REVIEW ARTICLE

Diabetes in the Arab World: Prevalence and risk factors

JV Nielsen

Key words Arabs; diabetes rnellitus; prevalence; obesity; sedentary life-style

Introduction Accurate prediction of the number of people with diabetes in the future depends on stable population growth and stable diabetes preva- lence rates. While the growth of population in the Arab World has been stable at 2- 3%lyear, diabetes prevalence rates have increased dramatically.

The term ‘Arab’ is of uncertain origin and beaning. The word probably means ‘those who speak clearly’. It came into general usage in the seventh century when all the peoples of the Arab Peninsula were united by the religion of Islam. Today the word ‘Arab’ refers not only to people of the Arab Peninsula, but also to large segments of the populations of the Middle East and North Africa, as well as minorities elsewhere. Not all Arabs are Muslims; there are Arab minorities devoted to other religions in all Arab countries.

The term ‘Arab World’ in the present paper refers to the people living in the belt of arid lands that stretches from the Atlantic Ocean in northern Africa, between the Sahara desert and the Mediterranean, and almost all the way to Central Asia (Figure I). The total size of the population is uncertain but is estimated to be more than 160 million. The desert Nomads, Tuaregs, and the Bedouins typically constitute 1-5% of the Arab population.

In recent decades rapid demographic changes have taken place in the form of increasing urbanisation in many parts of the region. Whereas in the early 1970s 25% of the Saudi Arabian population lived in urban areas, by the early 1990s more than 75% did so. Urbanisation has been accompanied by affluent diet and sedentary life-style. Obe- sity, once a luxury for the few, is now a normality for the many.

Type 2 diabetes in the Arab World is the subject of the present essay, which gives an update of the present rates and, where possible, a historic perspective. It takes a look at obesity and sedentary life-style, two common risk factors for diabetes. No attempts are, in the Arab prevalence studies, usually made to categorise diabetes into subtypes. Type 1 diabetes is rare in Arab

countries; in Libya, for example, type 1 dia- betes accounted for only 2.2% of 10,772 people with diabetes’.

Epidemiologic methodology In type 1 diabetes the onset is usually abrupt, necessitating hospitalisation, thus making the calculation of incidence rates straight- forward. The insidious onset of type 2 diabetes, however, is often poorly defined. For this reason the preferred epidemiologic method is the estimation of prevalence rates, which is the percentage of diseased persons in a population sample at a given time. The rate can further be given as specific rates, for example age-specific, sex-specific, rural- urban, lower or higher socio-economic groups, etc.

The number of cases in the <20 year age group is negligible. Since half or more of the Arab population are aged below 20, preva- lence rates for whole populations must be doubled in order to find rates for the adult population.

Prevalence will, in the present essay, whenever possible be given as age-specific for people 40-60 years old. At this age people are usually still active and, in addi- tion, the rates predict the number of young people who are likely to be afflicted with diabetes in the future.

WHO criteria -sampling and screening procedures In 1980 the WHO study group of diabetes

Figure 1. The Arab World

Blekingesjukhuset Hospital, Karlshamn, Sweden JV Nielsen MO, Consultanf Physician, Department of Medicine Former post: Head, ConsultantPhysician, The Diabetes Centre, Dallah Hospital, Riyadh, Saudi Arabia.

Correspondence to: Jorgen Vesti Nielsen, Radhusgatan 19,37436 Karlshamn, Sweden

Submitted: 12October1998 Accepted in revised form: 17 March 1999

defined a set of international criteria for the diagnosis of diabetes, recommending the use of a 75 g oral glucose tolerance test (OG’IT) with determination of fasting and two-hour blood glucose levels’.

The WHO criteria require a 75 g glucose load and a two-hour venous blood glucose level >10.0 mmovL (venous plasma glucose >ll.lmmoVL) for the diagnosis of diabetes. Values 6.7-40.0 mmovL (plasma: >7.8- 4 1 . 1 mmoyL) are diagnostic for impaired glucose tolerance (IGT) and values <6.7 mmom (plasma: 7.8 mmoy1) are considered normal.

In most cases in the present Arab in- vestigations simple cluster samples or sim- ple random samples of households were chosen. In other cases (Saudi, Egypt) multi- stage, stratified cluster, random sampling techniques were used to ensure accurate representation

The participants in the Arab WHO-com- patible studies were nationals of the res- pectivecountries only; no expatriate workers were included. The responserates among the invited participants were 70-96%. Where both genders were included, the response

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REVIEW ARTICLE Diabetes in the Arab Wor1d:prevalence and risk factors

rate was equal between the genders. The rural populations represent agricultural vil- lages, but do not normally include the desert nomads.

Prevalence rates On the whole, all investigations, whether WHO compatible or not, indicate a rising diabetes prevalence in the Arab World (Tables I and 2). The prevalence in Tunisia in 1988, when WHO criteria were applied, was 4.7% and 5.2% inurban men and women aged 40-50 years, respectively. Nine years later, in 1997, the rates of self-reported dia- betes in a corresponding population were 7% and 13% re~pectively'.~. The rate of un- diagnosed diabetes comes close to the known diabetes prevalence in the Arab countrie~~-~. The 1997 Tunisian rate is likely to be two- fold higher if WHO methodology should be employed.

A steady increase in diabetes prevalence has been noted in a series of investigations from Saudi Arabia6"I2. The first study from 1982 included rural males only. Table 2 shows that since 1982 the rates have doubled in rural populations. The rate among the Egyptian rural population is lower, a dif- ference that could be associated with differ- ences in income, obesity, or activity. These factors are discussed later.

The proportion of people with undiag- nosed diabetes compared to the total was 45-56% in Saudi Arabia, 40-56% in Egypt and 3040% in Bahrai~~~.~.~.

Prevalence rates in the Arab World are now among the highest in the world. Figure 2 shows the rates in selected populations for comparison.

Age-adjusted rates indicate that in Egypt today 9.3% of the population aged > 20 years have diabetes compared to 6.5% in 1987. In Oman 10% of people aged >20 years have diabetes, and in Saudi Arabia, the figure is 12% in people aged > 15

The age-adjusted rates of impaired glu- cose tolerance (IGT) compare well with the open diabetes rates; they are 9.6% in Egypt, 12% in Oman, and 10.2% in Saudi ArabiaJ,4,6.

A clearer picture of the real diabetes prev- alence in the Gulf States would have been obtained if the investigators had included expatriate workers. These constitute a sub- stantial part of the population, for example 20-30% in Saudi Arabia, 36% in Bahrain, and 21% in Oman6.s*4. It is, however, im- possible to guess the consequences should the expatriates be included.

Urbanisation, income and diabetes The growth in the urban populations has been excessive. While the average annual growth rate 1970-1995 in the industrial

Table 1. Investigations of diabetesprevalence in Arabpopulations adopting WHO recommendations

Country Year Sample Population Age Diabetes % size (years)

Men Women

Tun isia3 1888 5613 Urban 4049 4.7 5.2 50-59 8.2 9.5

Oman' 1991 5497 Urban-rural 40-49 15.2 16.4 50-59 19.2 22.6

"Bahrain5 1998 2128 Urban-rural 4049 23.0 - 50-59 29.0 36.0

Saudi' 1997 13179 Urban 41-50 28.0 36.0 51-60 39.0 49.0

Urban 2 245 22.3 51.7 BEgypt7 1995 4620 Urban1 245 18.9 33.7

Diabetes rates among the 39+ years old. Oral glucose tolerance test with 75 g glucose was used in all investigations. Aln Bahrain only women >50 years were included. " Urban 1 = lower socio-economic status (40% of the population.). Urban 2 =urban higher socio-economic status (10 %of the population).

Table 2. Diabetesprevalence in Arab ruralpopulations

Country Year Population Age Diabetes % sample size (years)

Men Women ~~~ ~

*Saudis 1982 1385 males 45-54 9.6 >55 11.0

Saudi'O 1987 5222 35-54 7.0 16.0 >55 10.2 18.7

Saudi6 1997 131 79 41-50 17.0 11.0 51-60 22.0 26.0

Egypt' 1995 4620 >45 10.2 11.2

Oral glucose tolerance test was used in all investigations. Only men were examined in the early Saudi Arabian investigation.

countries has been approximately 1%, growth rates in the Arab countries have been an average 3.9% in North Africa and 7.7% in the oil-producing countries, from 4.25% in Kuwait to 12.75% in Oman. Egypt differs from the other Arab countries in this respect, the rate being only 2% with the proportion of urban residents being 44%, compared to 75-97%, in the Gulf States and 55-75% in the other Arab nations".

Different age-adjusted diabetes rates are associated with various degrees of urbani- sation. At the time of the investigations the urban populations were 40-50510 and 44% of the total populations in Oman and Egypt, respectively. In Saudi Arabia the proportion of urban residents was 75%4vJ.6. Urban life is associated with a higher occurrence of dia- betes. Egyptian prevalence rates in the 1980s among persons >30 years of age illustrate this relationship. Among the Bedouin- nomads constituting 1.2% of the population, the diabetes prevalence was 1.8%. The prevalence in the same age group in the rural, agricultural villages was 6.5%, and in the

urban areas 11.8%. The increase in the Egyptian age-adjusted (>20 years) rate from 6.5% in 1987 to 9.3% in 1995 is caused exclusively by the increase in the urban populati~n'~.'~*~.

Different densities of motorised vehicles may reflect different income levels, as well as suggest different levels of physical activity. In 1994 the number of motorised vehicles in Egypt, Oman and Saudi Arabia was 28, 139 and 280 per 1000 population, re~pectively'~. The gross domestic product (GDP) per capita in 1995 was $790 in Egypt, $4820 in Oman, and $7040 in Saudi Arabia" (see footnote). Such differences might con- tribute to variations in age-adjusted diabetes rates since a high income, in the Arab World,

~~ ~

Footnote - Figures for GDP do not pretend to be accurate. Different sources, even from different UN branches, do not agree. However, the pro- portional relations are fairly descriptive. Real GDP is used instead of purchasing power parity because real GDP matches import of technical equipment and machinery such as cars, while purchasing power parity does not.

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REVIEW ARTICLE Diabetes in the Arab World: prevalence and risk factors

Figure2. Diabetesprevalence in men and women aged 40-49 years

FIgure 3. The age-adjusted rates of diabetes, obesity and sedentary life-style are related to income-status in Egypt, 1995’

is associated with a high prevalence of diabetes and obesity.

In a Saudi Arabian rural population aged > 15 years the prevalence of diabetes in 1987 in the lower income bracket was 6.9%. while a high income was accompanied by a 26.7% prevalence. The same link is seen in the Egyptian population where, in the upper- income urban population, prevalence rates of diabetes, obesity and sedentary life-style are the highest in the

Such a positive association between in- come and diabetes is not seen in the Western World, where, on the contrary, a high income is coupled with a low diabetes occurrence. Diabetes occurs in the upper-income ranks among U.S. Hispanics and non-Hispanic

(Figure 3).

whites two-four times less frequently than in middle- and lower-income populations1’.

Obesity The increase of type 2 diabetes is associated with body mass indices (BMI = weight (Kg)/ height(m2). The relative risk of diabetes increases with increases in BMI, which is an independent risk factor for diabetesm. BMI 26-30 Kg/m2 is defined as overweight, BMI >30 Kg/m2 as obesity.

In Tanzania, with a low prevalence of diabetes, BMI >30 Kg/m2 was found in approximately 1 % of the adult population in 1989. In Brazil only 6% of 30-65 year olds had a BMI >27 Kg/m2 in 1996. The prevalence of obesity (BMI >30 Kg/mz) in

Figure 4. Prevalence of obesity in different investigations in the 7990s expressed as the name of the country with the age of the population examined

Swedish adults >15 years of age was 6.6% and 13.1 % in men and women, respectively, in 19901s*14.21. These relatively modest figures contrast sharply with the figures from the Arab World (Figure 4).

The 1997 prevalence of obesity (BMI >30 Kg/m2) in 13177 Saudi Arabian subjects aged>15years was 16%and24%inmenand women, respectively. The obese subjects were more likely to have diabetes (odds ratio = 1.5 and 3.0 in urban and rural areas, respectively)22. The 1995 prevalence of obesity in United Arab Emirates subjects aged >20 years was 10.7% in men, and 27.4% in women23. In Bahraini subjects, >30 years old, in 1997,2 1 % of men and 48 % of women were obeseN. In Tunisian subjects, >20 years old, the 1996 rates were 26.3% and 35.2% in men and women, respectively26.

In Egypt approximately half of the popu- lation lives in rural villages, the other half in metropolitan areas. Prevalence of obesity @MI >30 Kg/m2) in the rural population >20 years old was 6% and 25% for men and women, respectively, increasing to 10% and 41% in people aged 245 years. In the urban population with lower socio-economic status, which makes up 40% of the entire Egyptian population, among men and women 220 years old the prevalence of obesity was 19% and 64% respectively, increasing to 24% and 75% in those 145 years. Ten percent of the population has higher socio-economic status. The preva- lence of obesity among men >20 years old in this stratum was 56%, and 45% among women. The obesity rate among men aged 145 years actually declines to 36%, while

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REVIEW ARTICLE Diabetes in the Arab Wor1d:prevalence and risk factors

among women it increases to 73%7. There was an almost linear relationship

between obesity and the prevalence of diabetes inEgypt in 1995 (Figure 5).

On the Arab Peninsula Kuwait demon- strates the highest prevalence of obesity among adults. The rate was 36% in 1995 in the adult population (>20 years of age). At the same time the grade of urbanisation, (97%) the Gross National Product ($17,390 per capita) and the number of vehicles (370 per 1000 population) were the highest in the regionZS (Figure 4).

Caloric consumption Obesity is the result of overnutrition, gross imbalance between the caloric intake and the expenditure. In the Arab World the caloric consumption increased from approximately 2000 kcal per day in the mid-sixties to well over 3000 kcal per day in the mid-eighties. The consumption pattern of fat in Saudi Arabia showed a steady increase from 33.6 g per capitalday in the mid-seventies to 95 g per capitdday in the mid-eighties. The proportion of fat as a percentage of calories available during the same span of years increased from 10% to 30% while at the same time the consumption of complex carbo- hydrates declined correspondinglyz7.

There is no reason to assume that these trends have been reversed in the later years. The prevalence of obesity has not declined.

Sedentary life-style Sedentary life-style has been assessed by several investigators. In Bahrain the par- ticipants were questioned on their pattern of exercise and the amount of time spent watchingTVz4. Only 12.7% of menand 8.7% of women practised any sort of exercise. Watching TV is considered the main leisure time activity in the Gulf community. Three quarters of the population watch TV daily and more women than men watch TV for more than two hours per day. The inactivity of watching TV more than three hours per day doubles the probability of obesity com- pared to watching less than one hour per dayz8.

In Egypt the prevalence of sedentary life- style was estimated on the basis of occu- pational variables and outside-the-job vari- ables, where, on a four point scale, one re- flected a sedentary job and four reflected heavy, manual labour. Leisure time activities were assessed on a similar scale.

The prevalence of sedentary life-style was generally high. There is a linear relationship with diabetes prevalence (Figure 6). In the rural population 52% were sedentary; in the lower urban population 73%, and in the higher 89% were sedentary.

Figure 5. The prevalence of diabetes increases in relation to the obesify rate in Egypt, 19957

Self-perception and genotype Affluent diet and sedentary lifestyle are both major contributors to obesity and diabetes prevalence in the Arab World.

The presence of obesity defined as BMI >30 Kg/m2 is widely accepted in the Arab World. In the eyes of the health worker this would probably reflect failure of conveying insight on the importance of intervening with proper diet and exercise, but - to paraphrase the words of professor Al-Nuaim12 - it could well reflect how obesity is perceived with respect to well-being in the Arab popu- lation. Fifty-five per cent of obese women and 52% of obese men considered them- selves to have ‘about the right weight’. Four percent of the obese women rated themselves as underweight5.

To explain the high prevalence of obesity and diabetes in societies that are undergoing rapid demographic transformations the ‘thrifty genotype hypothesis’ was proposed. It states that certain populations may have genes that increased fat deposition in times of abundance. This represented a survival advantage in societies subject to cyclic food deprivation. When ‘sedentarisation’ increa- sed and calories became readily available, the genotype favoured the development of obesity and diabetes. The hypothesis would seem to hold in the Arab Worldz9.

Conclusion Diabetes prevalence rates in the Arab World, although dissimilar in different investiga- tions, are nevertheless all high.

Urban residency, personal incomes and economic growth are interrelated, and, in connection with affluent food and sedentary life-style, are associated with diabetes and

Figure 6. The prevalence of diabtes increases in relation to the proportion of people with sedentary life-style in Egypt7

obesity. All Arab countries have experi- enced various grades of economic growth and urbanisation. However, none of these factors are sufficient to explain the increased rates.

Cultural attitudes and perceptions seem to be required as well as a receptive genotype. In societies in rapid transition the ‘thrifty’ genotype leads to diabetes given that people’s concepts of well-being, i.e. obesity and sedentary life-style, are constant.

In the words of the Bahraini researchers Al-Mahroos etal.: “Health promotion strate- gies will have to take into account the apparent perception of obesity as a desirable attribute in the Arab populations”. And, regarding the convenient, energy-consu- ming activity of walking in a society where a car is at hand everywhere: “For walking to become an established activity changes in social attitudes would be neces~ary”~.

Using known rates the number of diabetes cases can be estimated to 3 4 million in the mid-eighties. In the mid-nineties it can be estimated to approximately 8 mi l l i~n~ .~ .~ .~ . ’~ . Due to the age-structure of Arab populations, less than 28 million (18%) are over 40 years of age while 20.8 million (13%) are aged 3040 years. Among the latter population, 1.5 million people with diabetes are found. The prevalence will increase among these young Arabs since incidence in 1995 was still high (2.5 per 1OOOpopulationperyearin 30-34 year old Libyans), and is twice as high as the American incidence among people c45 years of age (1.2 per 1000 popula- t i ~ n ) ~ , ~ ” .

The majority of the remaining 6.5 million people with diabetes are to be found among the 28 million people >40 years of age. This implies that diabetes is now found in perhaps

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REVIEW ARTICLE Diabetes in the Arab World: prevalence and risk factors

a quarter of the active and most experienced members of society. In 1987 it was found in less than 15% of this group, and in year 2005 it may well be found in a third. Already every second middle-aged urban woman has dia- betes in some areas of Egypt and Saudi Arabia.

Abandoning the OG'lT and lowering the fasting threshold plasma glucose (7.0 mmoY L) for the diagnosis of diabetes as proposed by the American Diabetes Organization (ADA) will lead to earlier diagnosis. It will also lead to an increase in the number of diagnosed people with diabetes in need of care. Already diabetes accounts for 36% of all encounters in a primary health centre in Riyadh32. But complete omission of the OGTT, at least as an epidemiologic tool, could lead to a decrease in the total preva- lence of diabetes. Studies have given con- flicting results".

The consequences for cardiovascular dis- ease in the Arab World are not known with certainty, but already coronary heart disease (CHD) was the leading cause of death in U.A.E. in 1992". Whether the impact of dia- betes on cardiovascular morbidity in Arab populations is more or less pronounced than in the Western countries is not known, but even a small increase in cardiovascular mor- bidity among the many people with diabetes will lead to a large number of patients with vascular disease.

The rates of amputations and foot ulcers, the other aspect of vascular disease in dia- betes patients, seem to be lower in urban Saudi Arabians with type 2 diabetes than in corresponding patients in the West3'. The absolute number of patients with this costly complication might nevertheless be over- whelming in the future. Rates of neuropathy, retinopathy and nephropathy seem to be at least as high among Arabs with diabetes as they are in the Westw3.

Perhaps it is worth mentioning that life expectancies in the Gulf States ranged between 70.3 years (Oman) to 75.4 years (Kuwait) in 1995. The corresponding figure in the UK was 76.8 years. Even with a diabetes onset in the middle-age the patients

will have sufficient life expectancy to suffer the ill-effects of the diabetes complications.

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