In the coming 35 years, 35 minutes, I'm going to cover the topic of diabetes in the MENA region, current and future trends. The agenda is going to include the definition of the MENA region, because we have different definitions and different literatures. So the IDF and the Global Burden of Diseases Study has a different prevention definition of the MENA region, and what is different about the MENA region so that we could compare them to the other IDF-defined regions. Then we are going to view what has changed in the past 20 or 30 years regarding the incidence, prevalence, and mortality of type 2 diabetes, type 1 diabetes, gestational diabetes, the prevalence of good glycemic control in the MENA region, and also the prevalence of diabetic complications, whether this is microvascular or microvascular complications. In the second part of the presentation, we are going to talk about the future of diabetes in the MENA region, and so we are going through the prevalence of the modifiable risk factors for having diabetes, the pre-diabetes, which are the future patients coming with diabetes, the suggested challenges, and the suggested recommendations to overcome the prevention of diabetes, and finally, the effect of the implementation of sound health policy on the diabetes prevention. Starting with what is defined as the MENA region, because we have two versions of the MENA region, one coming from the IDF and the other coming from the Global Burden of Diseases Study. So what about this study? This is called the Global Burden of Diseases, Injuries, and Risk Factors Study. It has studied more than 300 diseases, injuries, and risk factors in more than 200 countries. This was a systematic assessment of published available data on disease incidence, prevalence, and mortality, and the sources of the data included censuses, household surveys, vital statistics, disease registries, and health service use, with over 80,000 sources included in this analysis, including more than 30,000 reporting incidents, around 20,000 reporting prevalence, and about 20,000 reporting deaths. So this was the definition of the IDF, of the Global Burden of Diseases of the MENA region. They included 21 countries, and you can see the actual names of the countries included, but I'm highlighting Turkey, because actually, this is the main difference between the definition of the MENA region in the Global Burden of Diseases Study and the IDF, where in the Global Burden of Diseases Study, they include Turkey within the MENA region, and they exclude Pakistan, while the IDF includes Pakistan and excludes Turkey from their analysis. So actually, instead of talking about 21 countries, we are actually talking about 22 countries. 20 are fixed, and we have one interchangeable between the definition of Global Burden of Diseases and the IDF. Why are we having this presentation in the first place? What makes the MENA region different from other IDF-designed regions? So the MENA region has the highest proportion of patients with diabetes in all the IDF regions. They also have the highest percentage of diabetes-related deaths. They are the second highest expected increase in all the IDF regions, with an increase in the coming 20 years by 86%. One in three people living in diabetes in this region are actually undiagnosed. The second thing is what has changed in the past 20 or 30 years regarding prevalence, incidence, death rates, and that is related to type 2 diabetes. So the prevalence of type 2 diabetes has increased in all the countries in the MENA region, starting from 1990 and up to 2019. The Asian standardized rates actually increased in the past 30 years by 86%. The same happened for the incidence of type 2 diabetes. It increased in all the countries of the MENA region, with an Asian standardized rate increasing by 80% in the past 30 years. The highest increase, both in prevalence and incidence, in the past 30 years was reported from Egypt, Morocco, and Sudan. If you compare the reported prevalences now and then, in the year 1990, the highest prevalence of type 2 diabetes was reported from Qatar and Bahrain, and the lowest prevalence was reported from Egypt, while now in 2090, Bahrain still continued to have the highest prevalence of type 2 diabetes, but Yemen has the lowest reported prevalence of type 2 diabetes. Regarding the incidence, again in 1990, the highest incidence rate was also reported from Qatar and Bahrain, and the lowest was reported from Egypt, while Qatar and Bahrain still retains the highest reported incidence of type 2 diabetes. In 2090, the lowest rate was reported from Yemen. If you compare the MENA region versus the average global rate in 2090, in all countries of the MENA region, excluding Yemen and Turkey, the prevalence of type 2 diabetes is much higher than the average global rate, and again in the same year, the incidence of type 2 diabetes in all the countries of the MENA region, excluding Yemen, is also greater than the average global rate. If you talk about DALYs, DALYs refers to disability-adjusted life years, and it is the sum of years of life lost due to premature mortality, and years of life lived with disability. So you can see that in the past 30 years, DALYs attributed to type 2 diabetes have increased by 31%, and in the same year, the death rate reported from all the MENA countries was higher than the average global rate. Comparing the less common type of diabetes, which is the type 1 diabetes, and again, the data coming from the Global Burden of Disease, Global Burden of Disease Study, the actual numbers of patients diagnosed with type 1 diabetes increased in about 30 years by more than 300%, and the age-standardized prevalence increased in the same period by more than 90%. So actually, we are having a 92% increase in the age-standardized rate, and more than 300% increase in the actual numbers of reported type 1 diabetic patients, and we have more steep increase starting from the year 2014. The same happened for incidence. In the past 30 years, the incidence of type 2 diabetes, or new cases diagnosed with type 2 diabetes, yearly increased by about 190%, and the age-standardized rates increased by more than 80%. 84% increase in the age-standardized rates, and more than 190% increase in the total number of new cases diagnosed with type 1 diabetes, with a more steep increase starting from 2014. Actually, the highest reported age-standardized incidence and prevalence rates were reported from Saudi Arabia, Kuwait, and Emirates, while the lowest age-standardized incidence and prevalence rates were reported from Jordan, Afghanistan, and Sudan. For the mortality, mortality attributed to type 1 diabetes actually increased in the past 30 years by 44%. However, the age-standardized mortality rate actually decreased by 34%. For the DALYS attributed to type 1 diabetes, it has increased in the past 30 years by about 72%, but actually, the age-standardized rates of DALYS attributed to type 1 diabetes slightly decreased by 13%. A third type of diabetes, which is the gestational diabetes, this data doesn't come from the Global Burden of Diseases Study. This actually comes from a systematic review and meta-analysis that included more than 100 reports coming from 16 countries assigned to the MENA region. And actually, they found that the bold prevalence of gestational diabetes was as high as 13%. This is much higher compared to European countries, still higher than Asian countries, and only second to reports coming from sub-Saharan African countries. If we classify it according to the region and then to the country, starting by the region, the highest-weighted gestational diabetes prevalence comes from the Gulf countries, followed by North African countries, followed by Iran and Iraq, and the lowest prevalence was estimated from the Levant region countries. Actually, the highest gestational diabetes prevalence was reported from Qatar, with 21% bold estimate of gestational diabetes, and the lowest was reported from Jordan, with only 5% bold prevalence of gestational diabetes. Why are we having this such discrepancy between the lowest and the highest? Actually, this is attributed to two factors. The timing of the report, because reports of gestational diabetes prevalence coming from the year 2009 and before, it used to be low, but it used to increase after the year 2010, with 14%-plus prevalence of gestational diabetes. And the second factor is the diagnostic criteria used to define gestational diabetes. In all the reports that used the International Association of Diabetes and Pregnancy Study Group criteria, this reported a higher prevalence of gestational diabetes because the fasting plasma glucose criteria is much lower compared to other criteria. The reported risk factors for having gestational diabetes mellitus in the MENA country included an age of 30 years or more, being in the third trimester compared to the second trimester, and being obese compared to being overweight. The consequences of having gestational diabetes mellitus on the mother's side include the future development of type 2 diabetes, death and C-section, and on the child's side, neonatal death and long-term disability. Then what about the reports of good lysemic control? Are we achieving a good job controlling our patients? So we have this report coming from Kuwait in 2014, reporting only 35% of the patients achieving hemoglobin A1c of less than 7. Another report from Dubai was more than 25,000 patients reporting only 38% of the patients achieving hemoglobin A1c of less than 7. More evidence, a study coming from Mansoura, Egypt in 2020, was only 35% of the patients achieving hemoglobin A1c of less than 7. Another report exclusively including patients with type 1 diabetes coming from Kuwait, Emirates, Oman, and Bahrain was only 27% of the patients achieving hemoglobin A1c of less than 7. And finally, a systematic review and meta-analysis of more than 40,000 participants only reporting 37% of the patients achieving good glycemic control. The main factors related to the achievement of glycemic control were the smoking, obesity, disease duration, self-management, and physical inactivity. What about the rates of reported complications? This is micro and macrovascular complications. The rates of reported neuropathy coming from the MENA region ranged from 19% reported from Egypt, 42% reported from Libya, and up to 49% reported from Iran. These reports were using a standardized scoring system, while another study coming from Palestine reporting only 38% of our patients diagnosed with neuropathy using a simple monofilament test. For the retinopathy, we have this nationwide study, more than 50,000 patients coming from Saudi Arabia reporting an incidence or prevalence of retinopathy of about 20%. Another systematic review coming from Iran of more than 17,000 patients reporting 38% of the patients having diabetic retinopathy. Another hospital-based study from Egypt, 20%. Another clinic-based survey from Palestine, 22%, and another Tunisian clinic-based study reporting 26% prevalence of diabetic retinopathy. The reports of nephropathy in the form of prevalence of microalbuminuria as an early indicator of having diabetic nephropathy, we have reported prevalences ranging from 11% coming from Saudi Arabia, and up to 35% reported from Palestine. About the macrovascular complications, this was a systematic review and meta-analysis, including countries from the Middle East and Africa, and the crude prevalence was about 11%, and the age and sex standardized rate was about 9%. The highest report coming from Turkey, about 15%, and coronary artery disease being the most prevalent cardiovascular complication to be expected in patients with diabetes, and the reported range from 3% to 12%. The second part is going to be about preventing the development of diabetes in the MENA region, and we should start with the modifiable risk factors. How common are the modifiable risk factors among patients coming from the MENA region? So you can see here in this systematic review and meta-analysis that the prevalence of insufficient physical activity is significant in countries from MENA, and they have defined insufficient physical activity as less than 60 minutes of physical activity during a whole week. You can see that the highest reported prevalence comes from Kuwait, followed by Iraq and Saudi Arabia. For obesity, this is one of the most important modifiable risk factors, and you can see that it is highly reported from the MENA region, with the highest reports again coming from Kuwait, followed by Jordan and Qatar, and finally followed by Saudi Arabia and Egypt. So the next stage after suffering from a modifiable risk factor is the development of the prediabetes, which is the transition from a high-risk profile to having actual diabetes. So in this systematic review and meta-analysis, they have classified countries in the MENA region according to countries having a high, intermediate, or low prevalence of prediabetes. For those countries classified as having a high prevalence of prediabetes, that's to say 19% or more, this comes Iraq, Saudi Arabia, Emirates, and Kuwait. A very recent study reported from Egypt was more than 700 patients surveyed for having prediabetes, and they have defined prediabetes as having impaired fasting glucose or impaired glucose tolerance. Actually, 22% of the patients had prediabetes, which places Egypt among the countries with a high prevalence of prediabetes. Countries with intermediate prevalence of prediabetes, that's to say ranging from 14% to 15%, this includes Iran, Pakistan, and Qatar. And countries with a low prevalence of prediabetes, that is to say 9% or less, this includes Yemen, Syria, Oman, and Tunisia. The latest IDF Atlas in 2021, they have reported that the regional prevalence of prediabetes defined as impaired glucose tolerance is about 11%. And if it is defined according to impaired fasting glucose, it's going to be 6.6%. The greatest reported prevalence of prediabetes comes from Lebanon. So in this survey, they have surveyed patients and they have defined prediabetes as either having impaired fasting glucose or they use the hemoglobin A1C greater than 5.7 and less than 6.5. Actually, only a small study, small number of studies, uses the hemoglobin A1C as a screening criterion. And actually, this study reported up to 40% of the screened patients having prediabetes. So what are the current challenges for preventing diabetes and the corresponding recommendations? So this summit, this was called Evidence in Diabetes and Hypertension Summit. This was convened in September 2022, where we had 16 experts in the field. They have gathered to recognize what are the limitations and what are the possible solutions for the prevention of type 2 diabetes in the region. So they have classified the factors into four categories. The first category is the patient-related factors. And this includes cultural beliefs, for example, the belief that traditional herbal remedies are better than conventional therapy, the financial constraints to access medications, glucose traps, or even transport to health care facilities, and the self-treatment without consulting a physician. The proposed solutions included to provide access to health care providers for questions and support, to provide affordable access to medications and monitoring tools, and to empower patients with knowledge and to introduce healthy lifestyle concepts as early as kindergarten. The physician-related factors include lack of multidisciplinary team in the management of diabetes, lack of knowledge in personalized diet and exercise recommendations, lack of diabetes registries and electronic medical records, and limited resources allocated to primary health care facilities. The proposed solutions include to invest in diabetes training programs for multidisciplinary teams, to educate physicians about personalized diet and exercise recommendations, and to use modern technology to connect patients and physicians and to provide all treatment options. The culture-related factors include extreme weather, like here in the Gulf countries, and the lack of facilities to practice physical activity in other countries, the peer pressure and the negative messages that patients receive from social media influences, life complexity, and stressful lifestyle. The proposed solutions include to promote healthy lifestyle early in schools, workplaces, and villages, the culture of accountability at that the health of every individual is his own responsibility, and finally, to change the culture of following unqualified health advice only to follow experts in the field and to verify information found on the internet. Finally, government-related factors, which include lack of national strategies for prevention of diabetes, early detection and intervention and prevention of diabetic complications, lack of research and data about diabetes, lack of infrastructure assigned to primary health care facilities, which requires from the government to allocate budget for the prevention of diabetes, obesity, and other risk factors, and to create centralized electronic registry about diabetes and about its risk factors. The talk is just fine, however, if we implement such solutions, will it work or not? So actually, this study aimed to answer this question. So this was a population-based study designed to investigate the impact of public health interventions on the epidemiology of type 2 diabetes. Data were fed to a mathematical model, and the study aimed to evaluate the impact of interventions in the coming 30 years in the nation of Qatar. What are the interventions? What are the possible implications of applying such interventions? If we apply lifestyle management interventions applied to populations counted at high risk of type 2 diabetes, and they have selected the high-risk population as having either a body mass index greater than 35 years of age or advanced age more than 50 years of age. And actually, if we apply such lifestyle management on high-risk population, we can get a decrease in the prevalence of type 2 diabetes by 5% and up to a 9% decrease in the incidence of new cases of type 2 diabetes. The impact of increasing use of different modes of active commuting, and by active commuting, they are referring to increased use of public transportation use and increased use of cycling and walking. By such a simple intervention, we can get a decrease in the prevalence of type 2 diabetes by 2%, and we can get a decrease in the new cases of type 2 diabetes by 10% to 11%. The impact of increasing consumption of healthy diets, and they have defined healthy diets as having fresh vegetables and fresh fruits. Actually, this can decrease the prevalence of type 2 diabetes by 6%, and it can decrease the incidence of new cases of type 2 diabetes by up to 24%. The impact of implementing a subsidy and taxation. And subsidy means a reward for following healthy lifestyle and taxation for following unhealthy lifestyle. Actually, this can decrease the prevalence by 2% and can decrease the incidence by up to 10%. If we implement the whole combination, the whole thing, and using the least optimistic and the most optimistic combination of interventions, you can get a decrease in the prevalence ranging from 3% to 10%, and you can get a decrease in the incidence starting from 28% and up to 40% reduction. In summary, diabetes, including types 1, 2, and gestational diabetes is present at alarming rates in the MENA region. Obesity, physical inactivity, and subsequently the development of prediabetes are highly prevalent in the MENA region. Less than 30% of type 1 diabetic patients and less than 40% of type 2 diabetic patients are achieving good control, which results in high prevalence of both macro and macrovascular complications. Patient, physician, social, and governmental factors are involved in this image, and implementation of a sound disease prevention policy may effectively prevent diabetes in a significant number of at-risk complications. I hope that this was not a boring presentation because it included lots of epidemiological data, but this was the title assigned to me. Thank you.

Diabetes Trends

MENA Region

Gestational Diabetes

Glycemic Control

Risk Factors

Healthcare Access