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1 DECLARATION OF CONFLICT OF INTEREST none

2 Hypertension and Type 2 Diabetes in The Arab Countries M B BDEIR, MD Director, Cardiac Clinics King Abdulaziz Cardiac Centre, National Guard Health Affairs Riyadh, Saudi Arabia European Society of Cardiology Paris, France 30 August 2011

3

4 CHANGE AND RISK Socioeconomic/cultural change: Globalization Urbanization Aging Poverty Stress Behavioral risk factors: 80% CVD Unhealthy diet Physical inactivity Tobacco use Metabolic changes: Hypertension Dyslipidemia Diabetes mellitus Obesity World Health Organization (WHO), 2011.

5 Globalization

6 Arab countries Socioeconomic / cultural change: - Globalization - Urbanization - Average age years lower than developed countries Mean age of first AMI 10 years lower compared to other regions of the world World Health Organization (WHO), INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case- control study. Lancet. 2004;364:

7 Arab countries CVD is the leading cause of death - 45% Share similar cultural and ethnic backgrounds Variation in the patterns of CVD: - Varying degrees of affluence - Risk factor distribution Cardiovascular Disease in the Asia Middle East Region: Global Trends and Local Implications Tarik M. Ramahi; Asia Pac J Public Health : 83S

8 Eastern Mediterranean & North Africa Limited reliable data on CVD Few countries with quality information on healthcare Intractable political and military conflicts Increasing socioeconomic turmoil, poverty, and instability Cardiovascular Disease in the Asia Middle East Region: Global Trends and Local Implications Tarik M. Ramahi; Asia Pac J Public Health : 83S

9 Arab Gulf States: Countries in Transition Rapid modernization and socioeconomic development Transformed from nomadic existence to an affluent welfare society over 4 decades Reliable data recently available Cardiovascular Disease in the Asia Middle East Region: Global Trends and Local Implications Tarik M. Ramahi; Asia Pac J Public Health : 83S

10 k Global and regional food consumption Transition Countries Kcal per capita per day Per Capita Industrialized Countries World Developing Countries Years Food balance data (FAOUN), GNP data from the world bank

11 Highest BMI Countries 1- Nauru 2- American Samoa 3- Tokelau 4- Tonga 5- Kiribati 6- French Polynesia 7- Saudi Arabia 8- Panama 9- USA 10- UAE 11- Egypt 12- Bahrain 13- Kuwait World Health Organization (WHO) Regional Office for the Eastern Mediterranean (EMRO), 2010

12 DISEASE PATTERNS IN SAUDI ARABIA OVER 100 YEARS Cummunicable diseases Non-comunicable diseases Diabetes Mellitus Obesity Hypertension Hyperlipidemia (HT) Saudi medical journal 1992, vol. 13, n o 6, pp ; (HT) Eastern Mediterranean Health J Vol2, 2, 1996, (HT) Saudi Med J Jan;28(1):77-84.; (HT) Annals of Saudi Medicine, Vol 18, No 5, 1998(; HL) Saudi Med J Feb;29(2):282-7 (OB) Int J Obes Relat Metab Disord 1996, 20: ;2; (OB) Journal of Community Health Vol 22, No,

13 Prevalence of Hypertension 29% in the Eastern Mediterranean Region Complications increasing Stroke IHD End-stage renal disease Heart failure World Health Organization (WHO) Regional Office for the Eastern Mediterranean (EMRO), 2010.

14 Hypertension: Undetected - Undertreated Saudi Arabia National Survey: 17,230 Known HTN: 75% Undertreated - BP >140/90 No history HTN: 66.9% Undetected - BP>140/90 Saudi Med J 2007; Vol. 28 (1): 77-84

15 Hypertension: Undetected - Undertreated Self-reported normotensives (640): 33% Undetected Self-reported hypertensive (349): 76% Undertreated BMC Cardiovascular Disorders 2006, 6:24

16 Saudi Med J 2007; Vol. 28 (1): Prevalence of CAD, MS and DM Among Hypertensive And Normotensive Subjects P<0.001 Hypertensive Normotensive P<0.001 P<0.001

17 Diabetes Epidemiology in the Gulf DM is the most serious medical problem in the Arab world Growing pandemic in Gulf states

18 DIABETES IN GULF STATES

19 DM PREVALENCE Top 10 Countries in Prevalence of Diabetes* (20-79 Age Group) Country Prevalence (%) Prevalence (%) 1 Nauru United Arab Emirates Saudi Arabia Bahrain Kuwait Oman Tonga Mauritius Egypt Mexico International Diabetes Federation

20 Prevalence of DM in Saudi Arabia National Survey: 16, /16917 diabetics 1116/4004 unaware of diabetes (27.9%) Non Diabetic DM+ IFG: prevalence 37.8% Saudi Med J 2004; Vol. 25 (11):

21 Prevalence of DM / IFG in Saudi Arabia by Age >50 yrs: 50% DM / Pre DM 49.5% 51.4% 38.0% 15.7% 14.9% 24.2% 15.0% IFG DM 12.1% 33.8% 36.5% 23.0% 12.1% Age (years)

22 DM Complications in Gulf States Leading Cause of: Blindness ESRF IHD CVA Amputation

23 DM Complications in Gulf States One third of diabetics are affected by retinopathy and ~10% are blind One third of diabetics are suffering from nephropathy and ~1% are on dialysis One quarter of the diabetic population are suffering from ischemic heart disease >10% of total number of diabetics in the Gulf states are dying every year

24 All cause mortality attributable to DM 2010 MENA Region International Diabetes Federation 2010 >200,000 Death annually

25 CAUSES OF DEATH Patients with DM in Gulf States (age>20 years) AMI 18% SCD 6% Cancer 6% Others 6% CVA 17% IHD 47% WHO 2009

26 Standards of DM Care ACHIEVABLE AND SUSTAINABLE Prevention: education, promote healthy lifestyle Early detection: education, screening Good control: education, Rx, lifestyle counseling, enhance adherence Access to care: primary health care clinics International Diabetes Federation 2010

27 MENA Action Plan 1. Establish & maintain country-specific data on the prevalence, burden & economic cost of DM International Diabetes Federation 2010

28 MENA Action Plan 2. Prioritize DM within national healthcare framework There is one reason people fail to reach their goals they never take the first steps International Diabetes Federation 2010

29 MENA Action Plan 3. Drive greater collaboration between all parties involved with DM International Diabetes Federation 2010

30 MENA Action Plan 4. Improve disease awareness and education for people with/at risk of DM, healthcare professionals & community International Diabetes Federation 2010

31 MENA Action Plan 5. Strengthen the role of primary care in DM management through multidisciplinary team International Diabetes Federation 2010

32 MENA Action Plan 6. Deliver tailored care for specific populations International Diabetes Federation 2010

33 MENA Action Plan 7. Undertake monitoring and evaluation of National DM Programs International Diabetes Federation 2010

34 HTN/DM in Arab countries: Who is Responsible?

35 HTN/DM in Arab countries: Who is Responsible?

36 HTN/DM in Arab countries: Who is Responsible?

37 HTN/DM in Arab countries: Who is Responsible?

38 HTN/DM in Arab countries: Who is Responsible?

39 Poly Client Challenge Poly co-morbidities Poly-pharmacy Poly-side effects Poly-healthcare providers Poly-clinics Poly-labs/ investigations END RESULT Poly-confusion

40 Reasons for Non-adherence Forgetfulness Drug side effect Drug holiday Drug dependency Feeling well Medication not helping feel better Irregularity of f/u Lack of health education Unaware of chronicity of disease EMHJ, Vol 17, No 4,2011

41 Cultural Factors and Patients' Adherence to Data from 334 Kuwaiti adult males and females Lifestyle Measures Inclusion criteria: HTN, DM, or both Completed a routine visit in a family practice center Br J Gen Pract April 1; 57(537):

42 Cultural Factors and Patients' Adherence to Lifestyle Measures Not adhering to any diet regimen: 63.5% Barriers: Traditional Kuwaiti food (79.9%) High consumption of fast food (59.6%) High frequency of social gatherings (54.5%) Unwillingness (48.6%) Difficult to have food different from family (30.2%) Br J Gen Pract April 1; 57(537):

43 Cultural Factors and Patients' Adherence to Lifestyle Measures Not participating in regular exercise: 64.4% Barriers Excessive use of cars (83.8%) Household help (54.1%) Lack of time (39.0%) Coexisting diseases (35.6%) Adverse weather conditions (27.8%) Br J Gen Pract April 1; 57(537):

44 MORBIDITY & MORTALITY HIGH PREVALENCE HTN / DM in Arab countries UNDETECTED OTHER RISK FACTORS UNDER TREATED

45 CONCLUSION Response not proportional to this tsunami National Diabetes Program Promote culture of exercise Implement a health curriculum into all primary and secondary schools Create abbreviated training program for health care providers

46 THANK YOU

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