Bitter sweet

04 March 2003
Feasting on rich food and munching sweets is a traditional and enjoyable part of the Eid al-Adha holidays. But few Arabs tucking into the many treats will be aware of the dire risks they are taking. Diabetes, a chronic condition directly linked to over-consumption and a breakdown in the body's ability to produce or process insulin, is threatening to overwhelm the region's healthcare systems.

According to the World Health Organisation (WHO), 17 million people out of the region's estimated 220-million total adult population, between 20-79 years of age, have some form of diabetes - pointing to a prevalence of 7.7 per cent. And this is just the tip of the iceberg. The WHO estimates the number of diabetics in the developing world - which includes the Middle East - will have increased 170 per cent by 2025.

Nowhere is the problem more acute than the GCC, where the number of adults developing diabetes has already doubled over the past decade. More than 13 per cent of the adult population of the Gulf has diabetes mellitus (DM) - also known as Type 2 diabetes. Added to those suffering with impaired glucose intolerance (IGT), which is a precursor for developing the full-blown disease, the total number of diabetics and potential sufferers in the GCC reaches 24.7 per cent of all adults.

'Along with the discovery of crude oil in most of the Gulf, there has been rapid socio-economic change over the past three decades,' says Mohammed Hassan Ali, under-secretary for planning affairs at the Health Ministry in Oman. 'This has been accompanied by dramatic changes in the traditional way of living in the region, which is characterised by increasing levels of physical inactivity. Working on farms has been replaced by working as a clerk in the civil service, for example.'

Abdulrahman al-Nuaim, chief operating officer and consultant endocrinologist at the King Faisal Specialist Hospital & Research Centre in Riyadh, agrees that changes in social practice and the rapid urbanisation of previously agrarian or nomadic bedouin societies in the region have both played a big part in encouraging the rapid spread of the condition.

'Saudis and other Gulf nationals are leading sedentary lives these days and this is the root cause of the problem,' says Al-Nuaim. 'If you were to visit the souk 40 years ago the people you would see there were all thin and diabetes was not a problem. However, today more than 20 per cent of nationals have a body mass count of over 30 and the disease is rife.'

Obesity - gauged by an index equivalent to 30 kilograms of fat per square metre of body mass - is considered to be one of the primary causes of the disease in the Gulf. Many experts cite inactivity and the growing popularity of western-style fast food among GCC nationals as major points of concern.

Ali al-Shamlan, director-general of the Kuwait Foundation for the Advancement of Sciences (KPAS) - a leading think tank for medical research in Kuwait, says that almost 90 per cent of Kuwaiti nationals lead sedentary lifestyles and this is dictating the country's policy for treating the disease. 'An integrated approach to the prevention of some of the critical risk factors that underlie Type 2 diabetes should be based on the prevention of obesity, the promotion of physical activity and lifestyle modification,' says Al-Shamlan.

A sweet tooth and a dislike for exercise are not the only causes for concern, however. The disproportionately high occurrence of the disease in the GCC when compared to affluent countries in Europe and the US - the latter has a 6 per cent prevalence of diabetes among its adult population - points to a possible genetic predisposition among Arabs.

'There is certainly a hereditary issue that has to be addressed,' say Dr Jawad al-Lawati, head of the non-communicable diseases section of Oman's Diabetic Medicine Journal. 'Europeans and Americans have eaten fatty foods for years but have a relatively low occurrence of diabetes. When compared with figures in the Gulf, this suggests a genetic element is at play.'

Treating diabetes and its side-effects is an expensive and laborious process. The example of the US again is a case in point. The world's biggest economy spends about $44 billion a year directly on the treatment of diabetes and its associated conditions.

If governments in the region are serious about tackling the disease and redressing its spread, similar sums will have to be allotted to health budgets. But bringing in medical expertise does not come cheap. Top endocrinologists and podiatric specialists working in the region can command salaries of up to $50,000 a month in the best hospitals.

'As yet there has not been any study to estimate the exact cost of treating diabetes in the Gulf. However, provisional estimates show that the cost of treating each patient with diabetes in Oman at primary and secondary care levels is around $321 a year per patient, or about 3 per cent of the Health Ministry's present budget,' says Ali. At present the GCC spends just under $20,000 million a year on health, which compared with the vast sums being invested in the US and Europe, seems woefully inadequate.

In Saudi Arabia, where about 23 per cent of the adult population are either diabetic or displaying the early signs of glucose intolerance, the government is planning to invest millions in tertiary and outpatient care. The government acknowledges that one in five Saudis suffering from some form of the disease is both unacceptable and unsustainable in the long term. Beyond the suffering of the individual, the economic cost to the kingdom could be massive if a growing proportion of the adult population is rendered economically inactive by the disease.

King Faisal hospital is at the forefront of the battle against diabetes. The hospital, which is the biggest in the region, is investing millions of dollars in diabetic treatment and research facilities. 'We need a cost-effective national diabetes programme that looks at the following areas: screening high-risk groups; managing existing sufferers; and controlling related complications,' says Al-Nuaim. 'In the kingdom, diabetes is the leading cause of stroke, cardiovascular disease, blindness, kidney failure and limb amputation. The cost of its treatment stretches far beyond the condition itself.'

Many of these criteria are already being met at the King Faisal by its recently opened tertiary care centre, which conducts one amputation every 36 hours. Alternative treatments, including cell transplant therapy, are also being explored and further research is being carried out on advanced stem cell technology, which is expected to become available within the next three years. Like the best endocrinologists, such-cutting edge treatments do not come cheap.

Saudi Arabia is not alone in dedicating specialist resources to the treatment and prevention of the disease. The UAE and Kuwait have both invested in specialist units, while Bahrain, Qatar and Oman are evaluating proposals to build similar treatment centres. Yet opinion remains split on whether ploughing more money into treating the disease and not its causes will deliver the desired reduction in cases.

'Health budgets in the region are much more curtailed than, say, defence spending,' says Al-Lawati. 'So any intervention in the future will have to be very cheap if it is to be sustained. Tertiary hospitals and clinics with MRI [magnetic resonance imaging] facilities are expensive and not always cost-effective. Prevention, which means changing people's lifestyles, is the only long-term solution.'

In Oman, the government's recently-launched community-based intervention project with the WHO may provide a working model. The project, based in Nizwa, is intended to provide primary prevention for non-communicable diseases such as diabetes and obesity in rural areas.

But, as Al-Nuaim says: 'We need to change people's perceptions and lifestyles in the region. However, this is often harder said than done.' The cost might be high, but the price of failure is likely to be even higher.

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