Diabetes Mellitus in Egypt Prof. Samir Helmy Assaad Khalil by plu17302

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									Diabetes Mellitus in Egypt
     Prof. Samir Helmy Assaad Khalil
       Unit of Diabetes & Metabolic Diseases
          Alexandria Faculty of Medicine




                     2006
Agenda
•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
• Conclusion
Population Doubling Time in
Some Mediterranean Countries



         400
                            N                E            S
         300
 Years




         200



     100


          0
               ES   F   I   G   M   Y   IL       T   ET   L   AG
Current Age
Demographics in Egypt
Age Demographics in
Egypt 2050
Urbanization in Some Mediterranean
             Countries


    100                N                E            S
    80


    60
%




    40



    20


     0
          ES   F   I   G   M   Y   IL       T   ET   L   AG
    Gross National Product Per Capita in
      Some Mediterranean Countries

                           N                E            S
         20


         15
1000 $




         10



         5


         0
              ES   F   I   G   M   Y   IL       T   ET   L   AG
Egypt will face explosive growth
of diabetes

                                           9,000
                                                                          Due to a rapidly increasing & ageing
                                                                          population, Egypt will have the largest
                                                                          number of people with diabetes in the
                                           8,000
Source: Diabetes Atlas, 2nd edition, IDF




                                           7,000
                                                                          region by 2025       2003
                                           6,000                                                                             2025

                                           5,000

                                           4,000

                                           3,000

                                           2,000

                                           1,000

                                              0

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   Prevalence of Diabetes in Egypt
   (Above the age of 20 yrs)


            Ali et al, 1995                                            Arab et al, 1992

Whole                                                        Whole
Egypt                        9.3                             Egypt                6.29


Rural             4.9                              Rural Agriculture           4.76


Urban
                               13.5                    Rural Desert       1.58
(Low)

Urban
                                       20.0                  Urban                     8.93
(High)



        0     5         10     15     20      25                      0    5      10      15   20   25

             Percent Population (%)                                       Percent 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 University
Social Impact of
Modernization/ Westernization

   Unemployment
   Machine driven jobs
   Higher tech, computers, tv, dvd
   Lower quality foods
   Loss of traditional nutritious diets
   Loss of places for children to play

           Gigi El-Bayoumi, George Washington University
Mc….. Giant Meals

   A popular and
    usual order is a
    Mc….. Big Extra
    with Cheese,
    super-sized soft
    drink and fries
    with 1805 calories
    and 84 grams of
    fat!!!
  Prevalence of Sedentary Life &
         Obesity in Egypt
Prevalence of sedentary lifestyle & obesity in the Egyptian population
aged ≥ 20 years by residence and socio-economic status (1992-1994)

      Residence &                  Prevalence of Sedentary   Prevalence of Obesity
      Socio- economic                       Lifestyle                 (%)
         Status                              (%)


          Rural                            52                      16
          Urban (Lower SES)                73                      37
          Urban (Higher SES)               89                      49
          Total                            63                      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 to Be
 More Active in the Management of their Disease
                      What is the situation in Egypt
Distribution of Diabetic Patients According to their Activities in
                     Seeking Medical Care
                                  Total (n=1000)       NHI (n=400)        HI (n=600)
                                                                                            p
                                          %                %                 %

Regular follow up visits                77.8               50.0             96.3         <0.001
Accessibility to Clinic                  86.1              77.3             92.0         <0.001
Adherence to Diet Regimen                64.3              51.5             72.8         <0.001
Regular Use of Drugs                     88.6              84.9             94.3         <0.001
SMBG                                     7.8                6.5              8.7         0.211
Testing of Glucosuria at Home            26.2              24.5             27.3         0.318
Light or Moderate Physical Activity      65.2              49.2             75.8         <0.001
Never Smoking                            69.4              79.8             62.5         <0.001

   HI: Health insured; NHI: Non Health insured; SMBG: Self monitoring of blood glucose
   Therapeutic Patient Education is a Crucial
          Component of Health Care
        What is the situation in Egypt
   Distribution of Diabetic Patients According to their Health
           Information and Educational Intervention
                                       Total (n=1000)          NHI (n=400)              HI (n=600)
                                                                                                        p
                                               %                    %                     %

Having information about:
  Correct diet                                82.5                  82.3                 82.7         0.865
  SMBG                                        16.1                  10.3                 20.0        <0.001
  Dealing with hypoglycaemia                  77.4                  70.5                 82.0        <0.001
  Foot care                                   75.7                  65.5                 82.5        <0.001
  Self management of insulin *                56.7                  49.6                 62.1         0.041

Main source of information:
  Education meeting/Health news               14.6                  17.9                 12.3        0.280
  Physician                                   82.1                  78.8                 84.3
  Nurse                                        3.3                   3.3                  3.3
Frequency of health education:
   Never                                     31.9                  54.3                  17.0        <0.001
   Occasional/regular                        68.1                  45.7                  83.0
  HI: 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)
 Diabetes in Egypt



Alexandria University Survey, 1995-2002


  •   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
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 %
Diabetes in Egypt
     Direct Cost of Diabetes in Egypt
              (March 1988)
  Skin infection                 50   $ / year
  Neuritis                       60   $ / year
  Broncho-pulmonary infection    60   $ /year
  UT infection                   60   $ / year
  Eye problems                   70   $ / year
  Rheumatism                     70   $ / year
  IHD                           110   $ / year
  Foot problems                 115   $ / year
  HF                            160   $ / year
  Dialysis                      500   $ / 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
About 10% of the healthcare budget
will be spend on diabetes by 2025

Predictions of the future
costs* of DM as % of total
healthcare expenditure by
region, 2025




       lower estimate
       higher estimate




 *Direct costs only
  Distribution of Subjects with Type 2 DM by
  the type of Treatment in 1995 & 2005

      90%                  88%
      80%                          76%

      70%

      60%                                                                                        1
                                                                                          1995
      50%                                                                                        2
      40%                                                                                 2005
      30%

      20%                                                     13%
                                                10%      9%
      10%    1.10% 1.00%                   2%
       0%




1 Alexandria University, Alexandria, Egypt – Mario Negri Institute , Milan, Italy Survey 1995
2 Data derived from the IMS medical audit 2005
                  Types of Insulin Used in the
                  Egyptian Market
                   Short acting      Intermidiate      Premix    Analogues

            100%
             90%
             80%
Type of Insulin




             70%
             60%
             50%
             40%
             30%
             20%
             10%
              0%
                       1998       1999   2000   2001     2002   2003   2004   2005


       IMS medical audit
                  The Problem
   In Egypt, as in most developing countries, special situations
constitute a barrier for achieving therapeutic targets among which:

  •    Illiteracy in more than 40% of the population (in
      females more than 50%).
  •    Myths & misconcepts about health & disease.
  •   Low income.
  •   Limited resources.
  •   Poor distribution of available material & lack of
      maintenance.

  •   Socio-cultural barriers.
     Myths & Misconceptions among
     persons with Diabetes in Egypt

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
OPPORTUNITIES

 Great social expectation regarding reforms
  in the area
 Social awareness of the urgency of the
  reforms
STRENGHTS

 Health care for all
 Health centres network all over the country
THREATS

 Financial crisis
 Progressively unmotivated health-
  professionals
WEAKNESSES

 Excessively central and bureaucratic
  Public Administration
 Poorly developed information,
                      e
  communication and evaluation systems
Regional Meeting for CME (Alexandria,
         Summer Congress)


                               “The Delta Project” A large scale educational
                               program started in 2003 in collaboration with
                               the University of Virginia USA.
                               The Target: education of 2500 general
                               practitioners from different geographical
                               areas of Egypt.
Patients & community awareness days   Random blood glucose testing




     Nurses training (Lectures)       Nurses training (Practical class)
Camps for children with diabetes
Education film for children with diabetes (Jinn’s party)
        The Video Film
  “The Diabetes Jinn’s Party”

• Prepared to fulfill the local needs within the
  frame of the DESG-EASD educational
  guidelines.

• Preceded by a survey on the needs,
  situation and problems of the target
  population.
         The Video Film
• Describes in 60 minutes the story of a
  teenager with type 1 diabetes who had the
  visit of nice Jinnies in his dream.

• These Jinnies discuss with him the basic
  knowledge      about    diabetes,    local
  misconcepts, demonstrate the skills and
  practices needed for the management and
  discuss his attitudes towards the disease
  and its management.
Examples of the situation before the
intervention project derived from the pre-
project survey (1997)


• Less than 2% of subjects with diabetes or their
  parents attended any educational activity outside
  the consultation setting.
• 82% of subjects believed that their disease is
  temporary.
• 56% could not recognize or diagnose ketosis.
• 52% did not know how to adjust insulin dosage.
• 52% never changed the site of injection.
 Examples of the situation before the
 intervention project derived from the
       pre-project survey (1997)

• 56% never knew about foot care.
• 98% stated that their disease is a
  barrier against their success.

• 46% stated that control of diabetes is
  deprivation from good life
                   Mean percent of total scores
                     of subjects with diabetes
                for knowledge, skills and attitudes
            before intervention, immediately following
                       it and 3 months later
            130

            120

            110
                       10
            100                                  26
                               9                             31       14
                                         13
Score (%)




            90
                                                                           Pre Test
            80                                                             Immediate Post Test
                  20                                                       Remote Post Test
            70              81                   84                   81
            60
                       89          41
                                         77           45     81
            50

            40
                  57               45                 42
            30
                   Knowledge            Skills             Attitude
    Mean HbA1c (%) one year
        before and one year
after the educational intervention

               13
               12
   HbA1c (%)




                    2.22          1 year before the
               11                 intervention
                                  1 year after it
               10
                           1.15
                9
                    9.72
                8
                7          7.75   P < 0.001
                6
Mean duration of hospitalization
 (days/patient/year) one year
 before and one year after the
   educational intervention
                  8
                  7   6.53
Hospitalization




                  6                  1 year before
   (d/pt/y)




                                     the intervention
                  5                  1 year after it
                             3.10
                  4   5.35
                  3
                  2
                  1          2.52   P < 0.001
                  0
   Mean duration of absenteeism
(days/patient/year) one year before
 and one year after the educational
           intervention

                   12.67
              19
Absenteeism




              17
  (d/pt/y)




                                  1 year before the
              15                  intervention
                                  1 year after it
              13   16.5
              11           5.82
               9
               7                  P < 0.001
                           7.43
               5
    Frequency of ketosis (requiring
hospitalization) one year before and one
 year after the educational intervention


                     2
                   1.8
                   1.6
                   1.4                 1 year before
    (times/pt/y)




                         1.52          the intervention
       Ketosis




                   1.2                 1 year after it
                     1
                   0.8
                                0.62
                   0.6
                   0.4   0.90          P < 0.001
                   0.2
                                0.28
                     0
    Frequency of severe hypoglycaemic
episodes one year before and one year after
       the educational intervention


                   1.4
                   1.2   0.65
 hypoglycaemia
 (episodes/pt/y)




                                         1 year before the
                    1                    intervention
                                         1 year after it
     Severe




                   0.8
                   0.6
                         0.85
                   0.4          0.09
                   0.2                 P = 0.001
                                0.12
                    0
         The Outcome

• This beneficial outcome is due to the fact
  that intervention has been especially
  designed and tailored to the target
  population. A population with rather poor
  resources, high illiteracy and special cultural
  background.
Conclusion



• 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.
Thank You

								
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