Rates of diabetes across the UAE, and the MENA region more broadly, are at an all-time high. But why is incidence so high among Emirati populations, and might there be factors other than lifestyle at stake? Practical Patient Care Middle East explores a growing problem, and examines what can be done to ease the burden.
In November 2014, as World Diabetes Day drew near, doctors in the UAE described the prevalence of the disease as a ‘national health emergency’. With around 150 new cases reported every day, around 19% of the population suffer from Type 2 diabetes and its associated complications. What is more, this is no longer just an adult-onset condition, with a growing contingent of patients developing symptoms in childhood.
“The current pre-diabetes numbers could usher in a second wave of new diabetic patients in the next few years if efforts to educate and improve people’s lifestyles are not sustained,” Dr Ravi Arora of NMC Specialty Hospital, Abu Dhabi, told The National.
Along with Saudi Arabia, Egypt, Bahrain, Kuwait and Oman, the country has one of the highest incidences of type 2 diabetes in the world (it is currently ranked 16th, with Saudi Arabia at 7th). According to the International Diabetes Federation (IDF), 37 million people suffer from diabetes across the MENA region, a figure projected to rise to 68 million by 2035.
It is hardly surprising that the region should be on high alert – the disease can have hugely detrimental effects on quality, and length, of life. If untreated, it can lead to kidney and heart disease, stroke and poor blood flow in the limbs. Around a third of type II diabetics will go on to develop retinopathy, caused by swelling of the blood vessels in the eye, which can in turn cause irreversible blindness.
The financial costs are heavy too. Across the region, total expenditure on diabetes is set to rise from $16.8bn today, to $24.7bn by 2035. While these figures seem high, they may in fact be suboptimal – 9% of the world’s diabetics live in this region, but just 3% of the global healthcare budget is spent here. In Saudi Arabia, for instance, the government spends $943 a head on diabetes, compared with $9,880 in the United States.
Leading the turnaround
It is clear that something needs to change. Diabetes is in theory a preventable condition – the IDF suggests that up to 70% of cases of type 2 diabetes can be prevented or delayed by adopting healthier lifestyles. Associated with a lack of exercise and high-fat, high-sugar diets, the condition could often be held in check by adopting healthier habits.
As Professor El-Sayed, regional chair of MENA Region at the IDF has explained: “We are seeing an increase in diabetes prevalence and mortality year-on-year. However, we now have simple, cost-effective ways to tackle this increase. Investing in healthy nutrition and increasing the accessibility of healthy food choices will reduce the global burden of diabetes, and save billions in lost productivity and healthcare costs.”
That said, type II diabetes is a complex disease with an equally complex aetiology. By all accounts, it cannot be wholly eradicated through simple lifestyle measures.
Like many so-called ‘lifestyle’ diseases, diabetes risk in fact stems from a combination of genetic, behavioural and environmental factors. The condition is known to run in families, and Emirati populations appear to have a particularly strong genetic predisposition.
While expatriates to the region have a higher risk of diabetes too, underscoring the role played by poor diet and minimal exercise, there is evidently more at stake than what they’re eating. For instance, in the UAE National Diabetes and Lifestyle Survey, which surveyed expats with different ethnicities, 10.6% of Asians and 11.7% of Arabs were found to be diabetic, compared to only 3.6% of Africans and Westerners.
At the Imperial College London Diabetes Centre, which is situated in Abu Dhabi and Al Ain, the high prevalence among UAE nationals provides fertile grounds for research. Launched in 2006, the facility specialises in diabetes treatment, training and public health awareness, and has seen more than 800,000 outpatient visits to date. As well as helping individual sufferers, it also funds various studies, looking into the epidemiological, basic, clinical and genetic aspects of diabetes.
One key project is the Abu Dhabi Diabetes and Obesity Study (ADOS), which is currently being performed in collaboration with three centres around the UAE. The researchers are hoping to learn more about the aetiology, mechanisms and associated complications contributing to obesity and diabetes within the UAE population. Importantly, they are looking at body composition analysis as well as demographic data.
The study subjects (who include both children and adults) will be assessed for cardiometabolic risk factors and central adiposity, with full analysis of their metabolomic profiles. According to the study authors, this “may help define the risk factors associated with diabetes and differences in metabolic activity between various ethnicities.”
At the heart of the study is a very interesting premise – namely the fact that, while the UAE has a similar rate of obesity to the USA (36% versus 35.7%), its rates of type 2 diabetes and insulin resistance are around three times higher. It would therefore seem that body mass index alone is a blunt instrument for assessing risk.
Various hypotheses have been proposed to explain the difference between the two populations. For instance, there may be differences in weight distribution – it is well known that storing fat around one’s middle is associated with a higher risk of diabetes than storing it around the hips and thighs. If Emirati populations typically have a higher waist circumference and more visceral fat than their equally heavy US counterparts, this might provide some clues as to the discrepancy.
There might also be differences in body metabolism. The researchers are particularly interested in exploring the advanced glycation end-products (AGEs) metabolic pathways, which are formed at an increased rate in diabetes and lead to undesirable complications such as retinopathy and atherosclerosis. Through understanding the core mechanisms behind this metabolic disturbance, the researchers may be able to develop new treatments.
Perhaps most intriguingly, it is possible that diabetes incidence may have something to do with a virus. Adenovirus-36 (ADV-36) has been shown to play a significant role in both obesity and diabetes, although the exact role is not entirely clear-cut.
Known to cause obesity in animals, the virus’ effects in humans have been widely pondered by the research community. One study of ADV-36 infection in the United States showed that about 30% of obese individuals, and 11% of non-obese individuals, showed antibodies to the virus, with the likelihood of infection rising in line with body mass index.
Perhaps surprisingly, other studies have shown that ADV-36 infection can increase glucose uptake by adipose tissue, in other words improving insulin resistance and providing a potential weapon against diabetes.
This means analysing its occurrence within the Emirati population may help clarify the prevalence of both conditions, and explain something about the links between the two.
The way forward
Whatever the findings of this study, and others of its nature, it seems clear that reducing the burden of diabetes will require a several-pronged strategy. This will entail improving diet and exercise, but also introducing better screening measures, which ensures the condition is diagnosed at a suitably early stage and minimises the risk of complications.
In this age of personalised medicine, it will also mean developing a greater awareness of who is most susceptible and why. Armed with that knowledge, pharmaceutical companies will be better able to develop individually tailored treatments.
Currently, health bodies are working on establishing a pan-UAE diabetes registry, which tracks the prevalence, management and prevention of the disease. This will enable the country to launch robust preventative programmes for those who are prediabetic, or are showing early signs of insulin resistance.
Speaking at the 5th Emirates Diabetes and Endocrinology Congress in February 2015, Dr Fatheya Al Awadhi, vice president of the Emirates Diabetes Association explained: “A diabetes registry will help doctors in all hospitals across the UAE. Our vision for 2021 is to reduce the prevalence of diabetes in the UAE from 19% to 16.3%.”
Dr Abdul Razzaq Al Madani, head of the Emirates Diabetes Society, added: “It is our wish to have the UAE move out of the list of the top 20 countries regarding the occurrence of diabetes, and we hope to do so by increasing the levels of awareness over the next two to three years. Health authorities and civil institutions will organise awareness campaigns and additional plans include the important decision of the Ministry of Education to prohibit the sale of fast food or other foods with high levels of sugars and carbohydrates in schools.”
Evidently, the UAE, along with the rest of the MENA region, has a sizeable task ahead. However, as diabetes rates continue to soar, it is imperative that the region makes both prevention and management a top priority. This will require researchers, government bodies and healthcare systems to work together in a bid for change, assisting the growing number of people who are affected by this debilitating condition.
This article appears in the first edition of Practical Patient Care Middle East