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
• The impact on morbidity
• The economic impact
• The Trend of Care, Education & Management of DM
• Myths & Misconceptions
• Planning Strategies
•Success stories
• Conclusion
Population Doubling Time in
Some Mediterranean Countries
Years
400
N
E
S
300
200
100
0
ES
F
I
G
M
Y
IL
T
ET
L
AG
Current Age
Demographics in Egypt
Age Demographics in
Egypt 2050
Urbanization in Some Mediterranean
Countries
N
100
E
S
80
%
60
40
20
0
ES
F
I
G
M
Y
IL
T
ET
L
AG
Gross National Product Per Capita in
Some Mediterranean Countries
N
E
S
1000 $
20
15
10
5
0
ES
F
I
G
M
Y
IL
T
ET
L
AG
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
2003
9,000
7,000
6,000
2025
5,000
4,000
3,000
2,000
1,000
n
Ba
hr
ai
Li
by
a
t
Le
ba
no
n
Ku
wa
i
ia
Jo
rd
an
Tu
ni
s
UA
E
Su
da
n
ria
Sy
Ar
ab
ia
Al
ge
ria
M
or
oc
co
Ira
q
Sa
ud
i
Ira
n
0
Eg
yp
t
Source: Diabetes Atlas, 2nd edition, IDF
8,000
Prevalence of Diabetes in Egypt
(Above the age of 20 yrs)
Ali et al, 1995
Whole
Egypt
Arab et al, 1992
Whole
Egypt
9.3
Rural
Rural Agriculture
4.9
Urban
(Low)
Rural Desert
13.5
Urban
(High)
0
10
15
20
Percent Population (%)
4.76
1.58
Urban
20.0
5
6.29
25
0
8.93
5
10
15
20
Percent Population (%)
25
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
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
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!!!
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)
Residence &
Socio- economic
Status




Rural
Urban (Lower SES)
Urban (Higher SES)
Total
SES= Socio-economic status
Prevalence of Sedentary
Lifestyle
(%)
52
73
89
63
Prevalence of Obesity
(%)
16
37
49
27
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
We Should Empower Subjects With Diabetes to Be
More Active in the Management of their Disease
What 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
Therapeutic Patient Education is a Crucial
Component of Health Care
What 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
SMBG
Dealing with hypoglycaemia
Foot care
Self management of insulin *
82.5
16.1
77.4
75.7
56.7
82.3
10.3
70.5
65.5
49.6
82.7
20.0
82.0
82.5
62.1
0.865
<0.001
<0.001
<0.001
0.041
Main source of information:
Education meeting/Health news
Physician
Nurse
14.6
82.1
3.3
17.9
78.8
3.3
12.3
84.3
3.3
0.280
Frequency of health education:
Never
Occasional/regular
31.9
68.1
54.3
45.7
17.0
83.0
<0.001
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)
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)
Diabetes in Egypt
Alexandria University Survey, 1995-2002
•
A subsample (3000) from registered cases were
chosen
proportionally,
demographic
for
characteristics
the
of
study
of
patients
the
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
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
For Nephropathy
For Retinopathy
For Cardiac Complications
For Diabetic Foot
For Other Complications
30.5 %
66.8 %
44.6 %
77.9 %
71.5 %
92.0 %
Diabetes in Egypt
Direct Cost of Diabetes in Egypt
(March 1988)
Skin infection
Neuritis
Broncho-pulmonary infection
UT infection
Eye problems
Rheumatism
IHD
Foot problems
HF
Dialysis
50
60
60
60
70
70
110
115
160
500
$ / year
$ / year
$ /year
$ / year
$ / year
$ / year
$ / year
$ / year
$ / year
$ / year
Arab et al. 1988
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
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
Distribution of Subjects with Type 2 DM by
the type of Treatment in 1995 & 2005
88%
90%
76%
80%
70%
1
60%
1995
50%
2
2005
40%
30%
20%
10%
10%
1.10% 1.00%
13%
9%
2%
0%
1 Alexandria University, Alexandria, Egypt – Mario Negri Institute , Milan, Italy Survey 1995
2 Data derived from the IMS medical audit 2005
Types of Insulin Used in the
Egyptian Market
Short acting
Intermidiate
Premix
Analogues
Type of Insulin
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1998
IMS medical audit
1999
2000
2001
2002
2003
2004
2005
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.
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
hyperglycemia.
&/or
salty
foods
buffers
(WHO-EM/DIA/7-E/G) 1996
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
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
OPPORTUNITIES
Great social expectation regarding reforms
in the area
 Social awareness of the urgency of the
reforms

STRENGHTS
Health care for all
 Health centres network all over the country

THREATS
Financial crisis
 Progressively unmotivated healthprofessionals

WEAKNESSES
Excessively central and bureaucratic
Public Administration
 Poorly developed information,
e
communication and evaluation systems

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.
Patients & community awareness days
Random blood glucose testing
Nurses training (Lectures)
Nurses training (Practical class)
Camps for children with diabetes
Education film for children with diabetes (Jinn’s party)
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.
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.
Examples of the situation before the
intervention project derived from the preproject 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.
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
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
Score (%)
9
31
14
13
Pre Test
Immediate Post Test
Remote Post Test
20
41
Knowledge
45
Skills
Attitude
HbA1c (%)
Mean HbA1c (%) one year
before and one year
after the educational intervention
2.22
year before the
intervention
year after it
1.15
.
.
P < 0.001
Hospitalization
(d/pt/y)
Mean duration of hospitalization
(days/patient/year) one year
before and one year after the
educational intervention
6.53
3.10
year before
the intervention
year after it
.
.
P < 0.001
Mean duration of absenteeism
(days/patient/year) one year before
and one year after the educational
intervention
Absenteeism
(d/pt/y)
12.67
year before the
intervention
year after it
.
5.82
.
P < 0.001
Ketosis
(times/pt/y)
Frequency of ketosis (requiring
hospitalization) one year before and one
year after the educational intervention
.
.
.
.
.
.
.
.
year before
the intervention
year after it
1.52
0.62
.
P < 0.001
.
Frequency of severe hypoglycaemic
episodes one year before and one year after
the educational intervention
.
Severe
hypoglycaemia
(episodes/pt/y)
.
0.65
year before the
intervention
year after it
.
.
.
.
0.09
P = 0.001
.
.
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.
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.
Thank You