Anne L. Peters, MD; Aus Alzaid, MD


September 29, 2014

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Diabetes in the Middle East

Anne L. Peters, MD: Hi. I'm Dr Anne Peters, in Vienna at the European Association for the Study of Diabetes (EASD) meetings. Today I am talking with Dr. Aus Alzaid, a diabetologist from Saudi Arabia.

We are talking about the differences and similarities in healthcare between Saudi Arabia and the United States. I am interested in your perspective, knowing the epidemic of diabetes that you are having in Saudi Arabia. Can you tell us what diabetes care is like there vs what it is like in the West and the United States?

Aus Alzaid, MD: Diabetes is extremely common. The recent International Diabetes Federation (IDF) figures suggest that Saudi Arabia has the highest rate of diabetes in the world after the small island nations in the Pacific. We know from studies done in the past—proper surveys that have been published—that 1 in 4 people after the age of 30 has diabetes.[1] I don't know of any Saudi family that doesn't have a member or two with diabetes. Diabetes is extremely common in the Gulf region as well, the highest on the IDF list.

That part of the Middle East is steeped in history and tradition and culture, which means a lot to people. Then we have diabetes as a condition, which has to do with the person's perception of the lifestyle modifications that must be made. It is very important that the treating physician know how to approach this, and how to deal with the issues related to diabetes—the interface between diabetes and culture. It could be good or bad depending on the patient's cultural perception, and that is why I like to share our experience with colleagues. I have had the fortune of working in Saudi Arabia and the Middle East for many years.

Dr. Peters: I work with the Latino population in East Los Angeles, where everybody just shrugs and says, "Everyone in my family has diabetes, so of course I have it, too." How does the fact that it is so common influence the public health message to make people aware of it or come in early for treatment? How do you leverage that into reaching families?

Saudi Approach to Diabetes

Dr. Alzaid: Our approach has a number of avenues. One is to raise public awareness in general. We have to take the bull by the horns, as they say. We have a serious problem raising awareness in general at all levels. Education is a key issue as well.

Dr. Peters: Most healthy 30-year-olds don't go to the doctor. Are you making a push to convince young, healthy people to be checked earlier?

Dr. Alzaid: Absolutely, and there are messages going out about lifestyle modification. The realization has dawned that something has to be done, and things are now in motion to tackle the problem by encouraging the right lifestyle. The Ministry of Health has public-awareness campaigns. In our institution, we have Diabetes Awareness Day in November. It is still an overwhelming issue, and we are doing research to find out why we have such a high rate of diabetes.

Dr. Peters: Have diet and rates of physical activity changed? What have you seen over the course of your career?

Dr. Alzaid: Decades ago, people were more mobile. Very little food was available in years gone by, but over recent decades, with the dividends of the good fortune, there has been a "constant feast."

Dr. Peters: That is an interesting way to put it.

Dr. Alzaid: There are cultural things that we adhere to as part of our social etiquette. Food items such as rice and dates are very popular in our part of the world, and they are obviously very heavy in terms of calories. Fizzy drinks are very commonly consumed. On the other hand, there is less exercise. Everybody drives a car. But the train has been set in motion to improve the situation with diabetes, and I genuinely believe that with everything put together over the coming years, we will see a difference in terms of the scale and severity of the problem.

If you ask me what would be fundamental, I would say that education is a real issue. When people have diabetes, we need to explain it to them, to approach them, and to motivate them. It is difficult anywhere, and we have more than our share.

Dr. Peters: Yes, you have had more than your share, and you have had—at least historically—worse outcomes in terms of complications. Tell me about insulin. How is taking insulin perceived culturally?

Dr. Alzaid: That is a difficult issue, because there is still some social stigma towards insulin. If you come to my clinic, you will hear the bargaining that goes on, trying to convince someone to go on insulin. It is always a difficult issue and you have to have the right approach to convince the patient. There is also the fear that the average patient thinks, from what they have heard, that they won't wake up the following morning because of hypoglycemia. People are aware of weight; many people are conscious of their weight. Patients will even admit to noncompliance with their medication. If you ask them, "Do you take your basal insulin at night?" they say no. They skip it regularly, unfortunately.

Dr. Peters: Is that medication free for the people?

Dr. Alzaid: Yes. The vast majority belong to one of the government institutions, so they have free access to medications. So it is not an issue of supply as much as perception by society, and culture is the biggest obstacle, in my experience.

Special Challenges Posed by Ramadan

Dr. Peters: Fasting during Ramadan also might make insulin very difficult. Although, if you are only giving basal insulin at night, I suppose it could work. How have you approached that in your patients?

Dr. Alzaid: If the patient has type 1 diabetes, we are adamant that the patient doesn't have to fast. There is a fatwa—an edict from the religious authorities—that if it is harmful to your health, then you shouldn't fast. It is not easy to explain this to the average patient, even if you have a 14-year-old on multiple doses of insulin for type 1 diabetes. This year, Ramadan fell in July. The temperature was higher than 100º F for five months of the year, so fasting is not easy.

Dr. Peters: You can't eat or drink the whole day long? No fluids at all?

Dr. Alzaid: No food and no water.

Dr. Peters: What do you do for hypertension? This is an interesting concept because diuretics, for instance, are such a big part of treatment, and the SGLT2 inhibitors as well.

Dr. Alzaid: Thefirst thing I ask people is, "What did you do last year at Ramadan?” We won't compromise from a medical standpoint if the patient has type 1 diabetes, and the fatwa allows those patients not to fast. This is being promoted and it is gradually prevailing in society. In terms of type 2 diabetes, we have a different sequence. It depends on what insulin or what treatment the patients are on. We encourage them to visit the Diabetic Center before Ramadan to get their instructions on what to do, especially those who are having their first Ramadan since their diabetes diagnosis. We always strive to educate people before the onset of fasting. We have a campaign before Ramadan starts to alert people about how to avoid all the issues related to fasting.

It is a tricky subject, because you don't want to compromise health on the one hand—that is our priority as doctors—but you also don't want to undermine the personal values of the patient. Still, it shouldn't be seen that way. There is no conflict if you approach the patient in the right way.

Dr. Peters: I want my patients to live their lives just as they would without diabetes, but obviously there is a balance and concessions that must be made. If somebody wants to fast, I can help them do it safely. In Los Angeles they are fasting because they are cleansing or doing some other thing that they decided is healthy. For me, whatever the patient's belief system is, if fasting is part of it, that is okay. Unfortunately, they don't necessarily lose weight or reduce their calories because they are eating the other part of the day.

Dr. Alzaid: Some patients consciously or unconsciously almost take advantage of Ramadan. They sleep during the day or do very little during the time that they are supposed to fast, but then overindulge at night. From sunset to sunrise, they eat the dishes and sweets that are part of Ramadan.

Dr. Peters: It is part of the experience. Of course, you want people to do that, but clinically we need to understand different cultures.

Technology in Diabetes Management

Dr. Peters: As a physician in Los Angeles, I am seeing more patients from Saudi Arabia. What are the most important "take-home points" for me when dealing with a patient who comes to see me in Beverly Hills for their diabetes? What should I know for understanding the Saudi patient perspective?

Dr. Alzaid: First of all, you are familiar with the culture. We have talked about this. You have a grasp of the local culture, but we are like anybody else in this world in that we have our own flaws and we have our own attributes.

Dr. Peters: How much does technology interface with your patients? How much do they use the Internet? How much do they use glucose meters? Patients can send you their blood sugar results now, with so much technology for diabetes. Is your population technologically savvy? My Beverly Hills patients love technology. Other patients that I have, who are older, may not interface with it as much, but technology is a way that we can manage patients no matter where they are.

Dr. Alzaid: That is the direction that diabetes care seems to be going in. You have people who are technically conversant, and they may even be better than the average doctor in terms of knowing how things work. The average Saudi, however, is not as well versed in the Internet. You make a good point that there is room for improvement, especially with technology being part and parcel of treatment in this day and age. We are generally moving in that direction. I am heartened by that.

Dr. Peters: It is a wonderful way to use our knowledge to help people all over and for people to help each other, so a Saudi's experience is probably more like another Saudi's experience than it is like somebody living elsewhere. If we can harness some of that interconnectivity and use it locally as well as internationally, it can help a lot.

Dr. Alzaid: That is a good idea. Then the patient will fare well overall.

Dr. Peters: Diabetes is diabetes. There are cultural nuances, but we have to help our patients—diagnose them early and treat them aggressively. Thank you very much.


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