (medical and nonmedical costs such as transportation services and caring for dependants) and indirect costs (absenteeism due to illness, reduced earnings due to permanent disability and lost productivity due to premature death). 3 About 8.7% of the country s total healthcare expenditure is attributable to diagnosed type 2 diabetes. 3 Diabetes complications contribute significantly to healthcare costs Direct costs, including in- and outpatient medical services, medication and laboratory tests, are two times higher per capita for people in Iran with diabetes who have one or more diabetes-related complications than for those without diabetes. 3 In 2009, the direct cost of diabetes in Iran was approximately 2 billion dollars, of which around half was due to complications. 3 A study from 2014 on the cost of complications in Iran found that the total cost for each person with type 2 diabetes was 1,914 dollars per year, which is significantly higher than previously reported in 2009 (1,707 dollars per year). 4 1,914 usd IS THE ESTIMATED COST FOR EACH PERSON WITH DIABETES EACH YEAR 4 FIGURE 6 COMPLICATIONS DRIVE DIABETES-RELATED HEALTHCARE COSTS 3 49% 24% of the direct costs of diabetes are due to complications of the direct costs of diabetes are due to prescription medications 27% of the direct costs of diabetes are due to other factors, including visits to the doctor, laboratory use, patient education, etc. 3.8 billion usd IS WHAT DIABETES COST IRAN IN IRAN BB_ENG_ FINAL.indd 12 17/11/15 15:11

14 THE DIABETES CHALLENGE IN IRAN 13 Hospitalisation is a major contributor to direct medical costs The economic burden of hospitalisation is significant for governments, insurers, individuals and society. 5 In general, hospitalisation accounts for 50% of direct costs. 5 7 An analysis from 2009 of the hospital inpatient records of more than 4,000 people with diabetes in Iran found that the average length of stay was approximately six days and the average cost, irrespective of type of diabetes, was 716 dollars per person. 5 Diabetes hospitalisation was estimated to account for between 3.2% and 4.4% of the total health expenditure. 5 However, this did not reflect the true cost, which was likely to be higher given that some of the hospital costs had been state-subsidised and were not reflected in the study. 5 FIGURE 7 50% OF THE DIRECT COSTS OF DIABETES ARE ASSOCIATED WITH HOSPITALISATION 6 50% of the direct costs of diabetes are due to hospitalisation PREVENTING COMPLICATIONS CAN SAVE HEALTHCARE COSTS DIABETES COMPLICATIONS ARE LARGELY PREVENTABLE. THERE ARE PROVEN, AFFORDABLE INTERVENTIONS AVAILABLE. 7 The increasing number of people living with chronic illnesses, such as diabetes, can place a strain on any healthcare system. Evidence shows that the use of healthcare services by people with diabetes is much higher than for many other diseases. 5,8,9,10 Visits to doctors surgeries, hospital outpatient departments and emergency rooms contribute to increased costs. Many of these visits and the use of services and resulting costs are due to diabetes-related complications developed by people with diabetes. 11 People with diabetes are also more likely to be admitted to hospital and stay for longer periods at a time than those who do not have the condition. 5,9,10,12 When the prevalence of diabetes and impaired fasting glucose are combined, one in four Iranian adults are considered to have clinically significant abnormalities related to their blood sugar levels. 13 This places a tremendous strain on healthcare resources. 13 A high rate of long-term complications was present among a group of 1,000 Iranian study participants with type 2 diabetes. Treatment costs were reported to be equally high. 4 The study clearly showed that people with better blood sugar control had fewer complications and lower medical expenses. 4 ANNUAL COST FOR A PERSON WITH DIABETES INCREASES WITH POOR BLOOD SUGAR CONTROL 4 Good blood sugar control (HbA 1c <7%) was associated with lower expenditure (409 dollars) Poor blood sugar control (HbA 1c >8.5%) was associated with higher expenditure (3,788 dollars) This is equal to an 826% increase in the average cost for individuals with poor blood sugar control compared to those achieving treatment targets. 1. International Diabetes Federation. IDF Diabetes Atlas, 7th ed. Brussels, Belgium: International Diabetes Federation; Harati H, Hadaegh F, et al. Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran. BMC Public Health. 2009;9: Javanbakht M, Baradaran HR, et al. Cost-of-illness analysis of type 2 diabetes mellitus in Iran. PLoS One. 2011;6(10):e Farshchi A, Esteghamati A, et al. The cost of diabetes chronic complications among Iranian people with type 2 diabetes mellitus. J Diabetes Metab Disord. 2014;13(1): Ghaffari S, Seyed Ebrahim Hashemi, and Haleh Atabaki. The national financial burden of hospitalization of diabetes in Iran. Journal of Clinical Research & Governance American Diabetes Association. Economic costs of diabetes in the U.S. In Diabetes Care. 2008;31(3): International Diabetes Federation. Global Diabetes Plan Brussels, Belgium: International Diabetes Federation; Olveira-Fuster G O-MP, Carral-Sanlaureano F, González-Romero S, Aguilar-Diosdado M. Excess hospitalizations, hospital days, and inpatient costs among people with diabetes in Andalusia, Spain. Diabetes Care Tomlin AM, Tilyard MW, et al. Hospital admissions in diabetic and non-diabetic patients: a case-control study. Diabetes Res Clin Pract. 2006;73(3): Wang W, Fu C, et al. Factors affecting costs and utilization of type 2 diabetes healthcare: a cross-sectional survey among 15 hospitals in urban China. BMC Health Serv Res. 2010;10: World Health Organization. Fact sheet N 236. Diabetes: the cost of diabetes. who.int/mediacentre/factsheets/fs236/en/. Accessed 27 July, Gagliardino J, Martella A, Etchegoyen G, Caporale J., Guidi M, Olivera E, González C. Hospitalization and re-hospitalization of people with and without diabetes in La Plata, Argentina: comparison of their clinical characteristics and costs. Diabetes research and clinical practice Esteghamati A, Etemad K, et al. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: Diabetes Res Clin Pract. 2014;103(2): IRAN BB_ENG_ FINAL.indd 13 17/11/15 15:11

15 14 THE DIABETES CHALLENGE IN IRAN Prevention, early detection and effective treatment can make a difference IT IS IMPORTANT TO REMEMBER THAT DIABETES CAN BE PREVENTED. EDUCATION AND PERSONAL RESPONSIBILITY ARE CRITICAL ELEMENTS IN THE MANAGEMENT OF DIABETES, BUT THEY ARE NOT SUFFICIENT ON THEIR OWN. Giving people information about the importance of following a healthy lifestyle can prevent more than 50% of cases of IGT or diabetes. 1 A three-year Iranian study involving over 8,000 people found that reducing major modifiable diabetes risk factors had a great impact on weight reduction in people who were overweight or who had obesity, resulting in a 65% decrease in diabetes in both men and women. 2 REDUCING MAJOR MODIFIABLE RISK FACTORS RESULTED IN A 65% decrease IN DIABETES CASES 2 Steps are being taken at national level in Iran to address the escalating diabetes situation. The government allocates specific funding for diabetes, covering prevention, early diagnosis, treatment and prevention of secondary complications. 3 However, the most recent scorecard on diabetes in Iran from the International Diabetes Federation claims that increased funding for cost-effective diabetes prevention and treatment is needed. 3 PRIMARY PREVENTION (PREVENTING PEOPLE FROM DEVELOPING TYPE 2 DIABETES) Diabetes prevention programmes around the world show that the number of diabetes cases can be reduced through lifestyle modifications. 4 6 Recent studies show that screening for diabetes and prediabetes in people over the age of 40 is cost-effective 7 9 and therefore very good value in terms of optimising healthcare spending and getting the maximum benefit in return. 10 SECONDARY PREVENTION (PREVENTING PEOPLE WITH DIABETES FROM DEVELOPING COMPLICATIONS) Fewer long-term complications are reported in instances where early and intensive treatment has been implemented. In addition, there continues to be a positive impact on health as a result of the lifestyle changes made, even if treatment is stopped after some years. The problem is that, in many cases, opportunities for early treatment and control in order to avoid damaging complications are often missed. This is mainly because type 2 diabetes can develop over many years and can remain hidden until complications start to occur, so people are unaware of their condition and therefore do not take the necessary actions. DATA COLLECTION AND MONITORING Gathering and analysing data related to all aspects of diabetes can lead to improved decision-making in healthcare based on evidence, resulting in a reduction in costs and better quality of life for people with diabetes. With the aim of promoting quality research, and improving data collection and systematic analyses of data, the Endocrinology and Metabolism Research Center (EMRC) a research centre affiliated to Tehran University of Medical Sciences, and a member of the International Diabetes Federation formed the Iranian National Diabetes Research Network (INDIRAN). INDIRAN is a group of research centres throughout Iran that collaborate on diabetes research projects with the cooperation of international and ministerial advisors. 14 DIABETES PATIENT REGISTRIES INDIRAN has also been active in setting up an electronic registry in diabetes clinics to collect patient data. 14 A disease or patient registry collects information or data related to a patient s specific diagnosis, condition or procedure. Registries enable individual disease management, while assisting doctors in identifying and tracking patients at high risk. Registries can provide healthcare professionals (or even patients) with reminders to check certain tests in order to achieve certain quality goals. POTENTIAL BARRIERS TO EARLY DIAGNOSIS AND TREATMENT ADHERENCE People s adherence, attitude, beliefs and knowledge about diabetes may affect diabetes self-management. 15 Although medicines are readily available in Iran, people often lack knowledge about the illness and medications. This has meant that the instructions for diabetes medications are often poorly followed, which is a major factor in the lack of improvement in the levels of health of people with diabetes in Iran. 16 IRAN BB_ENG_ FINAL.indd 14 17/11/15 15:11

16 THE 15 DIABETES CHALLENGE IN IRAN 15 KOBRA BEIGLOU Iran Kobra has type 2 diabetes 1. Gillies CL, Abrams KR, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and metaanalysis. BMJ. 2007;334(7588): Harati H, Hadaegh F, et al. Reduction in incidence of type 2 diabetes by lifestyle intervention in a middle eastern community. Am J Prev Med. 2010;38(6): e World Health Organization. First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control International Diabetes Federation. Global Diabetes Scorecard. Brussels, Belgium: International Diabetes Federation; Reece EA. The fetal and maternal consequences of gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2010;23(3): Pan XR, Li GW, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997;20(4): Chalmers J, Cooper ME. UKPDS and the legacy effect. N Engl J Med. 2008;359(15): Lindstrom J, Ilanne-Parikka P, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006;368(9548): Ramachandran A, Snehalatha C, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006;49(2): Villarivera C, Wolcott J, et al. Analysis & commentary: The US Preventive Services Task Force should consider a broader evidence base in updating its diabetes screening guidelines. Health Aff (Millwood). 2012;31(1): Saudek CD, Herman, W. H., Sacks, D. B., Bergenstal, R. M., Edelman, D., & Davidson, M. B. A new look at screening and diagnosing diabetes mellitus. The Journal of Clinical Endocrinology & Metabolism IRAN BB_ENG_ FINAL.indd 15 Scotland G, McNamee, P., Gillett, M., Brennan, A., Goyder, E., Williams, R., & John, A. Screening for type 2 diabetes: literature review and economic modelling. York Publishing Services Lauritzen T, Sandbaek A, et al. HbA1c and cardiovascular risk score identify people who may benefit from preventive interventions: a 7 year follow-up of a high-risk screening programme for diabetes in primary care (ADDITION), Denmark. Diabetologia. 2011;54(6): Amiri-Moghaddam S, Heshmat, R., & Larijani, B. Iranian national diabetes research network project: background, mission, and outcomes. Arch Iran Med Nam S, Chesla C, et al. Barriers to diabetes management: patient and provider factors. Diabetes Res Clin Pract. 2011;93(1): Sarayani A, Rashidian A, et al. Low utilisation of diabetes medicines in Iran, despite their affordability ( ): a time-series and benchmarking study. BMJ Open. 2014;4(10):e /11/15 15:11

17 16 THE DIABETES CHALLENGE IN IRAN Strengthening the healthcare system A COMPREHENSIVE PACKAGE OF TREATMENT AND SUPPORT HAS BEEN PROVEN TO PREVENT OR SIGNIFICANTLY DELAY DIABETES-RELATED COMPLICATIONS IN PEOPLE WITH THE CONDITION, ENABLING THEM TO LIVE LONGER AND HEALTHIER LIVES. People with diabetes need continuous access to proper medical care, medication, equipment and, most importantly, healthcare professionals who have adequate training in the diagnosis and treatment of diabetes and its complications. Relevant guidelines and training programmes as well as essential medicines to treat diabetes are widely available, and there are established tools for measuring and monitoring the prevalence of diabetes and its complications. 1 These interventions are affordable and cost-effective for all resource settings and present an unparalleled opportunity for governments everywhere. 1 In a study of the quality of care provided to people with diabetes at a diabetes clinic in Iran, at which diabetesrelated complications were evident among 67% of those surveyed, the findings indicated major discrepancies in providing the required care in order for people with type 2 diabetes to manage their disease and so prevent complications. 2 CONSIDERING THAT 40% OF PEOPLE WITH DIABETES CONTINUE TO GO UNDIAGNOSED AND WILL MOST LIKELY PRESENT WITH COMPLICATIONS, THE COST OF DIABETES CARE COULD ESCALATE SIGNIFICANTLY FOR IRAN IN THE COMING YEARS. THEREFORE, PLANNING NATIONAL PROGRAMMES FOR DIABETES CONTROL AND PREVENTION NEEDS TO BE PRIORITISED. 3,4 DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT The successful management of diabetes depends not only on medical treatments. People with diabetes need to make multiple daily decisions about balancing food, physical activity and medicines. Patient education goes beyond a simple explanation of the condition, its complications and treatment. It includes activities that create changes in behaviour, lifestyle and taking on practices that lower the risk of complications and illness. 5 People with diabetes need to make many daily decisions about balancing their diet, physical exercise and what medicines to take. This often includes self-monitoring of blood glucose levels and selfinjecting insulin. 6 Diabetes interventions in Iran have been shown to not only work to reduce the risk of diabetes-related complications, but also improve quality of life of the person with diabetes. Effective interventions, such as educational booklets, educational outreach visits and even computerised tracking systems for issuing reminders, improve self-management in people with diabetes. These interventions are generally affordable and can lead to improvements in the performance of healthcare professionals and overall results Diabetes care requirements change significantly over the different life stages of a person with the disease. This means that people with diabetes require diabetes education and adjustment of treatment not only when first diagnosed, but on an ongoing basis. THE IRANIAN DIABETES SOCIETY The Iranian Diabetes Society (IDS) was founded in 1968 and has more than 100,000 people with diabetes registered at its 20 branches across various cities in Iran. The aim of IDS is to raise awareness of diabetes in Iranian society through education for members of the public, people with the condition as well as healthcare providers and policymakers. The IDS also supports diabetes-related research in Iran. Each year, the organisation hosts activities to mark World Diabetes Day. PAYAM-E-DIABET diabetes magazine is published quarterly in addition to other educational materials. UNIVERSAL HEALTHCARE COVERAGE FOR PEOPLE WITH DIABETES IN IRAN The healthcare system in Iran provides universal and comprehensive services for diabetes care and treatment the percentage of the costs covered by the healthcare system is up to 90% International Diabetes Federation. Global Diabetes Plan Brussels, Belgium: International Diabetes Federation; Shaghaghi A, Ahmadi A, et al. Iranian patients require more pertinent care to prevent type 2 diabetes complications. Adv Prev Med. 2014;2014: Esteghamati A, Khalilzadeh O, et al. The economic costs of diabetes: a population-based study in Tehran, Iran. Diabetologia. 2009;52(8): Ghaffari S, Seyed Ebrahim Hashemi, and Haleh Atabaki. The national financial burden of hospitalization of diabetes in Iran. Journal of Clinical Research & Governance Graber AL, Christman, BG, Alogna, MT, & Davidson, JK. Evaluation of diabetes patienteducation programs. Diabetes Baghianimoghadam MH, Ardekani, M., & Baghianimoghadam, B.. Effect of education on improvement of quality of life by SF-20 in type 2 diabetic patients. Acta Medica Indonesiana Cox DJ, Gonder-Frederick L. Major developments in behavioral diabetes research. J Consult Clin Psychol. 1992;60(4): Kirsh S, Watts S, et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care. 2007;16(5): Davies MJ, Heller S, et al. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ. 2008;336(7642): Gage H, Hampson S, et al. Educational and psychosocial programmes for adolescents with diabetes: approaches, outcomes and cost-effectiveness. Patient Educ Couns. 2004;53(3): Robbins JM, Thatcher, GE, Webb, DA, & Valdmanis, VG. Nutritionist Visits, Diabetes Classes, and Hospitalization Rates and Charges The Urban Diabetes Study. Diabetes care Duncan I, Birkmeyer C, et al. Assessing the value of diabetes education. Diabetes Educ. 2009;35(5): Redekop K. The Drug Reimbursement Decision-Making System in Iran. ISPOR IRAN BB_ENG_ FINAL.indd 16 17/11/15 15:11

18 THE DIABETES CHALLENGE IN IRAN 17 RECOMMENDATIONS FROM THE INTERNATIONAL DIABETES FEDERATION 1 The International Diabetes Federation (IDF) global guidelines for the proper management of type 2 diabetes recommend: Screening and diagnosis Early detection of diabetes through opportunistic screening of high-risk populations. Opportunistic screening is conducted when a patient visits a healthcare professional for a reason other than the medical condition in question. 2 Care delivery Establishing a collaborative relationship between healthcare professionals and patients, respecting cultural differences. The IDF also suggests an annual review of individual care plans for each patient including monitoring of risk factors and complication screening. Furthermore, it proposes implementing multidisciplinary care teams organised around patient needs, and that records be kept to monitor the quality of care delivered. Patient education and lifestyle management Patient education to be provided at the time of diagnosis and to include self-monitoring education and multidisciplinary education with teams that have skills in psychology, nutrition and physical activity. Clinical monitoring Annual visits to monitor treatment targets and assess cardiovascular risk in order to adjust treatment. Furthermore, screening for complications, including eye, kidney and foot complications, is recommended. 1. International Diabetes Federation. Global Guidelines for Type 2 Diabetes. Brussels, Belgium: International Diabetes Federation; World Health Organization, Department of Noncommunicable Disease Management. Screening for Type 2 Diabetes. Geneva, Switzerland: World Health Organization;2003. SAMAN BERAHIMANI Iran Saman has type 1 diabetes IRAN BB_ENG_ FINAL.indd 17 17/11/15 15:11

19 18 THE DIABETES CHALLENGE IN IRAN Good capacity-building practices to strengthen diabetes care in Iran THERE ARE ALREADY MANY SUCCESSFUL PROGRAMMES AND INITIATIVES IN IRAN TACKLING DIABETES IN INNOVATIVE AND EFFECTIVE WAYS. FURTHER SHARING OF DATA ABOUT WHAT WORKS AND A PARTNERING APPROACH ARE THE MOST PROMISING OPTIONS FOR THE FUTURE. CASE 1 DIABETES CLINICS ESTABLISHED TO INCREASE ACCESS TO CARE 1 Countries face a double burden of disease with having to deal with communicable diseases as well as rapidly emerging noncommunicable diseases such as diabetes. This puts a strain on the healthcare system, especially in less developed and more remote provinces of the country. The Isfahan Endocrine and Metabolism Research Centre, in close collaboration with the Iranian Ministry of Health and with the support of the World Diabetes Foundation (WDF), therefore set up a project to establish diabetes clinics throughout the country. The diabetes clinics function as centres for awareness raising, treatment of diabetes and prevention of complications resulting from diabetes. Training was provided for doctors, nurses, laboratory technicians and receptionists to enable them to manage the clinics in the future. As part of the project, community outreach programmes were conducted on a monthly basis. These outreach programmes targeted high-risk individuals, such as first-degree relatives of the people with diabetes registered and others with one or more risk factors for diabetes. 2 The impact of the project was that 30 diabetes clinics were set up and a minimum of 290,000 people were estimated to have been exposed to increased diabetes awareness through outreach programmes. 290,000 EXPOSED TO INCREASED DIABETES AWARENESS 1 Foot complications arising as a result of diabetes have put social and financial pressure on Iran. Therefore, controlling diabetes and its complications has become an important priority. Consequently, the Ministry of Health in Iran supported the Endocrinology and Metabolism Research Center in 2008 and 2009 in its efforts to improve diabetes foot care and reduce the number of amputations in seven provinces of Iran. During this period, nine foot care clinics were established within the structure of existing diabetes care facilities. The clinics provide primary foot care and education to people with diabetes. The project facilitated the training of approximately 2,000 healthcare professionals in the management of foot care in people with diabetes. 2,000 HEALTHCARE PROFESSIONALS TRAINED IN THE MANAGEMENT OF FOOT CARE IN PEOPLE WITH DIABETES 3 CASE 3 PEER-TO-PEER PATIENT EDUCATION TAKING ADVICE FROM PEOPLE FACING THE SAME CHALLENGE In 2006, Gabric Diabetes Education Association (GDEA), an Iranian nonprofit organisation, was founded by leading endocrinologists and a number of highly motivated people with type 1 diabetes in order to raise awareness of the disease and its complications. GDEA now has more than 40,000 members and provides services and activities that complement medical treatment. GDEA recruits and trains people with type 1 diabetes to undertake peer-to-peer patient education in order to foster an environment that promotes wellcontrolled diabetes. CASE 2 IMPROVING DIABETES FOOT CARE IN ORDER TO REDUCE AMPUTATIONS 3 People with diabetes can develop many different foot problems as a result of nerve damage, also called neuropathy. Even relatively minor problems can worsen and lead to serious complications, including limb amputation. 3 Educating people with diabetes about how to care for their feet can help prevent and slow down the onset of foot problems associated with diabetes. 1. World Diabetes Foundation. Projects. Diabetes clinics WDF worlddiabetesfoundation.org/projects/iran-wdf Accessed 27 July American Diabetes Association. Foot Complications. 2015; Accessed 27 July World Diabetes Foundation. Projects. Diabetes foot care WDF worlddiabetesfoundation.org/projects/iran-wdf IRAN BB_ENG_ FINAL.indd 18 17/11/15 15:11

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