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2006

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

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2006

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  1. Diabetes Mellitus in EgyptProf. Samir Helmy Assaad KhalilUnit 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 Y IL T ET L AG

  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 Y IL T ET L AG

  7. 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

  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 (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

  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 (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)

  17. 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

  18. 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

  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. Skin infection Neuritis Broncho-pulmonary infection UT infection Eye problems Rheumatism IHD Foot problems HF Dialysis 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 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) Oral therapy Alone Diet Regimen 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. Patients & community awareness days Random blood glucose testing Nurses training (Lectures) Nurses training (Practical class)

  35. Camps for children with diabetes

  36. Education film for children with diabetes (Jinn’s party)

  37. 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.

  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 < 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 < 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 < 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 < 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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