Keywords
complications - diabetes - diabetes care - epidemiology - management - professionalism
- United Arab Emirates
Introduction
Diabetes is a complex metabolic disorder with an increased risk of morbidity and mortality.
Based on the most recent International Diabetes Federation (IDF) data in 2021, diabetes
mellitus (DM) affects 537 million and is projected to reach 783 million by 2040.[1] In the Middle East and North Africa region, diabetes affects one in six adults.
The total number is expected to increase to 136 million by 2045.
The United Arab Emirates (UAE), like the rest of the Arab Gulf countries, has a high
prevalence of type 2 diabetes (T2D). These countries have similar populations and
cultural and socioeconomic characteristics (lifestyle, diet, income, language, and
religion). The rates of diabetes, primarily T2D, range from 8 to 22%, according to
the latest IDF report.[1] Many factors contribute to the high prevalence in this region, particularly obesity
and unhealthy lifestyles. As a result of increased wealth and prosperity, Gulf countries
now have increased health care expenditures and life expectancy.[2] However, genetic susceptibility and the incidence of T2D among children and young
persons are rising. Diabetes has severe implications for the person, family, and society.
The prevalence of diabetes in the UAE is estimated at 12.3% for the 20 to 79 age group
(age-adjusted 16.4%).[1] Given its public health importance, we will review the literature on the epidemiology,
types, clinical characteristics, complications, and quality of care in this chapter.
We will also review the role of technology in diabetes care, the challenges of diabetes
management, and future directions in clinical practice and research.
Methods
This is a focused narrative review of the literature on selected aspects of diabetes
and diabetes care in the United Arab Emirates. One author took the lead to identify
the most relevant aspects. The selected aspects were epidemiology, diabetes care,
impact of technology on diabetes care, and professional and patients' perspective
([Table 1]). Various sections were assigned to different authors who drafted their sections,
shared them with other coauthors, and reviewed the other sections. The manuscript
was further developed by all the authors through several cycles of discussions. The
final product was approved by all the authors.
Table 1
Rationale for the selection of themes of selected for inclusion in the review
|
Epidemiology
|
UAE is a typical example for new wealthy societies with rising rates of diabetes in
both native and expatriate populations worthy of study.
|
|
DM in Special groups
|
Interplay of increased parity and increased diabetes risk, diabetes in young people
|
|
Diabetes care
|
Demonstration of the impact of diabetes care provided by various models of care.
|
|
Cardiovascular disease
|
Cardiovascular morbidity is the leading cause of dealth in people with diabetes.
|
|
Technology in diabetes
|
UAE embraced advances in diabetes technology and the health system could afford it;
lesions could be learned from this unique experience.
|
|
Professional aspects
|
Reflections on how the medical profession responded to increasing burden of diabetes
in diabetes care, education and research.
|
Abbreviations: DM, Diabetes mellitus; UAE, United Arab Emirates.
Epidemiology
Several studies evaluated the epidemiology of diabetes in the UAE. The majority focused
on T2D and reported on the prevalence of the disease. However, only some studies reported
data from the entire country ([Table 2]). Malik et al studied the prevalence of diabetes among 5,844 adults (>20 years)
between October 1999 and June 2000.[3] Diabetes diagnosis was based on fasting blood glucose (FBG) and 2-hour postoral
glucose tolerance test (OGTT) criteria. The overall crude diabetes prevalence was
20%. The age-adjusted diabetes prevalence was higher in UAE nationals (25%) than in
expats (16–21%). Of interest, 41% of those with diabetes were undiagnosed before the
survey. The prevalence of IFG was 5% in women and 7% in men. Saadi et al surveyed
2,455 adults in 452 houses in Al Ain between December 2005 and November 2006.[4] Of those, 10.2% reported having diabetes. Among the 373 men and nonpregnant women
who underwent testing, the age-standardized rate for diabetes was 29% among the 30
to 64 age group. Microvascular complications were present in 35 to 52% of patients
with diabetes, while peripheral vascular disease and coronary heart disease were present
in 11.1 and 10.5%, respectively. The reported prevalence of prediabetes was 20.2%
in this study.
Table 2
Summary of the T2DM prevalence studies in the UAE
|
Authors, year
|
Patient population/setting
|
Prevalence
|
Comments
|
|
Malik et al 2005[3]
|
5,844 adults (>20 years) between Oct 1999 and June 2000
|
Crude 20%
Age-adjusted:
UAE: 25%
Expats: 16–21%
|
40% of UAE citizens of the cohort; DM Dx: FBG >7 mmol/L and or BG > 11.1 mmol/L post-2h
OGTT; Of interest, 41% of those with diabetes were undiagnosed prior to the survey
IFG/IGT prevalence: 5%/21% in women, 7%/16% in men.
|
|
Saadi et al 2007[4]
|
Survey of 2,455 adults in 452 houses in Al Ain (Dec 2005–Nov 2006)
|
29% of 373 people tested; 30–64 years
|
Microvascular complications were present in 35–52% of patients with diabetes, while
peripheral vascular disease and coronary heart disease were present in 11.1 and 10.5%,
respectively.
PreDM prevalence:20.2%
|
|
Hajat et al 2012[5]
|
50,138 self-enrolled adults at primary care clinics for weqaya screening in Abu Dhabi (2009- 2010)
|
Age-standardized 24.6%
|
DM Dx: HbA1c> 6.5%, RBG >11.1 mmol/L or history of DM on medications; limitations:
selection bias due to self-enrollment of participants, data from Abu Dhabi emirate
only, and type of DM not defined; PreDM prevalence:29.5%
|
|
Hamoudi et al 2019[8]
|
3,203 individuals.
|
UAE nationals (M: 21%/ F: 23%)
Asian non-Arabs (M: 23%/ F: 20%).
|
Results were derived from the UAEDIAB Study. DM Dx: HbA1c> 6.5%, FBG> 7 mmol/L. 25%
of UAE nationals in this cohort. Nationals with DM had the highest rate of positive
family history of diabetes (64%) compared with other ethnicities. Data from all emirates
except Abu Dhabi
|
|
Suliman et al 2018[6]
|
872 adult UAE nationals living in the Northern Emirates.
|
Crude: 25.1%
|
Results were derived from the UAEDIAB Study: Diabetes Dx based on HbA1c of >6.5%;
Undiagnosed diabetes was reported in 14.8% of the participants; Data from all emirates
except Abu Dhabi
|
|
Suliman et al 2018[7]
|
2,724 migrants in UAE
|
19.1%
|
Results were derived from the UAEDIAB Study. The cohort was derived from individuals
coming to medical centers for visa renewal. The majority were males, Asians, non-Arabs,
and 40 years or younger. Data from all emirates except Abu Dhabi
|
|
Alawadi et al (2014)[9]
|
2,245 adults from the Dubai household survey
|
UAE nationals: 19.3%; Expats: 12.4%
|
The results are similar to the data from the DHHS 2014/17, with the reported prevalence
of 19% for UAE nationals and 14.7% for expats (9).
|
Abbreviations: DM, diabetes mellitus; Dx, diagnosis; FBG, fasting blood glucose; HbA1c,
glycosylated hemoglobin; IFG, impaired fasting glucose; IGT, impaired glucose tolerance;
PreDM, prediabetes; RBG, random blood glucose; UAE, United Arab Emirates; UAEDIAB,
UAE National Diabetes and Lifestyle Study.
The cardiovascular risk factors were evaluated in 50,138 self-enrolled adults (>18
years) presenting to 25 primary care clinics for the Weqaya screening program in the Emirate of Abu Dhabi between April 2009 and June 2010.[5] In this study, the age-standardized prevalence rates of diabetes were 24.6 and 29.5%
for prediabetes. Also, the cross-sectional study evaluated the prevalence of diabetes
among UAE nationals and expatriates living in the Northern Emirates, Dubai, and Sharjah
over 4 years.[6] A total of 3,202 individuals (25% UAE national) were included, and the reported
adjusted diabetes prevalence of diabetes was highest in UAE nationals (males 21% and
females 23%) and Asian non-Arabs (males 23% and females 20%). Also, the crude diabetes
prevalence of 25.1% among 872 adult UAE nationals in the five northern Emirates was
observed.[7] The results were derived from the UAE National Diabetes and Lifestyle Study collected
in 2013, and diabetes diagnosis was based on hemoglobin (HbA1c) of >6.5%. Undiagnosed
diabetes was reported in 14.8% of the participants. The same group reported an age-adjusted
diabetes prevalence of 19.1% among 2,724 migrants in the UAE.[8] This cohort was derived from individuals coming to medical centers for visa renewal.
The majority were males (81%), Asian non-Arabs (71%), and younger than 40 years (65%).[8] Furthermore, Alawadi et al recently reported on 2,245 adults from the Dubai household
survey, indicating an overall prevalence of diabetes. The national prevalence was
significantly higher than among expats (19.3 vs. 12.4%).[9] The findings are similar to the 2014/17 data, with a reported prevalence of 19%
for UAE nationals and 14.7% for expats.[10]
There is limited information on the incidence of diabetes in the UAE. The incidence
of diabetes was studied in a small study among Emiratis in Ajman in 2010.[11] One hundred one patients with a new diagnosis of T2D were included (age 23–78 years
and 65% females). The overall incidence was calculated as 4.8/1,000 person-years (PY).
Incidence was higher in females than males, and the highest incidence was in the 55
to 59 age group.[11]
Special Populations
Diabetes in Young People
Autoimmune diabetes, defined as diabetes-associated autoantibodies without ketoacidosis
or insulin requirement for at least 6 months after diagnosis, was assessed in a study
from a large center in Abu Dhabi.[12] Among 17,062 patients with diabetes aged between 30 and 70 years, the prevalence
of LADA was at 2.6% in these settings.
The characteristics of neonatal diabetes mellitus (NDM) in patients across pediatric
diabetes clinics in Abu Dhabi were studied. Twenty-five cases were identified, and
the incidence of NDM was approximately 1:29,000 live births. Of those, 23 had permanent
NDM, while 2 had transient NDM.[13] Genetic alterations were detected in 21 cases (9 EIF2AK3 mutations, 6 INS mutations,
2 PTF1A enhancer deletion, 1 KCNJ11 mutation, 1 ABCC8 variant, and four without mutations).
For the transient NDM, the genetic abnormalities were 6q24 methylation defect and
homozygous INS c-331C > G mutation.[13]
The prevalence of diabetes and prediabetes among 555 young Emirati female college
students was studied in a cross-sectional study in 2021 in Al Ain using HbA1c and
fasting plasma glucose (FPG).[14] Their age range was 17 to 25. Based on HbA1c values, the prevalence of prediabetes
and diabetes were 24 and 8.6%, respectively. Remarkably lower corresponding estimates
were detected using FPG 9.2 and 0.5%, respectively. Abnormal glycemic status was significantly
associated with abnormal lipids and increased inflammatory markers. Using FPG to evaluate
glycemic control underestimates the burden of undiagnosed diabetes, which could significantly
impact clinical practice. On the other hand, Meo et al estimated the prevalence of
T2D among men in the Middle East (including the UAE) from a review of 74 studies.[15] From 17 studies included, the prevalence of T2D among men in the UAE was 25.8%.
The prevalence in the Gulf was obviously related to the gross domestic product of
these states (p = 0.0005).
A large cross-sectional study investigated the prevalence of diabetes and risk factors
in the school-attending adolescent population of the UAE in 2021.[16] A stratified random sample survey of 151 public and private schools across seven
emirates involved 6,365 school-attending adolescents (12–22 years). Overall, diabetes
was reported by 0.9%. This was higher in males than females (1.5 vs. 0.5%, respectively).
Diabetes status was positively associated with some characteristics of adolescents,
including male sex, parental marital status, and smoking/illegal drug use. The high
prevalence of smoking and illegal drug use in adolescents with diabetes suggests a
need for mental health and behavioral interventions and better parental support and
involvement.
Diabetes during Pregnancy
Emirati women, similar to other Arab women, have been identified as carrying a high
risk of gestational diabetes and diabetes during pregnancy on several counts. Obesity,
ethnicity, and high fertility with pregnancies continue to the third and fourth decades
of life.[17]
[18] The earlier research by obstetricians from UAE, mostly in clinic-based surveys,
addressed the overall frequency and the contribution of diabetes to the general outcome
of the pregnancy and some specific complications such as macrosomia and shoulder dystocia.[19]
[20] Also, several studies, particularly from Al Ain, investigated the validity and utility
of various strategies for screening and diagnosing gestational diabetes in this high-risk
multiethnic population.[21]
[22]
However, more recent studies are larger and include the epidemiology of diabetes in
pregnancy in the UAE, the applicability of several diagnostic guidelines, and the
impact of lifestyle management.[23]
[24]
[25]
[26]
[27]
[28]
[29] The Mutaba'ah study is the largest multicenter mother and child cohort study in
the UAE with an 18-year follow-up. Discrepancies among the diagnostic criteria in
identifying gestational diabetes mellitus (GDM) cases were evident emphasizing the
need to unify diagnostic criteria to provide accurate and reliable incidence estimates
for health care planning, particularly as the agreement with the recommended criteria
was not optimal.[23]
The pregnant women's perception and knowledge of the impact of obesity on prenatal
outcomes was evaluated in a cross-sectional study using 526 self-administered questionnaires,
with a response rate of 72%. Most (81.8%, n = 429) entered pregnancy as overweight or obese.[24] The percentage of pregnant women who underestimated their weight category was 12.1%
in normal-weight participants, 48.9% in overweight participants, and 73.5% in obese
participants (p < 0.001). The overweight and obese participants were 13 times more likely to underestimate
their weight status and 3.6 times more likely to select their healthy gestational
weight gain (GWG) correctly. Women's awareness of pregnancy-related complications
from weight varied from 80.3% for diabetes to 44.5% for fetal complications; their
awareness of breastfeeding difficulty was the lowest at 2.5%. Moreover, there was
a misconception about personal body mass index (BMI) and the appropriate range for
GWG. Healthy lifestyle counseling urgently needs to be addressed in preventative health
programs such as premarital and preconception counselling. Whether lifestyle intervention
in early pregnancy can prevent GDM in high-risk pregnant women in the UAE was addressed
in a randomized controlled trial.[25] A open-label, pragmatic, randomized clinical trial included 63 women, with ≤12 weeks
of gestation, singleton pregnancy, with ≥ two risk factors for GDM. They were randomly
assigned to the lifestyle intervention (LI) group (n = 30) kl g and usual care (UC) group (n = 33). The LI group received a 12-week, moderate-intensity lifestyle intervention
with individualized counseling on diet, physical activity, and behavior change by
a licensed dietitian. The UC group received the usual antenatal care. They revealed
that a 12-week moderate-intensity lifestyle intervention in early pregnancy could
reduce the relative risk of GDM by 41% among high-risk pregnant women in the UAE.
These findings could impact public health outcomes in the region.[25]
The maternal early-life risk factors and later gestational diabetes mellitus were
the subjects of the cross-sectional analysis of the UAE Healthy Future Study.[26] Three more focused studies on Ramadan fasting, the use of technology by pregnant
women, and the outcome of twin pregnancies were also published in the UAE. Hassanein
et al[27] explored the safety of fasting in GDM in Ramadan while understating the glycemic
variability. Twenty-five patients with GDM who choose to fast were enrolled and provided
optimum care that included Ramadan-focused education, and FreeStyle Libre Flash Continuous
Glucose Monitoring (FSL-CGM) was utilized for a 2 to 4 weeks assessment period of
non-Ramadan days plus 2 to 3 weeks during Ramadan and medication adjustment. The average
glucose improved significantly, while time in target and percent above target numerically
improved during Ramadan compared with pre-Ramadan. There was a significant increment
in the number of hypoglycemic events in Ramadan. The average lowest blood glucose
reading was reduced significantly by 14 mg/dL, with the average hypoglycemic event
duration increasing significantly by 38.5 minutes. Our study reinforces the importance
of structured education before Ramadan to deliver optimal care for diabetes management.
Strikingly, FSL-CGM demonstrated that hypoglycemia significantly increases during
Ramadan fasting. There was an effective reflection of hyperglycemic spikes immediately
after Iftar.[27] Afandi et al assessed the value of CGM and self-monitoring of blood glucose in patients
with GDM during Ramadan fasting in a prospective observational study that recruited
GDM patients treated with diet ± metformin. Twenty-five patients were recruited. Thirty-six
thousand six hundred twenty-eight readings by the CGM device and 408 readings using
glucose meters were captured. The average glucose level was 103 and 113 mg/dL on CGM
and glucose meters, respectively. The rates of hyperglycemia were 5.7 and 14.2% and
hypoglycemia were 4.4 and 1.5% by CGM and glucose meters, respectively. While all
hypoglycemic episodes occurred between 16:00 and 19:00 in both approaches, only 38
(9%) self-monitoring of blood glucose (SMBG) readings were done.[28] Also, a 5-year retrospective review of hospital records of twin pregnancies in 404
women in Al Ain using relevant data was carried out from two major hospitals in the
city.[29] They were 30.1 years of age, overweight or obese (66.5%), and multiparous (66.6%).
A higher incidence of GDM occurred in twin pregnancies (27.0%). GDM mothers were older
and heavier. They were also very likely to have had GDM in their previous pregnancies.
The prognosis of mothers with twin pregnancies and GDM leads to independent and increased
odds of cesarean section and hospitalization during pregnancy.[29]
Diabetes Care
Diabetes Guidelines
Diabetes requires continuous medical care consisting of multifactorial risk modification
strategies, not merely glycemic control. Diabetes care keeps changing with new evidence,
therapies, and technologies that may improve the well-being and outcomes of people
with diabetes. Consequently, most international bodies concerned with diabetes (e.g.,
the American Diabetes Association [ADA], European Association for the Study of Diabetes,
IDF, etc.) produce and regularly update guidelines that cover all aspects of diabetes
care based on the interpretation of the latest available evidence.[30]
[31] These international guidelines were developed mainly for populations in the Western
world. In 2020, the Emirates Diabetes Society (EDS) revised its national EDS consensus
guidelines for managing T2D.[32]
[33] The guidelines considered the screening, diagnosis, and management of T2D in adults
and individuals at risk for developing the disease. These guidelines have been adapted
for local use to improve the care for people with diabetes by increasing awareness
among health care providers practicing in the country.
Goals and Organization of Care
The aim of diabetes management is to prevent complications and maintain a good quality
of life.[34]
[35]
[36] To achieve this, hyperglycemia and cardiovascular risk factors should be controlled,
necessitating regular follow-up. A patient-centered approach should be adopted to
enhance patient engagement in self-care activities. Individualized treatment goals
and strategies should be informed by carefully considering patient factors and preferences.
Patients with diabetes benefit from the services of coordinated multidisciplinary
teams. Such teams include physicians experienced in diabetes management, diabetes
educators, dieticians, and podiatrists. Other health care professions, such as pharmacists,
ophthalmologists, cardiologists, nephrologists, and vascular surgeons, contribute
with their relevant expertise.[34] Glycemic control is usually assessed by HbA1c, which reflects average glycemia over
the previous 3 months, SMBG, and more use has been made of CGM.[35] For most patients with diabetes, a target HbA1c of <7% should be the aim. This target
corresponds to SMBG fasting glucose values of 80 to 130 mg/dL and postprandial levels
of <180 mg/dL.[35] However, targets should be individualized based on age, hypoglycemic risk, diabetes
duration, patients' motivation, and comorbidities, especially cardiovascular disease.[34]
Strategies for Glycemic Management
To achieve the glycemic targets stated above, a comprehensive diabetes care program
is required. This program consists of structured education, glucose monitoring, lifestyle
modification by physical activity and diet, and appropriately selected pharmacotherapeutic
agents.[32]
[33]
[34]
[35]
[36]
Diabetes self-management education (DSME) in a structured manner should be offered
to all patients with diabetes and/or their family members as appropriate. DSME and
support should be patient centered and may be offered in group or individual settings.
DSME aims to empower the patient with the necessary knowledge, skills, and capabilities
needed for confident diabetes self-management and to provide activities that sustain
the lifestyle modifications needed to manage the condition in the long term.[36]
All patients with diabetes should have access to a qualified dietician at diagnosis
and as needed later (at times of intensification, suboptimal responses, and problems
with hypoglycemia, weight gain, etc.). The aim is to provide patients with nutritional
recommendations that address specific needs and goals based on personal and cultural
preferences and practical tools to adopt healthy eating patterns.
As most patients with T2D are either overweight or obese, nutritional plans should
aim for a weight loss of 5% or more to achieve favorable outcomes in optimal control
of blood glucose, plasma lipids, and arterial blood pressure.[31]
[33]
There is not enough evidence to advocate an ideal percentage of calories from carbohydrates,
fat, and protein for all people with diabetes. Hence, the distribution of macronutrients
should be based on an individualized assessment of metabolic goals, eating patterns,
and patient preferences. In general, nutritional advice emphasizes the use of nonstarchy
vegetables, minimizes refined grains and added sugars, and gives preference to whole
foods over highly processed foods.[34]
[35]
[36]
Dietary plans for UAE patients need to consider the local custom of eating dates.[37]
[38] For instance, dates are a popular food item incorporated in stable food and as a
dessert. Dates are rich in calories; any meal plan should account for this. Dates
were shown to have high fiber content and as a source of antioxidants and minerals.[37] A local UAE study showed that dates have a low glycemic index and may not result
in significant postprandial glycemic excursions.[38] Nonetheless, excessive intake of dates is not uncommon, especially in summer, with
a negative impact on diabetes control, albeit transiently for many patients.
Regular exercise improves blood glucose control, reduces cardiovascular risk factors,
contributes to weight loss, and improves overall well-being and self-esteem.[39] Consequently, international and national guidelines recommend that patients with
T2D undertake more than 150 minutes of moderate aerobic exercise per week and two
to three sessions of resistance exercise weekly.[33]
[34]
[35]
[36] Of particular concern is that a local study found that 3% of patients with T2D in
the UAE reported physical activity levels that meet the recommended guidelines. Therefore,
much effort is needed to encourage patients with diabetes to exercise and to identify
and deal with barriers preventing them from doing so.[39]
Because of the progressive nature of T2D, most patients experience relentless deterioration
of β-cell function and rising hyperglycemia. Therefore, lifestyle changes alone will
not be enough to maintain euglycemia. For this reason, increasing pharmacotherapy
will be needed in most patients.[33]
[40] Traditionally, first-line therapy starts with metformin and comprehensive lifestyle
modification. After metformin, other drugs can be used, including sulphonylureas,
DPP4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, pioglitazone, and basal
insulin.[33]
[40] Over the last decade, several cardiovascular outcomes trials have provided evidence
that two classes of antidiabetic medications (the GLP-1RAs and the SGLT2 inhibitors)
have resulted in cardiovascular and renal benefits beyond their glycemic efficacy.[41] These findings have significantly influenced the latest guidelines on the choice
of antidiabetic medications.[33]
[40]
The national UAE diabetes guidelines have classified patients with T2D into four risk
groups: very high, high, moderate, or low, depending on several factors, including
CVD or target organ damage, age, diabetes duration, and cardiovascular risks.[33] The guidelines suggested that drugs with proven cardiovascular and renal benefits
(i.e., GLP-1RAs and SGLT2 inhibitors) should be offered to patients in the very high-risk
category and should be considered for those in the high-risk category regardless of
the level of glycemic control. For those at moderate and low risk, the choice of drugs
will depend on other factors such as hypoglycemia risk, impact on weight, and cost.[33]
Many patients with T2D eventually require insulin therapy. Patients should be made
aware of the progressive nature of T2D, and the use of insulin should be viewed as
a phase in the natural progression of the disease and should not be seen as a sign
of the personal failure of the patient. With careful patient education and an explanation
of the efficacy of insulin in maintaining glycemic control, patients' reluctance to
use insulin can be overcome.[27] Health care professionals should avoid clinical inertia, and there should be no
delay in recommending treatment intensification for patients not meeting treatment
goals.[27]
Cardiovascular Disease and Risk Management
Cardiovascular Disease and Risk Management
Atherosclerotic cardiovascular disease (ASCVD) encompasses coronary heart disease,
cerebrovascular disease, and peripheral arterial disease, presumed to be of atherosclerotic
origin. These are the leading causes of morbidity and mortality in patients with diabetes.[41] Established risk factors for ASCVD, such as hypertension and dyslipidemia, are commonly
associated with diabetes. Other risk factors for ASCVD include smoking, obesity, albuminuria,
chronic kidney disease (CKD), and a family history of premature coronary heart disease.
Modifiable risk factors should be identified and treated. In addition to coronary
heart disease, heart failure has been more recently recognized as a critical cardiovascular
complication in patients with diabetes. There is clear and undisputed evidence that
controlling these risk factors prevents or slows the progression of ASCVD in patients
with diabetes. For this reason, control of these ASCVD risk factors is vital in the
management of patients with diabetes.[41]
CVD risk factors need to be addressed more aggressively in patients with cardiovascular
disease in the Middle East as their risk is higher than their counterparts in Western
countries. It has been shown that patients who present with acute coronary attacks
in the Middle East are 10 to 12 years younger than those in Western countries.[42] Furthermore, patients from the UAE with T2D were found to have a high prevalence
of comorbidities such as hypertension, dyslipidemia, and obesity.[43]
Hypertension is a major risk factor for both ASCVD and microvascular complications,
and the current targets agreed by most international guidelines are a BP of <140/90 mm
Hg in patients with low risk for CVD, while a target of <130/80 should be aimed for
in those with high CV risk.[33]
[41] Specific antihypertensive drug classes that have been shown to lower cardiovascular
events in patients with diabetes include angiotensin-converting enzyme (ACE) inhibitors,
angiotensin receptor blockers, dihydropyridine calcium channel blockers, and thiazide-like
diuretics. Therefore, for patients with diabetes, ACE inhibitors or angiotensin receptor
blockers s should be the first-line medications, especially in the presence of coronary
artery disease or albuminuria patients.[33]
[41]
Low-density lipoprotein cholesterol (LDL-c) has been shown to correlate linearly with
the risk of ischemic heart disease; therefore, it is considered the primary lipid
parameter to be addressed. Together with lifestyle modification, statins are the drugs
of choice for treating dyslipidemia in patients with diabetes. To achieve the appropriate
lipid targets, patients should be prescribed high-intensity or moderate-intensity
statins.[33]
[41] Patients with a previous ASCVD event are considered very high risk, whereas those
with multiple risk factors are at high risk. The target LDL-c for those at very high
risk for ASCVD is <55 mg/dL, for high risk <70 mg/dL, and for moderate risk <100 mg/dL.
For patients who do not achieve targets on the maximum tolerated dose of a statin,
consideration should be given to adding ezetimibe or a proprotein convertase subtilisin/kexin
type 9 inhibitor.[33]
[41]
Aspirin should be prescribed to all patients with diabetes who have had a previous
ASCVD event (i.e., for secondary prevention). However, aspirin is generally not recommended
for primary prevention, as, for most patients, the risk of bleeding outweighs any
ASCVD reduction benefits.[33]
[41]
Diabetes and Technology in UAE
Diabetes and Technology in UAE
In the context of diabetes, technology denotes all hardware, devices, and software
that people with diabetes use to assist their condition management.[44] Diabetes technology encompasses two main categories: insulin administration tools
and blood glucose monitoring.
Insulin is administered by pens or pumps (i.e., continuous subcutaneous insulin infusion).
Blood glucose is assessed by SBGM, CGM, and flash glucose monitoring (FGM). However,
more advanced diabetes technology includes hybrid devices that monitor glucose and
deliver insulin. Some of these devices function automatically. The software also serves
as a medical device providing diabetes self-management support. Diabetes technology,
education, and close follow-up improve the lives of people with diabetes. However,
the complexity and rapid changes in the diabetes technology landscape can hinder patient
and health care providers' implementation. Technology has been evolving, using the
internet of things for diabetes care.
Digital health or mobile health (mHealth) is defined by the WHO Global Observatory
for eHealth as “medical and public health practice supported by several mobile devices.”
These devices include mobile phones, monitoring devices, personal digital assistants,
and other wireless devices.[44] Digital health apps can be generally considered under three categories: (1) those
used for tracking wellness, those that function as stand-alone medical devices; (2)
those that display, download, and/or use data from medical devices that diagnose,
prevent; monitor or treat a condition CGM, insulin pump; or (3) automated insulin
delivery system.[45] These devices improve health outcomes and quality of life by coaching patients,
supporting healthy behavior, encouraging glucose monitoring even remotely, assisting
with interpreting results, maintaining lifestyle modification, guiding dosing, and
reducing complications.[46]
Several studies have confirmed that self-care behavior specific to glucose monitoring
is essential in managing glycemic levels. Incorporating technology into diabetes management
can augment and facilitate self-management. The CGM systems have revolutionized how
diabetes is managed.[47]
[48]
[49]
Recent abilities to continuously measure interstitial glucose allow the detection
of time in range (TIR), glucose variations, and hypoglycemic events.[50] TIR is a novel concept based on the time in near normal glucose levels, defined
as under a range of 70 to 180 mg/dL for most patients. In 2017, an International Consensus
on Continuous Glucose Monitoring Standardized the Use of CGM technology. TIR generally
refers to the time spent in an individual's target glucose range (usually 70–180 mg/dL
but occasionally 70–140 mg/dL. Use of CGM helps promote therapy adjustments in both
T1D and T2D, especially for patients with frequent hypoglycemia.[51] Based on current evidence, a TIR of >70% is recommended for most individuals with
T1D and T2D. Other metrics derived from CGM technology include mean glucose, glucose
variability, and glucose management indicators in addition to time below range and
time above range. All metrics should be examined in every patient–physician encounter
and appraised against the recommendations.
Technology-Related Studies in UAE
Technology-Related Studies in UAE
The UAE has been an early adopter of CGM technologies. Glucose monitoring devices
are available to most patients with diabetes in both public and private health care
facilities. Several groups have published their CGM experience in different patient
populations and clinical settings ([Table 3]).[52]
[53]
[54]
[55]
[56]
[57]
Table 3
Summary of the studies on CGM and telemonitoring conducted in the UAE
|
Authors, year [ref]
|
Patient population (N)
|
Clinical setting
|
Technology used
|
Summary of findings
|
|
Alawadi et al., 2019[53]
|
High-risk patients with diabetes and chronic kidney disease stage 3 (CKD 3)
N = 25
|
Ramadan fasting (RF.)
|
FSL-CGM
|
RF under close supervision and optimal diabetes care was not associated with worsening
of HbA1c and renal function. More frequent and prolonged hypoglycemic episodes occurred
during RF.
|
|
Hassanein et al 2019[54]
|
Patients with T2D with stable known CHD
N = 21
|
During and after RF.
|
FSL-CGM
|
No associated adverse cardiovascular effects with RF in patients with stable CHD under
optimal diabetes care. A higher frequency of hypoglycemia occurred during RF.
|
|
Afandi et al., 2018[55]
|
Children with T1D (N = 24)
|
|
Freestyle Libre or Dexcom G5
|
Hypoglycemia is typically encountered during the hours preceding Iftar, indicating an over-effect of basal insulin; hence, basal insulin reduction is necessary
to minimize hypoglycemia risk.
|
|
Ehtisham and Adhami
2019[56]
|
Children with T1D
|
Routine follow-up
|
Comparison of FSL-CGM-derived estimated HbA1c
(eHbA1c) with measured HbA1c (mHbA1c)
|
eHbA1c tended to be lower than the mHbA1c, with no relationship between sensor wear
time and HbA1c. eHbA1c was within 0.75% of the mHbA1c 79.2% of the time.
|
|
Farooqi et al 2022[57]
|
Lost-to-follow-up T2D patients.
N = 38
|
Routine follow-up
|
home-based Telemonitoring (TM) devices
|
TM significantly improved overall DM outcomes (glycemic control and body weight),
indicating its effectiveness in a challenging population previously lost to follow-up.
|
|
Ashraf et al 2021[58]
|
T2D adults
N = 21
|
COVID lockdown
|
FSL-FGM
|
Despite reduced exercise and the psychological stress of the COVID-related lockdown
period, FGM-derived markers of glycemic control were improved.
|
Abbreviations: CGM, continuous glucose monitoring; CHD, coronary heart disease; COVID,
coronavirus disease; e-HbA1c, estimated HbA1c; FL-FGM, FreeStyle Libre Flash Glucose
Monitoring; HbA1c, glycosylated hemoglobin; MhbA1c, measured HbA1c; RF, Ramadan fasting;
T1D, type 1 diabetes; T2D, type 2 diabetes.
Two studies from the same tertiary care center in the UAE employed FSL-CGM in two
high-risk groups fasting during Ramadan (2016).[52]
[53] The first prospective interventional study included 25 patients with T2D and CKD
stage 3.[52] FSL-CGM data showed significantly longer duration and more frequent hypoglycemic
episodes during Ramadan than non-Ramadan. The mean BG readings were also significantly
lower during Ramadan than in the nonfasting period. The renal function showed no significant
change due to fasting. Therefore, in patients with diabetes and CKD-stage 3, RF under
close supervision and optimal diabetes care were not associated with worsening HbA1c
and renal function. The other study was a prospective study aiming to determine the
safety of fasting in coronary heart disease (CHD) patients with diabetes who insisted
on fasting.[53] Twenty-one patients with T2D with stable known CHD were recruited. Similarly, FSL-GCMS
data showed a higher frequency of hypoglycemia during Ramadan fasting. However, there
were no associated adverse cardiovascular effects with fasting in patients with stable
CHD under optimal diabetes care.
In a different patient population, Afandi et al assessed the frequency, timing, and
severity of hypoglycemia in 21 adolescents (mean age 16 years) with T1D while fasting
during Ramadan.[55] They were monitored using the FSL-CGM system. The data were analyzed by times of
the day and night and the eating pattern during Ramadan. The authors demonstrated
that hypoglycemia is typically encountered during the early evening immediately before
the iftar time, suggesting that basal insulin reduction is needed to minimize the
risk of hypoglycemia.[54]
Ehtisham and Adhami investigated whether the sensor-estimated HbA1c over 90 days accurately
predicted the measured HbA1c and whether its accuracy correlated with the percentage
of sensor data captured in 24 children with T1DM who were wearing a glucose sensor
(20 Freestyle Libre and 4 Dexcom G5).[56] The mean measured HbA1c was 7.9%, and the mean predicted HbA1c was 7.7%. Estimated
HbA1c tended to be lower than the measured HbA1c, but the mean difference (MD) was
negligible. There was no correlation between lower sensor wear time and HbA1c. With
the increasing sensor accuracy, the estimated HbA1c may eventually replace the three
monthly HbA1c blood tests.
Farooqi et al evaluated the impact of telemonitoring devices on glycemic control and
compliance in 38 previously lost-to-follow-up patients with T2D in an interventional
single-center study in Dubai.[57] Patients were provided with home-based telemedicine devices at the initial visit.
The mean HbA1c decreased significantly from 10.3% at baseline to 7.4% at the end of
3 months of follow-ups (MD of −2.9%). The authors concluded that TM significantly
improved overall diabetes outcomes indicating its effectiveness in a challenging population
of T2D patients who had previously been lost to follow-up. Another group from Abu
Dhabi described their experience with telemonitoring.[57] They described data on 21 individuals using FSL-CGM who were remotely connected
to the diabetes clinic. Overall, glycemic control improved during the coronavirus
disease 2019 (COVID-19) lockdown compared with the weeks before. They demonstrated
that despite the reduced exercise and the lockdown-associated psychologic stress,
there was an improvement in FGM-derived markers of glycemic control.
These few studies in our region show how integrating technology into diabetes management
can improve the care of people with diabetes, particularly in ethnically relevant
issues such as Ramadan fasting. The technology continues to be refined and upgraded;
health care providers will have access to tools that can monitor patients more accurately
and provide real-time recommendations on management. Improvements in monitoring have
the potential to translate into a better quality of life with fewer diabetes-related
complications. UAE has been at the forefront of embracing these advances.
Insulin delivery systems are valuable tools for diabetes management. However, not
every patient with diabetes may be eligible for pump use. Identifying candidates is
the first step. The ADA recommends a list of questions to be answered when choosing
a given approach for insulin therapy (i.e., pump versus multiple dose injections).[44] These need to be addressed under regional circumstances to get the best possible
approach for the individual patient within his or her skills, financial means, and
access to professional support.
Professional and Patients' Perspectives
Professional and Patients' Perspectives
Since 2007, when the DM prevalence in the UAE was ranked the 2nd highest in the world
(19.5%) according to the IDF annual report, there has been a significant public, governmental
and professional interest in the challenges of diabetes.[1] Several epidemiological studies have documented the increased prevalence of diabetes
in both the native population and expatriates.[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11] Centers of excellence for diabetes care were established as stand-alone (such as
Rashid Center of Diabetes and Research, Imperial College London Diabetes Center, and
Dubai Diabetes Center [ICLDC]) or within the major health facilities (Sheikh Khalifa
Medical City, Dubai Hospital, and Tawam Hospital). Diabetes care received appropriate
prominence in all public and private health care facilities. An increasing volume
of research has been published ([Fig. 1]). Several annual and occasional conferences on diabetes have been conducted by the
EDS, Gulf Chapter of the American Association of Clinical Endocrinologists (Now Gulf
Association of Endocrinology and Diabetes [GAED]) to improve the understanding and
management of diabetes.[58]
[59]
[60]
[61]
Fig. 1 The increasing scientific research on diabetes in the UAE is reflected in the increasing
number of articles identified by the search term (Diabetes AND Emirates) in the abstract
or title fields of the PubMed database (January 1, 1998–December 31, 2023). They were
retrieved on March 6, 2024.
UAE recently became a focal point for health-related Ramadan fasting research, including
diabetes.[62]
[63]
[64] Furthermore, to support more physicians' knowledge and expertise, several international
universities providing postgraduate education in diabetes, particularly from the UK
(Cardiff, Warrick, and Leicester), have extended their presence in the UAE. A national
university (Sharjah University) recently provided its MSc degree in diabetes care.
In addition, an endocrinology fellowship program was established in Abu Dhabi as a
collaboration between ICLDC and SEHA hospitals (three years of training, one in UAE
and two in the UK). Another endocrinology fellowship program started at Dubai Hospital
in 2022. Two medical journals specializing in diabetes and endocrinology are in the
UAE (Dubai Diabetes and Metabolism Journal by Dubai Health Authority and Journal of
Diabetes and Endocrine Practice by GAED). This may encourage more locally conducted
research to find its way to publication. In addition, the Arab Society of Pediatric
Endocrine and Diabetes has its headquarters in the UAE and runs many of its activities
locally.[65]
UAE pioneered early access to the latest types and therapies, including modern pharmacological
classes, shortly after their approvals in their manufacturing countries. Also, health
insurance schemes widely support adopting high technology, such as CGM and insulin
pump therapy, as discussed above. Trained and qualified diabetes educators increasingly
support patients. There is a single layperson patients' society named Friends for
Diabetes Association based in Sharjah, which plays a vital role in patient advocacy
and conducts regular activities.
Conclusion
The review focused on a few pertinent aspects of diabetes and diabetes care in a young
nation that experienced a rapid increase in wealth and prosperity. The burden of diabetes
impacted both native and expatriate populations. We identified the interplay between
diabetes risk during pregnancy and youth. It underscored the increased cardiovascular
risk in people with diabetes as an example of long term complication. Diabetes care
challenges, guidelines, and professionals in routine care and in centers of excellence
provide lots of experiences being implemented under different health care systems
and models.
The incidence of T2D among UAE nationals who are overweight or obese was 16.3 per
1,000 PY. Age above 44 years obesity in women and prediabetes in men predicted the
development of diabetes.[66] Metabolic syndrome among adults in the UAE is approximately 37%. Age, sex, ethnicity,
age, sex, educational level, marital status, and BMI were positively associated with
metabolic syndrome.[67] Microalbuminuria is highly prevalent (61%) among patients with diabetes in the UAE.
The rate was higher in men, those with higher BMI, and in the setting of other diabetes-related
microvascular complications.[68] Over one-third of all deaths in adult UAE nationals with DM could be attributed
to nonoptimal glycemic control.[69]
A remarkable volume of the literature emphasizing on diabetes and diabetes care in
the UAE has been analyzed over the last three decades ([Fig. 1]). However, the available literature has some notable limitations.[70] Several studies are based on a single city or locality rather than a more comprehensive
national basis. Also, some outcome studies are based on the data collected from different
health care systems with differing levels of coverage and access to conventional and
advanced resources. These may introduce methodological and conceptual cofounders that
prevent the generalization of conclusions on a national level and direct comparisons
due to the different methods employed in various settings. Many studies are limited
to observational methodology rather than reflections on quality improvement exercises.
There are limited data on the incidence of diabetes in the UAE, particularly T1D and
monogenic forms of diabetes. Also, there are different models of health care provision
(national health services, independent sector, and employer-associated provision)
and financing (national, insurance-based, and out-of-pocket).
A concerted effort is needed to evaluate diabetes nationwide using the unified methodology.
Specifically, documenting the nationwide burden, exploring possible differences in
various epidemiological phenomena, and accessing health care are crucial. These should
ascertain the impact on outcomes and evaluate the cost-effectiveness of care using
different models.
