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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
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.
Globalization
Arab countries Socioeconomic / cultural change: - Globalization - Urbanization - Average age 10-15 years lower than developed countries Mean age of first AMI 10 years lower compared to other regions of the world World Health Organization (WHO), 2011. INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case- control study. Lancet. 2004;364:937-952.
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 2010 22: 83S
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 2010 22: 83S
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 2010 22: 83S
k 3600 3400 Global and regional food consumption Transition Countries Kcal per capita per day 3200 3000 2800 2600 2400 Per Capita Industrialized Countries World Developing Countries 2200 2000 1964-1966 1974-1976 1984-1986 1997-1999 2015 2030 Years Food balance data (FAOUN), GNP data from the world bank
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
DISEASE PATTERNS IN SAUDI ARABIA OVER 100 YEARS Cummunicable diseases Non-comunicable diseases Diabetes Mellitus Obesity Hypertension Hyperlipidemia 1898 1936 1975 1985 1995 2005 (HT) Saudi medical journal 1992, vol. 13, n o 6, pp. 548-551; (HT) Eastern Mediterranean Health J Vol2, 2, 1996, 211-218 (HT) Saudi Med J. 2007 Jan;28(1):77-84.; (HT) Annals of Saudi Medicine, Vol 18, No 5, 1998(; HL) Saudi Med J. 2008 Feb;29(2):282-7 (OB) Int J Obes Relat Metab Disord 1996, 20: 20. 547-5;2; (OB) Journal of Community Health Vol 22, No, 3. 1997
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.
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
Hypertension: Undetected - Undertreated Self-reported normotensives (640): 33% Undetected Self-reported hypertensive (349): 76% Undertreated BMC Cardiovascular Disorders 2006, 6:24
Saudi Med J 2007; Vol. 28 (1): 77-84 Prevalence of CAD, MS and DM Among Hypertensive And Normotensive Subjects P<0.001 Hypertensive Normotensive P<0.001 P<0.001
Diabetes Epidemiology in the Gulf DM is the most serious medical problem in the Arab world Growing pandemic in Gulf states
DIABETES IN GULF STATES
DM PREVALENCE Top 10 Countries in Prevalence of Diabetes* (20-79 Age Group) 2007 2025 Country Prevalence (%) Prevalence (%) 1 Nauru 30.7 32.3 2 United Arab Emirates 19.5 21.9 3 Saudi Arabia 16.7 18.4 4 Bahrain 15.2 17.0 5 Kuwait 14.4 16.4 6 Oman 13.1 15.2 7 Tonga 12.9 14.7 8 Mauritius 11.1 13.4 9 Egypt 11.0 13.4 10 Mexico 10.6 12.4 International Diabetes Federation
Prevalence of DM in Saudi Arabia National Survey: 16,917 4004/16917 diabetics 1116/4004 unaware of diabetes (27.9%) Non Diabetic DM+ IFG: prevalence 37.8% Saudi Med J 2004; Vol. 25 (11): 1603-1610
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% 30-39 40-49 50-59 60-70 Age (years)
DM Complications in Gulf States Leading Cause of: Blindness ESRF IHD CVA Amputation
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
All cause mortality attributable to DM 2010 MENA Region International Diabetes Federation 2010 >200,000 Death annually
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
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
MENA Action Plan 1. Establish & maintain country-specific data on the prevalence, burden & economic cost of DM International Diabetes Federation 2010
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
MENA Action Plan 3. Drive greater collaboration between all parties involved with DM International Diabetes Federation 2010
MENA Action Plan 4. Improve disease awareness and education for people with/at risk of DM, healthcare professionals & community International Diabetes Federation 2010
MENA Action Plan 5. Strengthen the role of primary care in DM management through multidisciplinary team International Diabetes Federation 2010
MENA Action Plan 6. Deliver tailored care for specific populations International Diabetes Federation 2010
MENA Action Plan 7. Undertake monitoring and evaluation of National DM Programs International Diabetes Federation 2010
HTN/DM in Arab countries: Who is Responsible?
HTN/DM in Arab countries: Who is Responsible?
HTN/DM in Arab countries: Who is Responsible?
HTN/DM in Arab countries: Who is Responsible?
HTN/DM in Arab countries: Who is Responsible?
Poly Client Challenge Poly co-morbidities Poly-pharmacy Poly-side effects Poly-healthcare providers Poly-clinics Poly-labs/ investigations END RESULT Poly-confusion
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
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. 2007 April 1; 57(537): 291 295
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. 2007 April 1; 57(537): 291 295
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. 2007 April 1; 57(537): 291 295
MORBIDITY & MORTALITY HIGH PREVALENCE HTN / DM in Arab countries UNDETECTED OTHER RISK FACTORS UNDER TREATED
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
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