There is a crisis that is impacting health care in the Arab nations of the Middle East and in north and west Africa: six countries in this region are on the top-ten list worldwide in terms of diabetes prevalence. Comprising 22 countries with a total population of 350 million people, these nations constitute only about 5% of the total world population. Yet, nearly 20% of the people in Kuwait, Lebanon, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) are diabetic. Not to be forgotten is the likelihood that between 41% (Oman, Saudi Arabia, and the UAE) to 62% (Algeria, Egypt, Iraq, Jordan, occupied Palestine, Sudan, and Tunisia) of the population is suffering from undiagnosed diabetes. Currently, nearly 10% of all adult deaths in Arab countries are related to the complications of diabetes. This disproportionate prevalence of diabetes within the Arab nations undoubtedly has long-term health implications that will manifest in several ways unless social norms regarding diet and exercise change, along with a serious effort to reconsider government priorities.
The prevalence of type 2 diabetes outweighs type 1 diabetes mellitus by roughly 10:1. Among the many causes of type 2 diabetes are the following: the inability of peripheral tissues such as skeletal muscle to respond to insulin (insulin resistance), impaired secretion of insulin from pancreatic cells, and eventually beta cell exhaustion and early programmed cell death of beta cells.
A discussion of type 2 diabetes invariably includes an understanding of the relationship between obesity and diabetes and a realization that fat deposits (particularly of visceral fat in the gut region and epicardial fat surrounding the heart) predispose patients to diabetes through a variety of mechanisms, most notably by releasing a variety of chemical mediators (adipokines) that have local and systemic effects. Fat cells release adipokines, which increase insulin resistance and also generate highly reactive free radicals that impair pancreatic function. Several studies reveal both ethnic and racial differences in plasma levels of adiponectin, an adipokine that has insulin-sensitizing effects. Vulnerable populations (e.g., south Asians) have increased insulin resistance, increased adiposity, and reduced levels of adiponectin.
An unknown in this scenario is whether adipokine biology (such as adiponectin levels, relationship to adiposity and insulin resistance, sensitivity to the protein, gene regulation) vary within Arab nations, perhaps in a gender-selective way. It would also be of interest to determine whether these levels change with time in migrant workers and other long-stay expatriates since there is evidence that Japanese moving to the United States take on the higher risk of diabetes and obesity levels of white Americans. Another possibility is that such populations may more easily accumulate fat deposits at even modest caloric intakes (in accordance with the hunter-gatherer or thrifty gene hypothesis, which proposes that obesity was beneficial in times of food scarcity but now, in a time of abundance and easy access and storage, has devastating consequences).
However, it has been shown that there is also a carryover effect when Arabs emigrate to other countries. Many Arab immigrants in the United States are prediabetic (as measured by glucose intolerance), with 41% of the subjects studied being affected. Of particular concern is the fact that it appears that more than 70% of those over 60 years of age are affected. There are several reasons that could explain this greater vulnerability, including maintaining a diet high in fat, sugar, and carbohydrates, coupled with a sedentary lifestyle. In addition, poor or weak acculturation has a negative impact on Arab Americans. Similar data are also true for Arab settlers in Australia and England. In fact, the first documentation of childhood type 2 diabetes (usually observed in adults) was in Arab girls. A study of Arabs and Jews in Israel reveals almost twice as many obese Arab women at similar body mass index (BMI) values (most likely due to differences in physique and deposition of visceral fat); of interest is that fewer Arab women were found to self-monitor their body weight.
Alarmingly, it is not uncommon these days to see children ten years old or younger being diagnosed with type 2 diabetes and obesity in Arab nations. It is therefore critical to understand the relationship between obesity (generally defined in terms of the BMI, although there is some issue to be taken with this as it may underestimate the role of fat distribution and may have limited use in growing children or in some ethnic groups) and the development of diabetes. While these two variables are well married, the contribution of obesity may vary by race and ethnicity. For example, while Asian Indians and Asian native Hawaiian and other Pacific Islander populations have the same overweight prevalence (~30–35%), the prevalence of diabetes is more than twice as high in Asian Indians (~15% versus 6%). Another important consideration involves dietary choices and diabetes prevalence: increasing intake of drinks and condiments laden with fructose as well as sugar-rich desserts (essentially empty calories) by 20% raises diabetes prevalence by 160%, and a daily diet with 20% more fat leads to a 67% increased diabetes prevalence.
Taking these numbers into account, it is relevant to note that the amount of dietary fat consumed in Saudi Arabia increased by 143% between 1971 and 1997. For example, a comparison of food products in Oman over a ten-year period (1993–2003) reveals that while there was a ~50% increase in sugar imports, there was only a 1% increase in imports of oranges over the same period. In contrast, increasing daily intake of fruits and vegetables by 20% reduces diabetes prevalence by 52%. Given the economic muscle of the Arab region, it would be affordable for those governments to encourage healthier food choices in vulnerable populations such as the young and the sedentary by subsidizing the cost of fruits and vegetables. Adding additional taxes to the cost of junk foods would be one way to recoup this cost.
The vexing dilemma of nature versus nurture is central to understanding the accelerated spread of obesity and diabetes in some regions. Supporting the impact of environmental and lifestyle factors is the observation that even expatriates in the Gulf region have a higher incidence of diabetes than compatriots in their home countries. One possible environmental and lifestyle factor is the rapid spread of fast food outlets in the Middle East region, a result of the attempt to provide comfort food to military personnel during the Gulf War period. Currently, 80% of Kuwaiti children are obese, and 70% of a typical Kuwaiti diet is based on fats (normal for humans is 30%) and fast foods. It is also of consequence that 75% of children in Kuwait consume one or more soft drinks a day.
There are some intriguing data (largely from animal studies with some corroboration in humans) showing that, in addition to the quantity and type of food consumed, another factor that could regulate adiposity is the time of day at which food is consumed. In short, much of the body’s cellular metabolic machinery is regulated by an internal clockwork mechanism (circadian rhythm) so that catabolic pathways related to glucose and fat metabolism are favored during daylight and anabolic pathways more so during the night. This could play some role in the rampant obesity in the Arab nations, where there is a culture of late-night meals and snacking.
Even more intriguing is the emerging biological data indicating that people in the Gulf region develop diabetes at lower BMI values and that this phenomenon can be related to the role of exercise. A proteomics report in 2013 showed that 47 proteins had a minimal 1.5-fold difference between lean and obese subjects and that at least 38 of these proteins can be favorably altered by exercise. Two genes that can be favorably influenced by exercise are thrombospondin 1 (involved in platelet aggregation, angiogenesis, and tumor formation) and histone deacetylase (important in transcriptional regulation and chromosome structure during fetal development). Exercise reduced expression of thrombospondin 1 in obese diabetic Kuwaitis while, at the same time, increasing the expression of histone deacetylase. An illustration of the seeming indifference of many Arabs to physical activity comes from the 2010 United Arab Emirates half-marathon: of the 306 participants representing several nationalities, there was not a single local runner. To encourage regular exercise, Arab governments should consider long-term strategic investments in exercise facilities, designated cycle paths, and parks.
Other emerging data indicate that nearly 50% of people who experience heart attacks have diabetes (and hospital death rates due to heart attacks are three times greater in diabetic patients), and more than 50% of Kuwaiti adults have high plasma lipid levels. An unfortunate consequence of Arab generosity, including lavish meals and generous hospitality, is the consumption of high-caloric food. The availability of relatively cheap migrant workers has also reduced the appetite for potentially beneficial lifestyle choices, both at home and outside the home.
There are also other regional and cultural factors that inevitably come into play as well, and these impose barriers to lifestyle modification. While obesity and diabetes affect both genders in the Middle East, it is generally females who are more severely affected. Some factors that make females more vulnerable include the lack of dedicated sporting or exercise facilities, the dearth of female sports clubs and leagues, the extraordinary expectations related to family obligations in relatively large households with extended family structures and complex social obligations, and concerns about being stigmatized. Complicating matters is the fact that Arab nations have one of the highest fertility rates in the world. The short spacing between multiple pregnancies increases the chance of fat deposition and weight gain, so it is not surprising that there is a linear relationship between the number of childbirths and BMI.
In addition, cultural determinants of obesity and diabetes in the Arab world have many facets: a Rubenesque figure may actually be a desirable attribute and possibly indicate affluence; a diet rich in red meat that is heavily laden with cooking oils (usually butter); and hospitality and social etiquette means generous servings and eating extravagant meals. It is unfortunate that about 99% of the nurses in the UAE are non-Arab speaking and are not culturally connected with local inhabitants. Another obstacle in patient education is that medical practitioners are often overweight (e.g., 44% in Bahrain). More recruitment from native health care workers will likely have a larger impact in working to change those cultural behaviors that increase disease vulnerability.
[accordion title=”Action Points”]
- Create innovative management solutions: Diabetes and obesity in Arab nations have many unique features based on cultural, geographical, and genetic factors. This suggests that rethinking is necessary in identifying those at greatest risk and creating a team-based approach (including government investment, legislative changes, and interprofessional management strategies).
- Identify root causes for greater vulnerability: Obesity and diabetes may occur at a lower set point in the Arab nations. The availability of new and improved molecular technology will aid in identifying specific changes in the biology of such vulnerable populations.
- Overcome barriers to positive changes in lifestyle modification: Concerted efforts should be made to target modifiable risk factors related to lifestyle choices particularly in the young, where lasting changes are easier to instill. Innovative strategies in patient-centered education in rural districts should focus on nutrition and increased physical activity. Exercise periods should be a part of daily school activities, coupled with nutritional guidance for all students (students teach parents). Creating awareness in school children is important since obesity and diabetes tend to occur at younger ages in Arabs, implying a greater lifelong risk for developing other chronic diseases. It is expected that this will increase health-related expenses by ~60% in the UAE within the next ten years.
- Determine what to fix: overeating versus underexercising? It may be that overeating, rather than a sedentary lifestyle, may be the main culprit in the wildfire of obesity and diabetes sweeping the Arab nations. (The World Health Organization Collaborating Centre for Obesity Prevention in Australia reports there has been no significant reduction in exercise levels in the past 30 years but there has been greater access to processed foods.) This needs to be rigorously studied in a local context in the Arab nations.
- Focus on creating lifelong eating habits: Prohibit, or at least severely restrict, insidious marketing to children via direct targeting or other more covert means. Place restrictions on marketing via food packaging, advertisements via television or social media, and school food outlets. Create more creative and more engaging school programs on nutrition, cooking, and health education for school children.
- Public education: Invest in walk-in clinics staffed by nutritionists and physical therapists who are Arabic speakers and very familiar with local habits and customs.
This situation, however, is not as gloomy as it may sound as significant inroads are being made with the establishment of centers of excellence focused on research, patient education, and the treatment of obesity and diabetes in the Middle East. Two such institutes leading this effort are the Dusman Diabetes Institute (Kuwait) and the Imperial College London Diabetes Centre (Abu Dhabi). Interestingly, some less traditional incentives for weight loss have also been put in place, including the reward system for weight loss that was created in Dubai in 2003 whereby locals are rewarded with a gram of gold (~US$50) for each kilogram lost in a 30-day period, with a threshold of a minimum of a 2-kg loss needed to qualify. Clearly, while attention grabbing, this incentive’s long-term benefits are untested, and it is also unclear if governmental incentives are reaping the desired rewards in patient education, reduced health care costs, and positive lifestyle changes.
In 2013, the American Medical Association declared obesity a disease that requires multiple treatment and preventative strategies; a similar awakening within the Arab World, coupled with changes in everyday practices, will go a long way toward garnering greater public awareness and targeted resources for managing this public health crisis.
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