diabetes mellitus in egypt
Post on 13-Feb-2017
234 Views
Preview:
TRANSCRIPT
Diabetes Mellitus in EgyptDiabetes Mellitus in Egypt Prof. Samir Helmy Assaad KhalilProf. Samir Helmy Assaad Khalil
Unit of Diabetes & Metabolic Diseases Unit of Diabetes & Metabolic Diseases Alexandria Faculty of Medicine Alexandria Faculty of Medicine
20062006
AgendaAgenda •Some demographic & socio-economic data
• Prevalence of Diabetes
• Mechanisms for the increased burden of diabetes
• The impact on morbidity
• The economic impact
• The Trend of Care, Education & Management of DM
• Myths & Misconceptions
• Planning Strategies
•Success stories
• ConclusionConclusion
Population Doubling Time in Population Doubling Time in Some Mediterranean CountriesSome Mediterranean Countries
ESES FF II GG MM ILIL TT ETET LL AGAG00
100100
200200
300300
400400
Year
sYe
ars
NN EE SS
YY
Urbanization in Some Mediterranean Urbanization in Some Mediterranean CountriesCountries
ESES FF II GG MM ILIL TT ETET LL AGAG00
2020
4040
6060
8080
%%
NN EE SS
YY
100100
Gross National Product Per Capita in Gross National Product Per Capita in Some Mediterranean CountriesSome Mediterranean Countries
ESES FF II GG MM ILIL TT ETET LL AGAG00
55
1010
1515
2020
1000
$10
00 $
NN EE SS
YY
Egypt will face explosive growth of diabetes
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
Egypt Ira
nIra
q
Saudi
Arabia
Algeria
Morocc
oSyri
a
Sudan
UAE
Tunisi
a
Jorda
n
Kuwait
Leba
non
Libya
Bahrai
n
2003
2025
Due to a rapidly increasing & ageing population, Egypt will have the largest number of people with diabetes in the region by 2025
Sour
ce: D
iabe
tes
Atla
s, 2
nd e
ditio
n, ID
F
Prevalence of Diabetes in Egypt Prevalence of Diabetes in Egypt (Above the age of 20 yrs)(Above the age of 20 yrs)
Whole Whole EgyptEgypt
RuralRural
Urban Urban (Low)(Low)
Urban Urban (High)(High)
00 55 1010 1515 2020 2525
20.020.0
13.513.5
4.94.9
9.39.3
Ali et al, 1995Ali et al, 1995
Percent PopulationPercent Population)%( )%(
Whole Whole EgyptEgypt
Rural AgricultureRural Agriculture
Rural DesertRural Desert
UrbanUrban
00 55 1010 1515 2020 2525
8.938.93
1.581.58
4.764.76
6.296.29
Arab et al, 1992Arab et al, 1992
Percent PopulationPercent Population)%( )%(
The increasing burden of diabetes
• Factors driving a rapid increase of the burden of diabetes– Population growth– Ageing population – Rising prevalence of obesity
• Fast food• Inactivity / lack of exercise
Gigi El-Bayoumi, George Washington UniversityGigi El-Bayoumi, George Washington University
Social Impact of Social Impact of Modernization/ Modernization/ WesternizationWesternization UnemploymentUnemployment Machine driven jobsMachine driven jobs Higher tech, computers, tv, dvdHigher tech, computers, tv, dvd Lower quality foodsLower quality foods Loss of traditional nutritious dietsLoss of traditional nutritious diets Loss of places for children to play Loss of places for children to play
Gigi El-Bayoumi, George Washington UniversityGigi El-Bayoumi, George Washington University
Mc….. Giant MealsMc….. Giant Meals
A popular and A popular and usual order is a usual order is a McMc…..….. Big Extra Big Extra with Cheese, with Cheese, super-sized soft super-sized soft drink and fries drink and fries with 1805 with 1805 calories and 84 calories and 84 grams of fat!!!grams of fat!!!
Prevalence of Sedentary Life Prevalence of Sedentary Life & Obesity in Egypt& Obesity in Egypt
Prevalence of sedentary lifestyle & obesity in the Egyptian population aged ≥ 20 years by residence and socio-economic status )1992-1994(
Residence & Socio- economic
Status
Prevalence of Sedentary Lifestyle (%)
Prevalence of Obesity (%)
Rural Urban (Lower SES) Urban (Higher SES) Total
52 73
89 63
16 37 49 27
SES= Socio-economic status
Why is this so important?
• Because more and more people will suffer from:• Cardiovascular complications
– Nephropathy– Neuropathy– Amputations– Retinopathy
• Because we can improve this situation
We Should Empower Subjects With Diabetes We Should Empower Subjects With Diabetes to Be More Active in the Management of their to Be More Active in the Management of their
DiseaseDiseaseWhat is the situation in EgyptWhat is the situation in Egypt
Distribution of Diabetic Patients According to their Distribution of Diabetic Patients According to their Activities in Seeking Medical CareActivities in Seeking Medical Care
Total Total (n=1000)(n=1000)
%%
Regular follow up Regular follow up visitsvisitsAccessibility to Accessibility to ClinicClinicAdherence to Diet Adherence to Diet RegimenRegimenRegular Use of Regular Use of DrugsDrugs
77.877.8 50.050.0 96.396.386.186.1 77.377.3 92.092.0
64.364.3 51.551.5 72.872.8
88.688.6 84.984.9 94.394.3
HI: Health insured; NHI: Non Health insured; SMBG: Self monitoring of blood glucoseHI: Health insured; NHI: Non Health insured; SMBG: Self monitoring of blood glucose
NHI (n=400)NHI (n=400) HI (n=600)HI (n=600)pp
%% %%
SMBGSMBGTesting of Glucosuria at Testing of Glucosuria at HomeHomeLight or Moderate Physical Light or Moderate Physical ActivityActivityNever SmokingNever Smoking
7.87.8 6.56.5 8.78.726.226.2 24.524.5 27.327.3
65.265.2 49.249.2 75.875.8
69.469.4 79.879.8 62.562.5
<<0.0010.001
0.2110.211 0.3180.318
<<0.0010.001
<<0.0010.001
<<0.0010.001
<<0.0010.001
<<0.0010.001
Therapeutic Patient Education is a Therapeutic Patient Education is a Crucial Component of Health CareCrucial Component of Health Care
What is the situation in EgyptWhat is the situation in EgyptDistribution of Diabetic Patients According to their Distribution of Diabetic Patients According to their Health Information and Educational InterventionHealth Information and Educational Intervention
Total Total (n=1000)(n=1000)
%%
Correct dietCorrect dietSMBGSMBGDealing with Dealing with hypoglycaemiahypoglycaemia
Education meeting/Health Education meeting/Health newsnews
82.582.5 82.382.3 82.782.716.116.1 10.310.3 20.020.077.477.4 70.570.5 82.082.0
14.614.6 17.917.9 12.312.3
HI: Health insured; NHI: Non Health insured; SMBG: Self monitoring of blood glucoseHI: Health insured; NHI: Non Health insured; SMBG: Self monitoring of blood glucose* Only cases treated with insulin are considered (115 in NHI and 153 in HI)* Only cases treated with insulin are considered (115 in NHI and 153 in HI)
NHI (n=400)NHI (n=400) HI (n=600)HI (n=600)pp
%% %%
PhysiciaPhysiciannNurseNurse
NeverNeverOccasional/regularOccasional/regular
82.182.1 78.878.8 84.384.33.33.3 3.33.3 3.33.3
31.931.9 54.354.3 17.017.068.168.1 45.745.7 83.083.0
0.8650.865<<0.0010.001<<0.0010.001
0.2800.280
<<0.0010.001
Foot careFoot care 75.775.7 65.565.5 82.582.5 <<0.0010.001Self management of Self management of insulininsulin* * 56.756.7 49.649.6 62.162.1 0.0410.041
Having information Having information aboutabout::
Main source of Main source of informationinformation::
Frequency of health Frequency of health educationeducation::
• Joint work of the Alexandria Faculty of Medicine, Medical Research Institute, High Institute of Public Health, Alexandria University, Egypt and the Mario Negri Institute, Milan, Italy
• Initiated a regional population based diabetes registry in Alexandria (86129 patients)
Diabetes in Egypt
Alexandria University Survey, 1995-2002
• A subsample (3000) from registered cases were chosen proportionally, for the study of the demographic characteristics of patients and complications of diabetes mellitus
• Overall prevalence of DM in Alexandria was estimated to be 4.39% with a M:F ratio of 1:1.3
Diabetes in Egypt
Alexandria University Survey, 1995-2002
Alexandria / Milan Universities Survey (1995-2002)Complications & Survival Probabilities
The probability of surviving free from complications for 20 years in Alexandria among subjects with T2 DM:
For Neuropathy 30.5% For Nephropathy 66.8% For Retinopathy 44.6% For Cardiac Complications 77.9% For Diabetic Foot 71.5% For Other Complications 92.0%
Skin infectionNeuritisBroncho-pulmonary infectionUT infectionEye problemsRheumatismIHDFoot problemsHFDialysis
Diabetes in Egypt
Direct Cost of Diabetes in Egypt (March 1988)
50 $ / year 60 $ / year 60 $ /year 60 $ / year 70 $ / year 70 $ / year110 $ / year115 $ / year160 $ / year500 $ / year
Arab et al. 1988
Diabetes in Egypt
Indirect Cost of diabetes in Egypt (March 1988)
• Days of absenteeism 38.76 days/pt/year
• Cost of absenteeism 60 USD/pt/year
• Cost of morbidity, invalidity and mortality ?
Arab et al. 1988
Predictions of the future costs* of DM as % of total healthcare expenditure by region, 2025
lower estimate higher estimate
About 10% of the healthcare budget will be spend on diabetes by 2025
*Direct costs only
Distribution of Subjects with Type 2 DM by the type of Treatment in 1995 & 2005
1.10% 1.00%
88%76%
2%10% 9%
13%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1995
2005
Diet Regimen Alone
Oral therapy Alone
Isulin Alone
Oral Therapy +
Insulin )Combination(
1
2
1 Alexandria University, Alexandria, Egypt – Mario Negri Institute , Milan, Italy Survey 19952 Data derived from the IMS medical audit 2005
Types of Insulin Used in the Egyptian Market
0%10%20%30%40%50%60%70%80%90%
100%
1998 1999 2000 2001 2002 2003 2004 2005
Short acting Intermidiate Premix Analogues
Type
of I
nsul
in
IMS medical audit
• Illiteracy in more than 40% of the population )in Illiteracy in more than 40% of the population )in females more than 50%(. females more than 50%(. • Myths & misconcepts about health & disease.Myths & misconcepts about health & disease.• Low income.Low income.• Limited resources.Limited resources.• Poor distribution of available material & lack of Poor distribution of available material & lack of maintenance.maintenance.• Socio-cultural barriers.Socio-cultural barriers.
The ProblemThe ProblemIn Egypt, as in most developing countries, special situations In Egypt, as in most developing countries, special situations
constitute a barrier for achieving therapeutic targets among which:constitute a barrier for achieving therapeutic targets among which:
Diet • Water intake should be decreased when passing
large amounts of urine.• All carbohydrates should be removed from the
diet.• Honey is good for diabetes control.• Consuming bitter &/or salty foods buffers
hyperglycemia.
(WHO-EM/DIA/7-E/G) 1996
Myths & Misconceptions among persons with Diabetes in Egypt
Treatment• Medications in the form of insulin or oral agents
suppress pancreatic activity and cause habituation.
• Medications should be stopped during acute illness.
• Herbal therapy is more efficacious and safer than insulin or oral agents.
• Tablets are oral insulin.
(WHO-EM/DIA/7-E/G) 1996
Myths & Misconceptions among persons with Diabetes in Egypt
Insulin • Affects the eyes, the liver and the kidneys
adversely.
• Addictive (once insulin, always insulin).
• Not to be taken for fear of hypoglycemia.
• Insulin leads to pancreatic failure.
(WHO-EM/DIA/7-E/G) 1996
Myths & Misconceptions among persons with Diabetes in Egypt
OPPORTUNITIES
Great social expectation regarding reforms in the area
Social awareness of the urgency of the reforms
WEAKNESSES
Excessively central and bureaucratic Public Administration
Poorly developed information, communication and evaluation systems
e
Regional Meeting for CME )Alexandria, Summer Congress(
““The Delta Project” The Delta Project” A large scale educational A large scale educational program started in 2003 in collaboration with program started in 2003 in collaboration with the University of Virginia USAthe University of Virginia USA..
The Target: education of 2500 general The Target: education of 2500 general practitioners from different geographical practitioners from different geographical areas of Egyptareas of Egypt..
Nurses training )Lectures(
Random blood glucose testing
Nurses training )Practical class(
Patients & community awareness days
The Video FilmThe Video Film““The Diabetes Jinn’s Party”The Diabetes Jinn’s Party”
• Prepared to fulfill the local needs within the Prepared to fulfill the local needs within the frame of the frame of the DESG-EASDDESG-EASD educational educational guidelines.guidelines.
• Preceded by a survey on the needs, Preceded by a survey on the needs, situation and problems of the target situation and problems of the target population.population.
• Describes in 60 minutes the story of a Describes in 60 minutes the story of a teenager with type 1 diabetes who had the teenager with type 1 diabetes who had the visit of nice Jinnies in his dream.visit of nice Jinnies in his dream.
• These Jinnies discuss with him the basic These Jinnies discuss with him the basic knowledgeknowledge about diabetes, local about diabetes, local misconceptsmisconcepts, demonstrate the , demonstrate the skillsskills and and practicespractices needed for the management and needed for the management and discuss his discuss his attitudesattitudes towards the disease towards the disease and its management.and its management.
The Video FilmThe Video Film
• 56% could not recognize or diagnose ketosis.56% could not recognize or diagnose ketosis.• 52% did not know how to adjust insulin dosage.52% did not know how to adjust insulin dosage.
• 82% of subjects believed that their disease is 82% of subjects believed that their disease is temporary.temporary.
Examples of the situation before the Examples of the situation before the intervention project derived from the pre-intervention project derived from the pre-project survey )1997(project survey )1997(
• 52% never changed the site of injection.52% never changed the site of injection.
• Less than 2% of subjects with diabetes or their Less than 2% of subjects with diabetes or their parents attended any educational activity outside parents attended any educational activity outside the consultation setting.the consultation setting.
• 46% stated that control of diabetes is 46% stated that control of diabetes is deprivation from good lifedeprivation from good life
• 56% never knew about foot care.56% never knew about foot care.
• 98% stated that their disease is a 98% stated that their disease is a barrier against their success.barrier against their success.
Examples of the situation before the Examples of the situation before the intervention project derived from the intervention project derived from the
pre-project survey )1997(pre-project survey )1997(
Mean percent of total scores Mean percent of total scores of subjects with diabetes of subjects with diabetes
for knowledge, skills and for knowledge, skills and attitudes before intervention, attitudes before intervention,
immediately following it and 3 months immediately following it and 3 months laterlater
57 4245
89 8177818481
30
40
50
60
70
80
90
100
110
120
130
Knowledge Skills Attitude
Pre TestImmediate Post TestRemote Post Test20
109
41
1326
45
31 14
Scor
e )%
(
Mean HbA1c (%) one year Mean HbA1c (%) one year before and one year before and one year
after the educational interventionafter the educational intervention
9.72
7.756
78
910
1112
13
1 year before theintervention1 year after it
HbA
1c )%
( 2.22
1.15
P < 0.001
5.35
2.52012345678
1 year beforethe intervention1 year after it
Mean duration of hospitalization Mean duration of hospitalization (days/patient/year) one year (days/patient/year) one year before and one year after the before and one year after the
educational interventioneducational intervention
Hos
pita
lizat
ion
)d/p
t/y(
6.53
3.10
P < 0.001
16.5
7.43579
1113151719
1 year before theintervention1 year after it
Mean duration of absenteeism Mean duration of absenteeism (days/patient/year) one year before (days/patient/year) one year before
and one year after the educational and one year after the educational interventionintervention
Abs
ente
eism
)d/p
t/y(
12.67
5.82
P < 0.001
0.900.280
0.20.40.60.8
11.21.41.61.8
2
1 year beforethe intervention1 year after it
Frequency of ketosis (requiring Frequency of ketosis (requiring hospitalization) one year before and hospitalization) one year before and
one year after the educational one year after the educational interventionintervention
Ket
osis
)tim
es/p
t/y(
1.52
0.62
P < 0.001
0.85
0.1200.20.40.60.8
11.21.4
1 year before theintervention1 year after it
Frequency of severe hypoglycaemic Frequency of severe hypoglycaemic episodes one year before and one year episodes one year before and one year
after the educational interventionafter the educational interventionSe
vere
hy
pogl
ycae
mia
)epi
sode
s/pt
/y( 0.65
0.09
P = 0.001
• This beneficial outcome is due to the fact This beneficial outcome is due to the fact that intervention has been especially that intervention has been especially designed and tailored to the target designed and tailored to the target population. A population with rather poor population. A population with rather poor resources, high illiteracy and special cultural resources, high illiteracy and special cultural background.background.
The OutcomeThe Outcome
ConclusionConclusion
• Unified Protocols for Registries should be adopted to be able to compare the evolution of the Epidemiology of the disease across time and regions• Registries and surveys should aim at evaluating the prevalence of complications as well as the cost of the disease • There is a great need for multicentric controlled, studies to re-evaluate the efficacy of the different intervention strategies on long term basis.
top related