International Diabetes Federation

Transcription

1 International Diabetes Federation 1

2 It is unacceptable that so much disability and death are caused by diabetes and its severe complications, when the solutions are clear and affordable. Small investments in prevention, awareness and care can improve the quality of life for individuals and bring about dramatic reductions in healthcare costs and improvements in productivity. Dr. Anil Kapur, managing director of the World Diabetes Foundation, 2007 We believe addressing the prevention and control of chronic noncommunicable diseases offers a window of opportunity to create healthy development. Unless this opportunity is seized by donors, governments and other partners, the current progress on the internationally agreed development goals will be undermined and countries will face unbearable costs to their economies and health systems. The world is thus at a unique tipping point in the history of public health; an opportunity that will rapidly fade if no timely action is taken. Professor Pierre Lefèbvre, chairman, World Diabetes Foundation, 2010 We need to realise that NCDs pose enough of a threat to the future development and security of the world that they warrant a large and commensurate response. Dr Ala Alwan, assistant director-general for Non-communicable Diseases and Mental Health, World Health Organization (WHO), 2010 Cancer, diabetes, and heart diseases are no longer the diseases of the wealthy. Today, they hamper the people and the economies of the poorest populations even more than infectious diseases. This represents a public health emergency in slow motion. Ban Ki-Moon, United Nations Secretary-General, 2009 This book is prepared for the Middle East and Northern Africa (MENA) Diabetes Leadership Forum, Dubai, December It has been edited by Prof. Dr Tawfik Ahmed Khoja, Dr Kamal Al-Shoumer, Prof. Riad Sulaimani, Prof. Mohsen Ali Faris Al-Hazmi, Dr Jonathan Betz Brown, Prof. Sherif Hafez, Prof. Dr Khalid Al-Rubean, Prof. Kamel Ajlouni, Prof. Mohamed Belhadj, Prof. Alireza Esteghamati, Prof. Dr Ibrahim Salti, Bjorn Ekman and Dr Enis Barıs. 2 1

3 Making a difference today Setting the scene the extent of the pandemic Diabetes: the hidden pandemic and its Impact on the Middle East and Northern Africa begins by setting out the startling extent of the diabetes pandemic. There are already 300 million people in the world with the disease 6.6% of the adult population and, by 2030, the International Diabetes Federation estimates that 438 million people will be affected. The increase in the MENA region is set to be even more dramatic, almost doubling from 26.6 million people today to 51.7 million in There will also be many more people with pre-diabetes, indicative of an elevated risk of diabetes an increase from 24.4 million to 43.1 million. The pandemic is being fuelled by a number of factors, notably demographic changes and increasing rates of overweight/obesity. More than 50% of cases of type 2 diabetes can be prevented or delayed in people with pre-diabetes and people with known risks for developing diabetes, through eating a healthy diet and increasing physical activity. Taking action The book sets out a number of key steps that must be taken if the pandemic is to be effectively tackled. a) Health checks As 50% of people with diabetes in the region are undiagnosed, identifying people with diabetes, pre-diabetes or heart disease before they manifest with symptoms is very effective in improving health outcomes for individuals. Health checks are a cost-effective solution, as early diagnosis can reduce the future costs of diabetes management and treatment. The resources dedicated to treating diabetes and its complications are already vast: the MENA region spends $5.5 billion a year (14% of total healthcare expenditure) on diabetes. Managing people with diabetes including close monitoring and control of blood glucose levels, blood pressure and blood lipids will help to delay or prevent the onset of serious complications, which can include blindness, amputation, stroke and heart attack. b) Improved management Managing diabetes requires complex and demanding self-care. At most, people with diabetes will spend five hours a year with a health care professional: the rest of the time they must manage their disease alone. Good diet and physical activity, diabetes-related counselling, and interventions such as educational outreach and computerised tracking systems can all play a valuable role at relatively low-cost. Management during Ramadan can pose a particular challenge. Essential for the success of all proper diabetes management is education. People with diabetes need to be aware of the best ways to manage their disease, and increased education can lead to dramatic reductions in complications such as congestive heart failure. Analysis of data from the DiabCare study in the Gulf region presented in this book reveals that patient education leads to significant delays and reductions in occurrence of both major and minor complications, and increases life expectancy by 17%. The analysis also revealed that lifetime costs associated with diabetes could be reduced by 8% if people with type 2 diabetes received patient education. c) Gestational diabetes Early diagnosis of gestational diabetes mellitus (GDM) among pregnant women is particularly important. Without careful management of blood glucose levels during pregnancy there is a greater risk of large baby syndrome, malformation or stillbirth. Mothers with GDM and their children also have an increased risk of developing diabetes in later life. Identification of mothers with GDM therefore allows for early intervention and monitoring of both mothers and children. The risk of complications for the mother and baby can largely be avoided if the mother s blood glucose level is well controlled between diagnosis and delivery through diet, physical activity and, in some cases, insulin. As most women visit a healthcare facility at least once during pregnancy, a valuable opportunity exists to perform a health check and provide advice on a healthier lifestyle for the whole family. Although there is a long way to go, much progress has been made and regional guidance is available to assist governments, healthcare providers and patients organisations to identify what steps need to be taken. The IDF MENA Action Plan (2009), the Joint Statement for The Ministers of Health for the Cooperation Council States on Diabetes (2007) and the Integrated Gulf Executive Plan for Diabetes Control are three such examples, outlining essential actions to address diabetes. There are other specific declarations on diabetes economics (the Riyadh Declaration) and care of diabetic patients (Jeddah Declaration). Finally, the book provides examples of best practice in the region, from a programme offering population-wide health checks of cardiovascular risk factors, to a peer-to-peer patient-education programme. Afghanistan Algeria Armenia Bahrain Egypt Iran Iraq Jordan Kuwait Lebanon Libya Mauritania Morocco Oman Pakistan Palestine Qatar Saudi Arabia Sudan Syria Tunisia UAE Yemen Islamic Republic of Afghanistan People s Democratic Republic of Algeria Republic of Armenia Kingdom of Bahrain Arab Republic of Egypt Islamic Republic of Iran Republic of Iraq Hashemite Kingdom of Jordan State of Kuwait Republic of Lebanon Great Socialist People s Libyan Arab Jamahiriya Islamic Republic of Mauritania Kingdom of Morocco Sultanate of Oman Islamic Republic of Pakistan Palestinian National Authority State of Qatar Kingdom of Saudi Arabia Republic of the Sudan Syrian Arab Republic Tunisian Republic United Arab Emirates Republic of Yemen This book would not have been written without invaluable support from and contributions of its editors. All the editors of this book chose to donate their time and resources, without compensation, in order to increase awareness of diabetes in the MENA region and globally. Although the editors have made every reasonable attempt to achieve complete accuracy of the content in this book, they assume no responsibility for errors or omissions. Furthermore, the book in no way expresses the opinions and beliefs of the editors and/or their institutions. 2 3

4 Quotes 1 Executive summary 2 A worldwide pandemic 6 Diabetes: a major problem for the MENA region 8 Diabetes growth in the MENA region 10 Factors causing the rise in diabetes 12 What is diabetes? 14 The burden of complications 16 Early detection of cardiovascular risks through screening 18 Prevention works 22 Improved management of diabetes 24 Cost-effective patient education 26 Mothers, babies and families 28 Best practice 30 What needs to change? 32 The Editorial Board 34 References

5 Diabetes has a major economic impact, especially in low- and middle-income countries: In the UK, of every 8 spent on acute hospital care in the UK, 1 now goes to someone with diabetes 5 and in the US, one of every five health care dollars is spent caring for someone with diabetes 6. Diabetes is now a global pandemic. Worldwide: 300 million people 6.4% of the adult population have diabetes today, over 95% of whom have type 2 1. Each year this increases by 7 million 1. By 2030, it is estimated that 438 million people will have diabetes (7.7% of the adult population) a rise of 54% in 20 years 1. This total is more than the combined population of the MENA region today. A further 344 million people in 2010 have impaired glucose tolerance*, which can often lead to diabetes. This number, too, is expected to rise to 472 million by High blood glucose is the third-highest risk factor for mortality in the world, estimated to account for 5.8% of total mortality 2. Almost half a million children under the age of 15 have type 1 diabetes, more than half of whom live in low-and middle-income countries 3. Diabetes often presents during the peak working period of a person s life, a time at which those affected are likely to be the breadwinners of the family. This can have severe consequences for family income. In the US the presence of diabetes and complications was found to reduce yearly earnings by one-third 7. The economic impact of diabetes arises largely from its complications, such as stroke, kidney disease, heart attack, amputation and blindness. These complications can be largely prevented or, at a minimum, delayed using very inexpensive, easy-to-use treatments and good management practices. In much of the world, however, people with diabetes do not discover that they have diabetes until it is too late to prevent complications. In the US people with diabetes and late stage complications are absent from work 1 out of every 3 work days 7. Even though 80% of the people with diabetes are in low- and middle-income countries, more than 80% of spending on medical care for diabetes is made in the world s richest countries 1. Diabetes is responsible for premature death and disability on a huge scale: During 2010, diabetes will kill 10,000 people every day 4 or about 4 million adults each year worldwide - 6.8% of deaths from all causes. Because diabetes-related mortality is often under-reported, this is likely to be an underestimate 1. Diabetes can lead to complications and severe disability, including kidney disease, blindness, heart attack, stroke and neural damage that can require limb amputation. * Impaired glucose tolerance is a pre-diabetic state that is associated with insulin resistance and increased risk of cardiovascular problems, and is a risk factor for mortality. 6 7

6 The International Diabetes Federation estimates that, in 2010, the MENA region is home to 9.3% of the world s adults with diabetes. Six of the region s countries appear in the list of the 10 countries with the highest average prevalence of diabetes in the world. Diabetes is already a major challenge in the MENA region. reduce obesity and other related risk factors. These include various policy measures and interventions aimed to increase physical activity and promote healthy diets at professional and school environments, as well as the regulation of the marketing and use of trans-fatty acids and sugar in food and non-alcoholic beverages. The international community has addressed the urgency of the threat of diabetes in a number of major declarations and plans. Among the earliest such documents are resolutions of the World Health Assembly first, on the prevention and control of diabetes (1989) 15 and then its Global Strategy for Diet, Physical Activity and Health (2004) 16. The 2006 UN Resolution 61/225 recognised that diabetes is a chronic, debilitating and costly disease associated with severe complications, which poses severe risks for families, [UN] Member States and the entire world and serious challenges to the achievement of internationally agreed development goals including the Millennium Development Goals. In May 2007, the MENA region s Joint Statement by the Ministers of Health for the Cooperation Council States on Diabetes highlighted the challenge posed by diabetes and began a joint commitment to overcome the challenge of the disease. Later in the same year, the Riyadh Declaration 17 was developed at a regional diabetes economics conference, giving guidance for addressing diabetes challenges, particularly its cost. The Integrated Gulf Executive Plan for Diabetes Control went on to set out detailed objectives for diabetes prevention, treatment and control over ten years. Most recently, in February 2010, the Jeddah Declaration on care of diabetic patients was developed by the Gulf Group for the Study of Diabetes. Diabetes in the MENA region (2010) 26.6 million adults have diabetes Diabetes prevalence in adults in Bahrain, Egypt, Kuwait, Oman, Saudi Arabia and the United Arab Emirates (UAE) are among the 10 highest national levels in the world Average prevalence of diabetes in adults in the MENA region is estimated as 9.3% 1. However, this masks differences between countries from 4.2% in Sudan to 15.4% (Qatar), 16.8% (Saudi Arabia) and 15.4% (Bahrain) 1 The MENA region spends US$5.5 billion annually on diabetes (14% of its total healthcare expenditure). This varies very significantly, from US$24 per person in Pakistan to US$2,960 per person in Qatar 1 Although these figures are very high, studies from the region report even higher prevalence of diabetes within certain age groups, particularly when impaired glucose tolerance (IGT) is included. In the UAE, the joint prevalence of diabetes and IGT is estimated at 30%, and in Iran the prevalence of IGT is 16.8%, equating to 4.4 million people with IGT 8. In Bahrain the prevalence rate of diabetes for people over 40 is 30%, in Iran it is 19.4% in women aged and in Saudi Arabia the prevalence for people over 30 is 40% 9. In addition, the high level of undiagnosed diabetes threatens to lead to an increase in diabetes-related complications, as delayed diagnosis and treatment makes complications more likely (see page 18), and will lead to increased healthcare costs in the future. Currently a high percentage of people in the MENA region have undiagnosed diabetes 10, with reported rates of undiagnosed diabetes varying from 29% in Iraq 11, to 50% in Algeria 12 and Iran 8, to 56% amongst women in Pakistan 13, to 86% in Tunisia 14. Addressing the problem Curbing the diabetes pandemic requires a multifaceted and multisectoral approach that goes beyond the traditional boundaries of the health sector. It calls for the use of a wider array of policy instruments and approaches and involves a broader set of stakeholders to promote lifestyle changes to Note: The data presented in this book is based on the International Diabetes Federation (IDF) definition of MENA, which includes Afghanistan, Algeria, Armenia, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, the United Arab Emirates and Yemen. 8 9

7 Projected deaths (1000s) from diabetes, by age and sex, 2008 and 2030 The growth of diabetes is so serious that healthcare systems will soon be struggling to cope with the costs of treating the predicted level of complications. Over the next 20 years, the International Diabetes Federation predicts that the number of people with diabetes in the MENA region will almost double, reaching 51.7 million by By 2030, diabetes is predicted to affect over 16% of the adult population in Qatar and Kuwait, over 17% in Bahrain and Saudi Arabia, and over 19% in the United Arab Emirates. Prevalence rates appear to vary between genders, but the gender differences are not statistically significant across the region The prevalence of diabetes in the region compared to elsewhere in the world is extremely high, despite its relatively young population. The risk of developing diabetes increases with age, so the burden of diabetes in the MENA region is expected to increase as the population ages. In 2010, 24.4 million people in the MENA region have impaired glucose tolerance (IGT), which is a marker of elevated risk of developing diabetes. The number of people with IGT in the MENA region is expected to rise to 43.1 million by Number of people with diabetes in MENA up by 94% in the next 20 years Number of people with IGT in MENA up by 77% in the next 20 years The IDF estimates that 9,100 new cases of type 1 diabetes are diagnosed each year in children under 14, and there are a total of 54,400 recorded cases of type 1 in children under 14 for the whole region 1. This, too, may well also be an underestimate 23. Deaths from diabetes are also increasing: by 2030 it is estimated that nearly 4% of all deaths in the MENA region will be caused by diabetes, a rise of 85% 24 since The increase in mortality for women is even more pronounced: by 2030, deaths from diabetes among women will be 63% higher than among men, despite similar prevalence rates. According to the WHO burden of disease measure Disability Adjusted Life Years (DALYs) cardiovascular disease (CVD) and diabetes account for more than 90 million lost DALYs every year in the world 24. Measured in this way, CVD and diabetes are responsible for 11.5% of the world s total disease burden. In the MENA region, diabetes and CVD account for 13% of the total disease burden equivalent to over 5 million DALYs lost every year

8 Obesity In the Middle East and Northern Africa, lifestyles vary significantly because of the different stages of economic development. Common to the region are many risk factors some of which can be modified and some that cannot including demographic changes (an ageing population over the next 20 years), rapid urbanisation 25 and rates of overweight and obesity that have reached 60% in many countries 26. Obesity (body mass index, BMI >30kg/ m 2 ) and overweight (BMI>25kg/m 2 ) greatly increase the risk of developing type 2 diabetes. Both are directly linked to lifestyle, and are modifiable risk factors for diabetes. The prevalence of obesity is high in the MENA region, estimated to be above 20% and in Iran the prevalence is estimated at 22.3% an increase of 8.7% in 8 years 39. This has serious implications for diabetes. Studies of obesity in Iran have shown that obese people were between 3.5 and 4 times more likely 40,41, (and overweight people 1.7 times more likely 40,41 ) to develop type 2 diabetes than people of normal weight. Studies in Kuwait have also found that obesity increased the risk of developing diabetes by 44% 38. Individual perceptions of being overweight or obese play an important role people may not consider themselves obese, regardless of their actual measurements 42. For example, only 11% of obese men and women in Bahrain thought they were very overweight and the majority thought that they were about the right weight 42. This is particularly important when planning public health campaigns, as overweight/ obese people may not realise that the messages are relevant to them. Diabetes prevalence: Demographics The number of people aged between 20 and 79 in the MENA region is predicted to grow from around 344 million in 2010 to more than 533 million by , including a doubling of the number of people over 40. People aged between 45 and 59 years are 8.5 times more likely to develop diabetes as those aged 15 to 29, and those over 60 are 12.5 times are likely to develop diabetes 27 so the demographic changes alone will account for an increase of 19.5 million people with diabetes between 2010 and Between 1960 and 2008, the life expectancy of both men and women in the MENA region has increased by over 50%, and now stands at 69 and 73, respectively 28. Although this is a positive development, indicative of the economic and social development of the region, it does mean that the burden of diabetes is also rising. Urbanisation Increasing urbanisation is also associated with a higher prevalence of diabetes, because people who live in cities tend to have a more sedentary lifestyle (i.e. take less physical activity), eat diets higher in processed food, and have higher rates of tobacco consumption. The ratio of urban to rural dwellers varies greatly between countries in the MENA region: countries with a higher rural proportion (for example, Pakistan and Afghanistan) are predicted to see greater migration into cities over the next 20 years than those that are already largely city-based (such as the UAE and Saudi Arabia) 29. A number of studies have found a higher prevalence of diabetes in urban areas. For example: Tunisia (9.4% men / 11.7% women in urban areas compared with 4.4% men / 5.7% women in rural areas) 30, Oman (18% in urban areas; 11% in rural areas 31 ), Algeria (15.3% in urban areas; 12.9% in rural areas) 32 and Iran (7% in urban areas; 3% in rural areas 33 ). However, studies in Pakistan have led to the conclusion that obesity is key to this differential 34. The prevalence of type 2 diabetes among the Tuareg nomads of southern Algeria (aged 34 65) is only 1.3%, whereas it is 3.5 times higher among those Tuareg nomads who have been living in urban areas for over 10 years. The reduction in physical activity associated with urbanisation is the reason suggested for this significant difference

9 Diabetes is a chronic, debilitating disease that requires life-long treatment disease management and care. It greatly increases the risk of serious, long-term complications. The stress involved in dealing with diabetes can often lead to mental-health issues such as depression, especially for young people with diabetes, so support from health professionals and family members is vital. As diabetes commonly presents during the peak income-earning period in an individual s life, the income lost due to early mortality and absence from work, is often large and affects not only individuals but also their families. The financial effect on the family is often greater than the direct costs of treatment and lost income, as other family members may bear primary responsibility for care, and themselves be unable to work 47. In Iran it was found that people with diabetes took nearly 2.5 times as many days off from work compared to the rest of the population 48. Those in rural locations also face many practical and financial problems, such as the difficulty of travelling to treatment centres, and affording medicines for which they usually have to pay. Diabetes is defined by a failure of the pancreas to produce insulin (type 1) or to produce enough adequately functioning insulin (type 2) to enable the glucose (a form of sugar) and fats from food to enter the cells of the body to be used for energy. As a result, in both types, the glucose and lipid levels in the blood remain too high. Blood glucose is commonly monitored as HbA1c, which is the haemoglobin bound by glucose (glycated) as a percentage of total haemoglobin. A normal HbA1c is below 6%; people with diabetes have HbA1c above 6.5%. Many serious complications can develop, usually after a number of years and particularly if diabetes is not treated properly or soon enough. These include heart disease and stroke, eye disease (retinopathy), and kidney disease (nephropathy) that can lead to kidney failure. Diabetes can also cause nerve damage (neuropathy), which is experienced as numbness or weakness in the hands or feet and can lead to development of foot ulcers, which may eventually lead to limb amputation. Problems with digestion and the bladder, sexual dysfunction and dementia are also more likely. Types of diabetes Type 1 diabetes occurs if the body s own immune system kills the cells in the pancreas that produce insulin. Blood glucose must be regulated with insulin treatment in combination with a balanced diet and physical activity. If the level of glucose falls too low, hypoglycaemia can lead to unconsciousness. If the blood glucose level remains too high (hyperglycaemia), the body breaks down fat reserves instead of glucose as an energy source, giving rise to the release of toxic ketones and acids (ketoacidosis), which can lead to coma and death. At present, there is no way to prevent type 1 diabetes, and people diagnosed with it must receive insulin treatment for life. Type 2 diabetes is much more common and accounts for 95 98% of people with diabetes. In type 2 diabetes, blood glucose starts to rise as the pancreas weakens due to ageing, or when it cannot keep up with the added demands introduced by lack of exercise and increasing amounts of abdominal fat. Abdominal fat releases free fatty acids and hormones into the circulation that reduce the effectiveness of insulin, stimulate the liver to release too much glucose, and has other destabilising effects. Once blood glucose levels rise, the circulating glucose itself attacks the pancreas, causing the insulin-producing beta cells to weaken further. Type 2 diabetes is preceded by prediabetes, also known as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). During this time, the glucose level in the blood is higher than normal, but not high enough for the person to be diagnosed as having diabetes. Insulin resistance often also precedes type 2 diabetes; the body produces insulin but the tissue cells do not respond fully, and more and more insulin is produced until insulin production fails and blood glucose rises 43. Type 2 diabetes can be controlled through a balanced diet, exercise and oral antidiabetic drugs and (usually at a later stage) injected insulin. Insulin is increasingly used to treat type 2 diabetes, and evidence is increasing 44-46, that early insulin treatment has a significant effect in delaying or preventing complications. What does diabetes mean for the individual? Acute hyperglycaemia which is often the first sign of diabetes when people have not been tested for the disease includes tiredness, thirst, frequent urination, frequent infections, palpitations, rapid respiration, excessive perspiration, difficulties in concentrating, confusion, dizziness and visual disorders

10 Diabetes greatly increases the risk of serious, costly complications including emotional distress 49, heart attack 50, stroke 51, kidney damage 52, blindness 53 and neural damage leading to amputations 54,55 and also reduces life expectancy 56. People with diabetes in Iran have four times higher levels of hospitalisation, 2.6 times higher numbers of annual physician visits and 2.5 times greater volume of drug prescriptions than nondiabetic patients 48. Diabetes A chronic disease in which blood glucose is too high because insulin is not produced or is insufficient. Acute symptoms Tiredness, weight loss, increased thirst, frequent urination, blurred vision. Complications In time, serious complications can result from raised blood glucose found in diabetes, some of which are illustrated here. These complications are largely preventable, and many could be delayed with early diagnosis and effective treatment. Life expectancy Diabetes reduces life expectancy by 5 10 years in western countries where data exists, and has been linked to high levels of excess mortality in the MENA region 56. Emotional distress Diabetes is often associated with depression, and people with diabetes are more than twice as likely to experience depression as those without it 49. The prevalence of depression is significantly higher in women with diabetes than in men 49. As diabetes is a chronic illness, it requires continuous treatment and often leads to dependence on others. This can create many problems, including the breakdown of relationships and family abandonment. Kidney disease Kidney disease related to diabetes is common and a clinic-based study in Saudi Arabia found that 54% of people with diabetes had kidney disease 52. Effective treatment can prevent the development of diabetic kidney disease, or delay the need for dialysis or transplant for years 3. Blindness Diabetes is a leading cause of blindness and in Egypt it was found that 42% of people with diabetes had diabetic retinopathy, 22% had peripheral neuropathy and 5% were legally blind 53. Effective treatment reduces serious deterioration by more than a third 3. Stroke Stroke is up to four times as likely as in people without diabetes. The MENA region has a stroke incidence comparable with many western countries, but the population is significantly younger. This indicates a likelihood of higher incidence of stroke in the future 51. Effective treatment, including blood pressure and cholesterol reduction, decrease the number of strokes by more than a third 3. Heart attack The risk of heart attack is three times as great for people with diabetes in the United Arab Emirates, over 10% of people with diagnosed diabetes have coronary heart disease 50. Effective treatment leads to a reduction in heart failure of over 50% 3. Amputation Diabetes is the leading cause of non-traumatic lower limb amputations. In Saudi Arabia, it was found that 38% of people with diabetes had some damage to peripheral nerves due to their diabetes and in Jordan 5% of people with diabetes have had an amputation 55. Effective education and treatment reduces the number of amputations

11 The preventive benefits of screening programmes mean that resources invested now in screening will reduce the resources needed for treatment in the future. Age, obesity, smoking, high cholesterol and high blood pressure are risk factors that are shared between diabetes and cardiovascular diseases (CVD) 57. Designing mechanisms to identify people at high risk of developing diabetes and CVD, as early as possible, in order to modify the risks and subsequently prevent or delay the onset of complications, has the potential to reduce the disease burden in the MENA region. The purpose of screening is to identify people without symptoms who are likely to develop the disease and prevent, or delay, the onset of disease through intervention. The WHO has developed criteria for identifying when screening programmes are effective measures to tackle challenges in public health 58. In brief, the criteria suggest that: the diseases should constitute a public health issue of sufficient severity; the diseases should be well understood and have early detectable phases during which symptoms are not present; interventions in the early phase should be effective in preventing or delaying onset of the disease and its complications; all individuals in the target population should have the same chance of being screened in order to ensure equity; and the programmes should be technically and economically feasible and sustainable. Stepwise screening based on risk factors for type 2 diabetes and heart disease where the population to be screened is assessed by non-invasive questionnaires, has been shown to live up to these criteria 59. Complications such as cardiovascular diseases, which are related to diabetes, can be postponed or completely avoided though early diabetes diagnosis and appropriate treatment and management, and if preventive measures are taken 60. Early intervention is effective and, even if the intervention is stopped after some years, the patient will benefit from fewer complications in the longer term because of the early lifestyle changes and treatments 61,62. Evidence from large-scale preventive studies show that more than 50% 60 of diabetes cases can be prevented or delayed by lifestyle or medical intervention in people detected with pre-diabetes. Detection of prediabetes is thus vital for prevention of type 2 diabetes. One cornerstone of an effective public health programme in the 21 st century is to identify those at risk and then to reduce the risk of developing CVD and diabetes through lifestyle modification, disease management and drug treatment. Cost-effectiveness of early detection of diabetes and other cardiovascular risks Very few assessments of costeffectiveness of early detection of diabetes that were carried out around and before the millennium saw the benefit of early detection of undetected diabetes 63,64 Since then, however, changes in the risk factors for undetected diabetes 63,64, improvements in effectiveness and reduction in cost of treatment have led to all assessments published since 2007 confirming the cost-effectiveness of early detection of undiagnosed diabetes and related cardiovascular risks in high-income countries 65,66,68,73,74. Demography and increases in diabetes Age is a major risk factor for diabetes: ageing of the world s population has, together with increased obesity, led to the number of people with diabetes almost doubling over the last 10 years 1 and in the MENA region, the number of people with diabetes has more than doubled 1,67. In Iran, the prevalence of diabetes among Iranian adults has increased more than 1.8-fold in a period of only 8 years since The estimated proportion of people with undetected diabetes has remained the same 50% of people with diabetes are unaware that they have the disease and receive no treatment 1,67. Thus, the chance of identifying a person with undetected diabetes has doubled in the last 10 years. Scope of testing Testing for two conditions pre-diabetes and diabetes with a single test is less than twice as costly than screening for only one 65. Using a risk score, in which people at high risk of having undetected diabetes are tested, is a more economical use of resources in healthcare systems. Modern screening programmes now include testing for diabetes, prediabetes and other cardiovascular risk factors such as cholesterol and blood pressure, which significantly reduces costs per case identified 69-72,

12 MENA countries need to implement national diabetes plans and allocate adequate resources to limit and control the increasing healthcare burden to come 20 21

13 Giving people the information they need to understand the importance of a healthy lifestyle can prevent more than 50% of cases of impaired glucose tolerance or diabetes 60. Once diagnosed with diabetes, helping people to manage the disease with lifestyle advice and medication helps to delay or prevent disabling complications. Taking preventive action has been shown to be cost-effective in a wide range of countries and ethnicities and across all stages of economic development 73. Strong scientific evidence from studies in many countries shows that the course of type 2 diabetes and its complications can be, to some extent, controlled. Indeed, it can be slowed down or even avoided altogether by two forms of preventive measure: lifestyle change and medical intervention. The course of type 2 diabetes in China (1997) 76, the Finnish diabetes prevention study (2003) 77 and the Indian Diabetes Prevention Programme (2006) 78 showed that the incidence of diabetes could be reduced through lifestyle modifications. The challenge is to translate the promising results from studies into real-life settings, which is the aim of the Weqaya programme run by the Health Authority Abu Dhabi 70. Secondary prevention (i.e. preventing people with diabetes from developing complications) involves early diagnosis, allowing people to be treated early, before the disease can progress. This involves advice on lifestyle changes that slow the development of the condition, and appropriate medication and close monitoring for any developing complications. The United Kingdom Prospective Diabetes S t u d y (UKPDS) showed conclusively that effective treatment, with close monitoring and control of blood glucose levels, blood pressure and blood lipids, can greatly reduce diabetes complications such as heart attack (by more than 50%), stroke (44%) and serious deterioration of vision (by up to 33%). The Steno-2 Study showed that mortality could be reduced to 50% by intervention on all the risk factors that impact on the development of diabetesrelated complications 79. In addition, a cost-effectiveness analysis of this intervention showed that it was cost saving after eight years 80. Improving glycaemic control in people with an HbA1c level of over 8% has been shown to be cost saving, as avoidance of the costs of treating shortand long-term complications exceeded the initial outlay of medical costs 73. To achieve this type of glycaemic control, intensified treatment and management is often required, coupled with lifestyle interventions. The Steno-2 Study found that, in at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behaviour modification had sustained beneficial effects, reducing major and minor complications and death rates from any cause and from CVD. The intervention was found to cut cardiovascular events by half 79. Primary prevention (i.e. preventing people from developing type 2 diabetes in the first place) includes encouraging people to choose a diet rich in vegetables and fruit, and low in fat and processed food, and to be physically active and avoid tobacco and excessive alcohol. Recent studies 73-75, have also concluded that screening for diabetes and pre-diabetes is cost-effective in people aged over 40. Early intervention in people with pre-diabetes produces a significant reduction in the development of type 2 diabetes. The Da Qing study 22 23

14 Effective diabetes self-management requires complex, and often demanding, self-care, including lifestyle changes such as improved diet and increased physical activity, as well as careful monitoring of medication and blood glucose levels. People with diabetes are often unable to implement the lifestyle changes demanded to achieve good control. To increase the success of diabetes self-management, patient-focused interventions that understand patients needs (including their dependence on family, friends and community) are required. inadequate help. This study revealed that the percentage of male and females with HbA1c levels above 10% fell significantly over three years, indicative of a marked decrease in the development of complications in the future 91. However, current levels of patient education in the region are not sufficient to meet the needs of patients. The DiabCare study in Algeria, for example, revealed insufficient patient knowledge of diabetes treatments and its complications 92. The importance of education is particularly important in Ramadan. Fasting during Ramadan, a holy month of Islam, is a duty for healthy adult Muslims; however, people for whom fasting might lead to harmful consequences are exempt. Although diabetes falls into this category, many people with diabetes continue to fast, which poses a medical challenge for them and their healthcare professionals 93. Fasting by people with diabetes leads to an increased frequency of complications, such as severe hypoglycaemic episodes 94. There is, therefore, a need for increased, targeted patient education, especially before and during Ramadan, to disseminate existing guidelines and clarify misconceptions about insulin adjustment during this holy month. Educating people with family and their healthcare professional is essential to improving diabetes self-management and preventing complications. Investing in patient education is the best prescription for diabetes Diabetes self-management education seeks to understand the experiences and perspectives of people with diabetes, with the aim of increasing their involvement 81 in the management and treatment of their own disease. Patient education, in this context, is more than mere explanation of diabetes, its complications and treatment; it comprises activities that facilitate changes in behaviour and adoption of practices that could decrease the risk of disease and illness 82. Effective interventions such as provision of educational materials, educational outreach visits and computerised tracking systems issuing reminders improve the management of people with diabetes 83. These interventions are generally low-cost and lead to improvements in performance of healthcare professionals and health outcomes People with diabetes have been found to be more satisfied with healthcare treatment when it included diabetes-related counselling 89. Educating people with diabetes about the disease has been shown to reduce their HbA1c levels and associated complications. An education programme for Saudi nationals aged between 12 and 75, with type 1 (38.7%) and type 2 (61.3%) diabetes, found that such education improves glycaemic control regardless of type of diabetes, gender, age and educational attainment 90. A multi-disciplinary approach to diabetes management was implemented in a Saudi Arabian diabetes clinic, focusing on caring for young people (aged 14 20) with type 1 diabetes, who had previously received 24 25

15 Understanding diabetes, its risk factors and complications significantly affects treatment outcomes. People with diabetes can better control their diabetes when they are well informed about diet, physical activity and medication. At most, people with diabetes spend five hours a year with healthcare professionals; for the other 8,755 hours of the year, they must manage their diabetes alone. Knowing how to self-manage the disease is therefore vital. The economic costs associated with the treatment and management of diabetes was based on a study from Saudi Arabia 101. The relevant costs were adjusted by per capita GDP for Kuwait, Saudi Arabia and the UAE, and the cost of patient education was estimated to be double the standard annual treatment costs ($399). This analysis showed that lifetime costs associated with diabetes could be reduced by 8% if people with type 2 diabetes received patient education ii. This issue was further explored in a DiabCare study performed in three Gulf countries (Kuwait, Saudi Arabia and the UAE). It was found that 49% of people with diabetes who had good HbA1c control (<6.5%) had received four or more days of education 95. To explore this further, a validated computer simulation model of type 2 diabetes, the CORE Diabetes Model 96, was used to make long-term projections of clinical and economic outcomes of a hypothetical education intervention. The model 96 is a validated health-economics model used to predict outcomes in people with diabetes based on large prospective diabetes studies, including the UKPDS and the Framingham Heart Study The Model is used to predict the course of diabetes when different interventions are made. The simulation below contrasts two groups of people with diabetes who are the same age (52), have high blood pressure, high levels of blood glucose and high cholesterol i. The simulation compared two groups of type 2 diabetes patients one group that received education ii and another that did not. The effect of education on clinical outcomes, such as HbA1c level, lipids and blood pressure, was estimated from the DiabCare data. The analysis revealed dramatic reductions in complications from increased education. In addition, complications in the group who received relevant education ii were delayed by an average of three years. People who received diabetes education ii reduced their relative lifetime risk of many serious complications, including end-stage renal disease, requiring dialysis, and congestive heart failure, which were reduced by 25% and 87% respectively. Furthermore, their life expectancy increased by over 17%. Total lifetime costs ($1,000, 2010) associated with diabetes by scenario % reduction in complications between patients receiving and not receiving patient education* i No education group: HbA1c=9.45%, SBP= mmhg, T-CHOL=189.7mg/dl; Education group: HbA1c=8.02%, SBP= mmhg, T-CHOL= mg/dl. ii In the group that received education, 18% received one day of education, 25% received two days of education, 15% received three days of education, 11% received four days of education and 31% received more than five days of education. In the example above, people who received patient education experienced fewer major or minor complications, and led longer, healthier lives. Patient education allows people to improve their self-management of diabetes, increases their involvement in treatment, can improve overall quality of life, and frees up resources in the healthcare system

16 Women are essential to the survival and health of the next generation. Diabetes can affect them at any time, but diabetes developed during pregnancy carries extra immediate and longterm risks for both mother and baby. to 90% of GDM cases, optimal control can be obtained through diet and physical activity alone; the remaining women with GDM may need insulin. If lifestyle education can be provided, the mother can be guided to change her behaviour to prevent future disease in herself and her child. Most women visit a healthcare facility at least once during pregnancy 120, so this can be a valuable opportunity to offer screening for other diseases and advice on diet and a healthier lifestyle for the whole family. On 22 September 2010, the United Nations Secretary General Ban Ki-Moon announced the Global Strategy for Women s and Children s Health 121. A number of pharmaceutical companies have made commitments relating to this Strategy 122. The importance of maternal health The connection between maternal health, diabetes and future disease has been repeatedly confirmed in recent studies, and is receiving increased global attention. Despite this, knowledge has yet to be fully translated into measurable health impacts for women and their families. The issue is not given sufficient priority in many healthcare systems, and women may also have less access to healthcare than men for social, religious, cultural, educational or occupational reasons 102. There are close links between economic development, education, empowerment of women and the general health of families 103. In most countries, women are responsible for raising children and feeding the family, so their own health and knowledge about healthy food, lifestyle and disease management are vital for their family s future. However, in many places women lack access to health facilities because of inadequate transport or resources, have no time due to heavy workloads or cultural or religious constraints restrict their access to healthcare 104. The burden of diabetes in pregnancy Women already diagnosed with diabetes need careful management in pregnancy. Unless it is closely managed, diabetes during pregnancy increases the risk of large baby syndrome, which makes caesarean delivery more likely, and increases the risk of malformation or stillbirth. In addition, about 10 times as many women as those already diagnosed will develop diabetes while they are pregnant 105. This is gestational diabetes mellitus (GDM), which brings a whole series of extra major problems and longterm risks to the mother and child, in addition to the other types of diabetes. Diabetes is a major problem for women s health, particularly in the MENA region where more than 13 million women (approximately 8% of the total) are living with the disease 1. Uncontrolled diabetes causes fatigue, restricts the woman s ability to work, and increases her risk of other conditions. One of these conditions is heart disease, which is 50% more likely to kill women than men 106,107. In some cultures, girls with diabetes are not wanted for marriage, and parents may even withdraw care and education 57. In addition, over the last 20 years, more young people have been developing type 2 diabetes, so more pregnant women will have diabetes or develop the disease during their pregnancy 108. GDM has far-reaching implications for controlling diabetes in the future, as mothers with GDM and their babies both have an increased risk of developing type 2 diabetes in later life GDM is known to be increasing in prevalence it now affects up to 20% of pregnancies in countries in the MENA region, ranging from 5 8% in Iran, 5.4% in Algeria 117, over 12% in Bahrain and Saudi Arabia, to 20% in the UAE. The prevalence in UAE was found to vary slightly across ethnic and cultural groups with prevalence of 20 22% in East African Arabs, people from the Indian Subcontinent, UAE nationals and Chaami Arabs, but it was somewhat lower (13 16%) among North African Arabs and Asian Arabs 118. Studies conducted in Iran and Saudi Arabia 114,115,119 have confirmed the findings from other parts of the world that the main risk factors for GDM are age, obesity, history of previous GDM and a family history of diabetes. Whether developed before or during pregnancy, diabetes can be controlled effectively through early diagnosis, careful dietary management, physical activity and, in some cases, medication. Many pregnant women with diabetes do not receive proper care, either because the disease remains undiagnosed or because the high risk associated with the disease are not recognised and managed by healthcare professionals. The risk of complications for the baby can largely be avoided if the mother s blood glucose level is well controlled between diagnosis and delivery. In up 28 29

17 There are already many examples of good practice in the Middle East and Northern Africa that are tackling diabetes in innovative and effective ways. Sharing information and ideas about what works is one of the most positive options for the future. This book has spelled out the impact of diabetes both on the quality of life of individuals and on the economies of the countries in which they live. It has also examined the actions best able to reduce human suffering, namely lifestyle change to prevent diabetes, better management and treatment though improved diabetes awareness, and education and early detection to delay diabetes or prevent the development of complications. The following examples are of good practice that is contributing to better diabetes prevention and care. Unifying and aligning diabetes priorities in the Gulf In 2008 the Gulf Executive Plan for Control of Diabetes was prepared by the Gulf Committee for Control of Diabetes of the Executive Board, Health Ministers Council for Cooperation Council States. The plan aims to promote awareness in the Gulf community about diabetes and its risk factors, support early-detection programmes and integrate healthcare to decrease morbidity and mortality due to diabetes and its complications. The plan promotes common priorities through encouraging participation of all governmental and non-governmental organisations that have an impact on community health. The plan sets out measurable targets in the areas of primary and secondary prevention of type 2 diabetes, quality improvements of health services for diabetes, supporting mechanisms for control, monitoring and evaluation, and encourages empowerment of people with diabetes and their families and community participation for control of diabetes. In all these areas, indicators were chosen for follow-up every six months. The plan has inspired many initiatives including the Health Promoting Schools in the UAE, the Health Promotion Council in Bahrain, Specialised Clinics in Saudi Arabia and healthy lifestyle projects in Oman. Fighting diabetes requires a multi-sectoral approach The Jordanian strategy for prevention and control of diabetes focuses on promotion of a healthy diet and increased levels of physical activity, combined with improving management of diabetes and hyperglycaemia. The strategy focuses on strengthening capacity and reducing risk factors in the population, so as to empower people with diabetes to manage their treatment more effectively. As changing peoples diet and physical exercise routines is not straightforward, an action plan has been developed in consultation with public and private stakeholders. The action plan aims to increase awareness of diabetes in the general public, and educate healthcare professionals and better define their role in diabetes care. It strives to re-orient the current system from acute care to chronic care. A policy framework is also necessary for the plan to be successful, that will assist in promoting a healthy diet and increasing physical activity through, for example, establishing sidewalks and cycle lanes. The plan eventually hopes to implement screening programmes to facilitate earlier identification and diagnosis of both diabetes and prediabetes in high-risk groups, as well as screen for complications in people with diabetes. This plan is still in its early stages, having recently developed a national strategy. However, in the first quarter of 2011, the roll-out of the plan will begin with the development of a web-page of up-to-date information on diabetes, national dietary guidelines and a culturally appropriate advocacy plan. Setting ambitious targets based on health checks In response to the high prevalence of CVD and diabetes in the UAE, the Abu Dhabi Health Authority launched the Weqaya programme. This programme began in 2008 with a populationwide screening for cardiovascular risk factors. To date, over 183,000 initial health checks have been performed. Results show that 44% of the national population has either diabetes or prediabetes. Individual results from these health checks have been distributed in the form of individual confidential report cards that are linked to an interactive website that allows people to monitor their risk factors and enrol in relevant preventive initiatives. The health checks will be further developed, refined and repeated in phase 2 of the Weqaya programme, so that progress and the risk factors can be continually monitored. The results from stage 1 revealed the current situation and have subsequently been used to set ambitious targets including: a 25% reduction in the rate of obese children; a 10% reduction in the rate of obese adults; and a 10% reduction in projected CVD events by Moreover, an ambitious target has been set to reduce projected cardiovascular-related mortality by 75% and cardiovascular events by 40% by Peer-to-peer patient education taking advice from people facing the same challenge In 2006 an Iranian NGO called GDEA (Gabric Diabetes Education Association) was founded by leading endocrinologists and a number of highly motivated people with type 1 diabetes 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 as employees to foster an environment that promotes wellcontrolled diabetes. GDEA takes a multifaceted approach to management and treatment of diabetes. It runs educational programmes, campaigns and seminars, and also produces publications and sponsors research projects in collaboration with universities. GDEA currently runs 15 different education programmes for people with diabetes, and has a diabetes-educator training programme and the most comprehensive web resource on diabetes in Farsi. To date, GDEA has run face-to-face training programmes for more than 20,000 people with diabetes, trained more than 100 diabetes educators all over the country, and employed more than 50 people with well-controlled type 1 diabetes to undertake peer-topeer patient education. Monitoring gestational diabetes leads to better outcomes for the mother and child The Établissements Hospitaliers Universitaires (EHU) in Oran, Algeria, provides intensive management of gestational diabetes beginning with pre-conception screening and continuing until after birth 123. In addition to providing screening for gestational diabetes, the hospital provides education for children with diabetes. During pregnancy, the hospital undertakes close monitoring through clinical examinations, laboratory tests, education sessions and appointments with dieticians and psychologists every second month. Obstetric checks are also provided on a monthly basis. The hospital also encourages the use of a blood-glucose monitoring diary to enable more effective diabetes selfmanagement. Compared to women with GDM who had only irregular monitoring, the women with gestational diabetes who followed this programme had substantially fewer babies of excessive weight (16.6% vs. 45.4%), their newborns experienced less hypoglycaemia (13% vs. 27%) and fewer newborns were transferred to intensive care (13% vs. 36.6%). Better diabetes care through specialised diabetes centres In response to the high prevalence rates of diabetes in the region, the Ministry of Health in Saudi Arabia developed and supported a plan to establish more specialised diabetes centres in the different parts of the Kingdom. These centres provide education, training, and treatment and management plans for people with diabetes. As diabetic foot complications are a leading cause of lower-limb amputation, some of these centres were given specific responsibility for increasing awareness among healthcare providers and people with diabetes of diabetic foot care and the prevention of complications. The preliminary results from these centres suggest that the programme has been successful in increasing awareness and decreasing the rate of amputation. Furthermore, the success of these programmes have been effective in all locations, with satisfactory results being achieved in tertiary care facilities as well as remote hospitals affiliated to the Ministry of Health. Reducing risk factors for the development of diabetes In Egypt, a National Strategy for the prevention and control of diabetes was created with a supporting action plan, to be implemented over five years beginning in January The plan has three main objectives; to understand the epidemic, to reduce risk factors for diabetes and to strengthen healthcare systems and delivery. The first objective involves mapping the diabetes epidemic in order to analyse its social, economic, behavioural and political determinants. This objective has a specific focus on disadvantaged populations, in order to provide guidance for policy, legislative and financial measures related to the development of an environment that is supportive of diabetes control. The second objective is to reduce individuals exposure to diabetes risk factors, particularly obesity, through tackling unhealthy diet and physical inactivity. The final objective aims to strengthen healthcare for people with diabetes by developing norms and treatment and management guidelines in association through cost-effective interventions

18 Since 2007, there have been five major plans and declarations on diabetes in the MENA region: the IDF MENA Action Plan, the Integrated Gulf Executive Plan for Diabetes Control, the Joint Statement for the Ministers of Health for the Cooperation Council States on Diabetes, the Riyadh Declaration on Diabetes Economics and the Jeddah Declaration on Care of Diabetic Patients. These plans and declarations share several common features. All make reference to a number of major international and regional declarations and resolutions, particularly highlighting the need to put the 2004 WHO Global Strategy on Diet, Physical Activity and Health into practice. They all call for diabetes to be a national priority, for accurate data-gathering, and for awareness to be raised about the critical importance of the pandemic. They also set targets for reducing incidence of the disease. IDF MENA Action Plan (April 2009) The essential steps in addressing diabetes in the Middle East and Northern Africa were fully defined in 2009 by the IDF MENA Action Plan, prepared jointly by experts from the member associations of the IDF MENA region. The action plan is a direct response to the UN Resolution on Diabetes to improve the prevention, treatment and care of diabetes, and sets out specific actions to be taken by all stakeholders in the region: Prioritise diabetes within the national healthcare framework Strengthen the role of primary care in diabetes through a multi-disciplinary approach, setting a minimum standard of care Deliver tailored care for children and adolescents, pregnant women and elderly people Achieve improved disease awareness and education for people with diabetes, healthcare professionals and the community Establish and maintain data on the prevalence, burden and economic cost of diabetes Drive greater collaboration between the various stakeholders All of these actions should take place against a background of monitoring and evaluation of national diabetes programmes. Integrated Gulf Executive Plan for Diabetes Control This plan outlines and defines the essential actions to address the problem of diabetes and sets out specific action points for all stakeholders in the region, including: primary prevention of type 2 diabetes (preventing people from developing diabetes); secondary prevention of type 2 diabetes (preventing people with diabetes from developing complications); improving the quality of health services provided to people with diabetes; strengthening methods of monitoring, follow-up and evaluation of diabetes; conducting and supporting research and studies of diabetes; empowering patients and their families to take part in control of diabetes and its complications; and giving effect to community participation in diabetes control. In summary, this plan calls for recognition, across the MENA region, of the seriousness of the diabetes burden and a political determination to make non-communicable diseases such as diabetes a priority and to allocate them an appropriate level of resources. All sectors must contribute to reducing and preventing diabetes politicians, healthcare providers and policymakers, industry, business, NGOs and donors. In order to provide the incentive for action and the creation of national diabetes initiatives, data collection on the scope of the problem is essential to provide the evidence base, followed by thorough appraisal of healthcare structures to offer integrated and comprehensive, long-term care. Attention must also be given to preventive educational programmes to empower and raise awareness of the impact of lifestyle, for people already suffering with diabetes and for the community in general, particularly young people. Providing this knowledge to healthcare professionals, and the skill to inspire effective self-care in their patients, is a final, essential part of the solution. Joint Statement for The Ministers of Health for the Cooperation Council States on Diabetes (January 2007) The Joint Statement takes the form of a concise pledge by seven Health Ministers of the Gulf Cooperation Council States to work at national level to prioritise diabetes, with the aim of decreasing the mortality rate by 2% compared to projected trends over a period of 10 years. Steps to achieve this include setting and implementing national strategies on the risk factors (including raising awareness of their importance), supporting research into diabetes and its economic impact, and integrating patient management and care into the primary health system. It states that the States will strive to establish a Supreme National Council for Control of Diabetes, recognising that control of diabetes is a joint national mission. Riyadh Declaration on Diabetes Economics (November 2007) Although mentioned in many of the Declarations, the economic impact of diabetes is the main focus of the Riyadh Declaration. It calls for the establishment of an international unit on Diabetes Economics...under the umbrella of the United Nations, with regional offices to develop a database on relevant indicators, forecast the economic burden, and advise Member States on diabetes expenditure. It suggests that Member States and relevant organisations meet each year to review progress and share experience and best practice in diabetes economics. It calls on countries to prioritise national plans on diabetes, and increase expenditure on both care and prevention, as this will prove to be cost-effective in the long term, urging countries to decrease diabetes incidence by 25% in a decade. Jeddah Declaration on Care of Diabetic Patients (February 2010) The patient is at the heart of the Jeddah Declaration. Following a Preamble setting out the seriousness of the epidemic for development, the economy and individual health, it calls for an international reference body... for empowerment of diabetic patients to be founded under the umbrella of the United Nations. This body would have regional offices, responsible for establishment of a database on diabetes and giving advice to member states on optimal use of resources, and an international network to promote the empowerment of patients. Like the Riyadh Declaration, it suggests that member countries and relevant organisations meet annually to share experience and best practice, and review progress in diabetic care. Integrating care and treatment within the primary healthcare system is also highlighted, as is the importance of educating healthcare professionals, and cross-sector working (again referring to diabetes control as a joint national mission ). Tackling the risk factors for diabetes is central to the Declaration, and there is a call to work towards reducing the incidence of diabetes by 2% per year. As the most recent of the documents, this Declaration also specifically calls for a UN General Assembly Special Session (now the UN Summit) on NCDs. The evidence investigated in this book will be presented to political and healthcare leaders at the Middle East and Northern Africa (MENA) Diabetes Leadership Forum, Dubai, December. We hope that it will contribute to the development of sustainable improvements in diabetes prevention, diagnosis and provision of affordable, effective care in the MENA region

19 Professor Dr Tawfik Ahmed Khoja is the director general of the Executive Board of the Health Ministers Council for Gulf Cooperation Council States and a consultant to the Council of Nursing and Nursing Specialisation. He is a fellow of the Royal Medical Board and of the British Royal College for Public Health. In 2007, he was included in the Cambridge Information Institute second edition as one of the most important 100 people in the field of public medicine, because of his efforts to improve the quality of healthcare, the safety of patients and family medicine. Professor Mohsen Ali Faris Al-Hazmi is a professor of medical biochemistry and molecular medicine. He is chairman of the National Committee for Hereditary Diseases at the Ministry of Health, a member of the Board of Trustees of the Prince Salman Centre for Disability Research, and a member of the British Biochemical Society and the American Association for the Advancement of Science. He has held other distinguished posts and was also the founding director and chairman of the College of Medicine Research Centre. Professor Dr Khalid Al-Rubean is the director of the Diabetes Centre at King Abdulaziz University Hospital and a consultant endocrinologist and assistant professor of medicine at King Saud University. He is also the editor-in-chief of Al-Sukari Magazine for Patient Education in the Middle East, and is the head of the Saudi National Diabetes Registry and a former president of the Pan Arab Group for the Study of Endocrinology and Diabetes. His major research interests are endocrine diseases, especially diabetes mellitus. Professor Kamel Ajlouni is the president of the National Centre for Diabetes Endocrine and Genetic Diseases in Amman, Jordan, and is an internationally recognised physician and researcher in the field of endocrinology. Professor Ajlouni has served in various public offices, including Minister of Health of Jordan, president of the Jordan Medical Council, president of the Jordan University of Science and Technology, president of the Association of Arab Universities, and Senator in the Upper House, Jordan Parliament. Dr Enis Baris is a senior public health specialist in the Europe and Central Asia Region of the World Bank. He is responsible for health projects in Azerbaijan, Bulgaria and Turkey and worked extensively on health and development issues, including HIV/AIDS, tuberculosis and tobacco control, in East Asia. His technical work includes development research on HIV/AIDS, tuberculosis, indoor air pollution and lung health, as well as broader health-system development issues. He is also the editor and author of several books and peer-reviewed publications. Bjorn Ekman is a senior health economist in the World Bank s Middle East and Northern Africa Region. He is currently working on health financing and insurance reform in a number of countries in the MENA region. Prior to joining the World Bank, Bjorn Ekman was a researcher at Lund University. His research is primarily focused on health financing and systems reform in low- and middle-income countries, and on the economics of maternal and child health. He has published extensively on these topics in various international academic journals. Dr Jonathan Betz Brown is the vice president of the International Diabetes Federation, where he has for many years chaired the Task Force on Health Economics, which is completing studies of the financial and social impact of type 2 diabetes in Africa (5 countries), China (14 regions), Kazakhstan, and Central America (5 countries). Previously he was a senior investigator at the Kaiser Permanente Center for Health Research in Portland, where he published widely on the economics, epidemiology and management of complex chronic health conditions. Professor Alireza Esteghamati is currently a member of the National Committee for Diabetes in Iran and is a nationally recognised physician and researcher in the field of endocrinology and diabetes. He had been past director general of the educational development centre and head of national medical societies in the Ministry of Health in Iran. Professor Esteghamati is a member of numerous local organisations including the Board of Directors of the Iran Endocrine Society and the Board of Directors of the Iranian Society of Internal Medicine. Professor Dr Ibrahim Salti is a Professor of Medicine and Head of the Division of Endocrinology and Metabolism at the American University of Beirut in Lebanon. His academic research interests lay within diabetes and dyslipidemia, and he has published extensively in these areas in various international journals. Professor Dr Salti s specialisation is in endocrinology and he has a fellowship and board certification of Internal Medicine from the Royal College of Physicians of Canada. Professor Riad Sulimani is a professor of medicine and consultant endocrinologist at the College of Medicine, King Saud University, in Riyadh in Saudi Arabia. He is also president of the Saudi Osteoporosis Society, chairman of the Scientific Committee for Adult Endocrinology and Metabolism and head of the Research Committee at the Security Forces Hospital. He has also published extensively, and his scientific and academic interests are in osteoporosis, thyroid disease and diabetes. Professor Dr Kamal Al-Shoumer is an associate professor of medicine and clinical endocrinology at the Department of medicine and Clinical Endocrinology at the Department of Medicine at Kuwait University. He is also a Senior Consultant and Head of the Division of Endocrinology & Metabolic Medicine at Mubarak Al-Kabeer Hospital in Kuwait. He has published widely in both international journals and textbooks within the fields of endocrinology and diabetes and is an editorial board member of several international journals. Professor Sherif Hafez is Professor of internal medicine, Faculty of Medicine Cairo University, he is a Consultant Endocrinologist and Dialectologist at Cairo university Hospital and Asalam International Hospital in Cairo. He chaired the Pan Arab Conference for ten years from 2001 until now and he is a member of various international societies within Diabetes such as EASD and Vice President of Mediterranean Group for the Study of Diabetes (MGSD). Professor Mohamed Belhadj Professor Mohamed Belhadj is Head of the Department of Internal Medicine and Diabetology at EHU (Établissements Hospitaliers Universitaires) in Oran, Algeria. He is also president of the Diabetes National Committee and the Algerian society of Internal Medicine. Professor Mohamed Belhadj is the president and a founding member of Réseau Diabéte Oranie and was previously the vice president of the Mediterranean Group for the Study of Diabtes. He is also a member of the board of directors for ALFEDIAM (SFD) which arims to promote scietific excellence in diabetes

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22 The Middle East and Northern Africa (MENA) Diabetes Leadership Forum will be held on December 2010 in Dubai, United Arab Emirates. It is co-hosted by the UAE Ministry of Health, the executive board of the Health Ministers Council for GCC States (GCC), the World Bank Group (MENA region) and the World Diabetes Foundation. It will be co-organised and sponsored by Novo Nordisk, and supported by the International Diabetes Federation, the Gulf Group for the Study of Diabetes, the Emirates Diabetes Society, the MENA health Policy forum, the Health Authority Abu Dhabi (HAAD), the Joslin Diabetes Center, the Steno Diabetes Center and the Sheik Hamdan Bin Rashid Al Maktoum Award for Medical Sciences. The Middle East and Northern Africa (MENA) region faces major problems from the growth of diabetes and other non-communicable diseases (NCDs). This Forum is an initiative to generate wider awareness of diabetes and other NCDs in the MENA region. The Forum also aims to share knowledge, understanding and practical advice for improving diabetes care, and measures to improve the availability and affordability of diabetes products. The Forum is bringing together representatives from: government; national, regional and international organisations; professional and patient associations; healthcare professionals; research and academic institutes; think tanks; foundations; business; NGOs and the media. It will examine the current state of diabetes and its care in the MENA region, as well as the impact of diabetes in terms of both personal suffering and national economic burden. It is also an opportunity to share examples of best practice initiatives that are really working to improve diabetes care and to define the priorities for changing diabetes in the Middle East and Northern Africa. Novo Nordisk is a global healthcare company with 88 years of innovation and leadership in diabetes care. The company also has leading positions within haemophilia care, growth hormone therapy and hormone replacement therapy. Headquartered in Denmark, Novo Nordisk employs over 30,000 employees in 76 countries, and markets its products in 179 countries. Novo Nordisk s B shares are listed on the NASDAQ OMX Copenhagen (Novo-B). Its ADRs are listed on the New York Stock Exchange (NVO). For more information, visit novonordisk.com