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Diabetes Mellitus in Egypt Prof. Samir Helmy Assaad Khalil Unit of Diabetes

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Title: Diabetes Mellitus in Egypt Prof. Samir Helmy Assaad Khalil Unit of Diabetes


1
Diabetes Mellitus in Egypt Prof. Samir Helmy
Assaad Khalil Unit of Diabetes
Metabolic Diseases Alexandria Faculty
of Medicine
2006
2
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

3
Population Doubling Time in Some Mediterranean
Countries
400
N
E
S
300
Years
200
100
0
ES
F
I
G
M
IL
T
ET
L
AG
Y
4
Current Age Demographics in Egypt
5
Age Demographics in Egypt 2050
6
Urbanization in Some Mediterranean Countries
N
E
S
100
80
60

40
20
0
ES
F
I
G
M
IL
T
ET
L
AG
Y
7
Gross National Product Per Capita in Some
Mediterranean Countries
N
E
S
20
15
1000
10
5
0
ES
F
I
G
M
IL
T
ET
L
AG
Y
8
Egypt will face explosive growth of diabetes
Due to a rapidly increasing ageing population,
Egypt will have the largest number of people with
diabetes in the region by 2025
Source Diabetes Atlas, 2nd edition, IDF
9
Prevalence of Diabetes in Egypt (Above the age
of 20 yrs)
Ali et al, 1995
Arab et al, 1992
Whole Egypt
Whole Egypt
9.3
6.29
Rural
Rural Agriculture
4.9
4.76
Urban (Low)
Rural Desert
13.5
1.58
Urban (High)
Urban
20.0
8.93
0
5
10
15
20
25
0
5
10
15
20
25
Percent Population ()
Percent Population ()
10
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
11
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
12
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!!!

13
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)
14
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

15
We Should Empower Subjects With Diabetes to Be
More Active in the Management of their
DiseaseWhat is the situation in Egypt
Distribution of Diabetic Patients According to
their Activities in Seeking Medical Care
Total (n1000)
NHI (n400)
HI (n600)
p



Regular follow up visits
77.8
50.0
96.3
lt0.001
Accessibility to Clinic
86.1
77.3
92.0
lt0.001
Adherence to Diet Regimen
64.3
51.5
72.8
lt0.001
Regular Use of Drugs
88.6
84.9
94.3
lt0.001
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
lt0.001
Never Smoking
69.4
79.8
62.5
lt0.001
HI Health insured NHI Non Health insured
SMBG Self monitoring of blood glucose
16
Therapeutic Patient Education is a Crucial
Component of Health CareWhat is the situation in
Egypt
Distribution of Diabetic Patients According to
their Health Information and Educational
Intervention
Total (n1000)
NHI (n400)
HI (n600)
p



Having information about
Correct diet
82.5
82.3
82.7
0.865
SMBG
16.1
10.3
20.0
lt0.001
Dealing with hypoglycaemia
77.4
70.5
82.0
lt0.001
Foot care
75.7
65.5
82.5
lt0.001
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
lt0.001
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)
17
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)

18
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 MF ratio of 11.3

19
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

20
Diabetes in Egypt
Direct Cost of Diabetes in Egypt (March 1988)
50 / year 60 / year 60 /year 60
/ year 70 / year 70 / year 110 /
year 115 / year 160 / year 500 / year
  • Skin infection
  • Neuritis
  • Broncho-pulmonary infection
  • UT infection
  • Eye problems
  • Rheumatism
  • IHD
  • Foot problems
  • HF
  • Dialysis

Arab et al. 1988
21
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

22
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
23
Distribution of Subjects with Type 2 DM by the
type of Treatment in 1995 2005
1
2
Oral Therapy Insulin (Combination)
Diet Regimen Alone
Oral therapy Alone
Isulin Alone
1 Alexandria University, Alexandria, Egypt
Mario Negri Institute , Milan, Italy Survey
1995 2 Data derived from the IMS medical audit
2005
24
Types of Insulin Used in the Egyptian Market
Type of Insulin
IMS medical audit
25
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.

26
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
27
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
28
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
29
OPPORTUNITIES
  • Great social expectation regarding reforms in the
    area
  • Social awareness of the urgency of the reforms

30
STRENGHTS
  • Health care for all
  • Health centres network all over the country

31
THREATS
  • Financial crisis
  • Progressively unmotivated health-professionals

32
WEAKNESSES
  • Excessively central and bureaucratic Public
    Administration
  • Poorly developed information, communication and
    evaluation systems

e
33
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.
34
Random blood glucose testing
Patients community awareness days
Nurses training (Lectures)
Nurses training (Practical class)
35
Camps for children with diabetes
36
Education film for children with diabetes (Jinns
party)
37
The Video Film The Diabetes Jinns 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.

38
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.

39
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.

40
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

41
Mean percent of total scores
of subjects with diabetes
for knowledge, skills and attitudes
before intervention, immediately following it and
3 months later
10
26
9
31
14
13
Score ()
20
41
45
42
Mean HbA1c () one year before and one year
after the educational intervention
2.22
HbA1c ()
1.15
P lt 0.001
43
Mean duration of hospitalization
(days/patient/year) one year before and one
year after the educational intervention
6.53
Hospitalization (d/pt/y)
3.10
P lt 0.001
44
Mean duration of absenteeism (days/patient/year)
one year before and one year after the
educational intervention
12.67
Absenteeism (d/pt/y)
5.82
P lt 0.001
45
Frequency of ketosis (requiring hospitalization)
one year before and one year after the
educational intervention
1.52
Ketosis (times/pt/y)
0.62
P lt 0.001
46
Frequency of severe hypoglycaemic episodes one
year before and one year after the educational
intervention
0.65
Severe hypoglycaemia (episodes/pt/y)
0.09
P 0.001
47
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.

48
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.

49
Thank You
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