National Diabetes Program Kuwait Dr Monira Al Arouj

National Diabetes Program Kuwait Dr. Monira Al Arouj Assistant Director, Dasman Diabetes center, Kuwait

Diabetes in Kuwait Type 2 Increasing prevalence; – 1970 -1980 : – 1980 -1990 : 7% (MOH) 12% – 1996 -1998 : overall prevalence 15. 7% IGT 7. 0 % Abdella etal, Diabetes Res. & Clinical Pract. 42 (1998) 187 - 196

Characteristics of 3003 Kuwaiti adults aged 20 and above Characteristics Non diabetic (%) Type 2 DM (%) IGT (%) Exercise Inactive Occasional 58. 9 24. 0 67. 5* 20. 1* 58. 2 25. 3 Family history No Yes 50. 1 49. 9* 43. 5 56. 5* 38. 5 61. 5* Hypertension Normal Ht 90. 0 10. 0 74. 8 25. 2 80. 2 19. 8 BMI Normal 25 G 1 25 -30 G 2 >30 21. 6 38. 5* 39. 5* 14. 5 30. 5* 55. 0* 11. 0 25. 3* 63. 7*

Type 2 DM in children and adolescents • Increase in the incidence of type 2 DM in children and adolescents parallel to increase in obesity • In 2004, among 155 diagnosed with DM in the age group below 18 years, 46 had type 2 (30%) Kuwait Nutrition Surveillance System, 2004

Type 1 Diabetes - Kuwait • 1983 (Taha etal) 3. 9/ 100000 age 0 -14 year • 1991 type 1 diabetes registry was started (DIAMOND) – 1994 : 12. 8/100000 – 2000 : 18. 0/100000 – 2002 : 20. 1/100000 Shaltout etal, Diabet Med. 2002 Jun; 19(6): 522 -5

Diabetes Services in Kuwait • Primary Care Level – Diabetes mini clinics (34) – Drs, nurses, dietitians, lab & pharmacy • Secondary Care Level – Diabetes units in hospitals (3/6) • Tertiary Care Level (specialized center)

Primary Care Level Health Areas Total Al Asima Population (2004) Hawalli Farwaniya Al Ahmedi Al Jahra 423, 998 614, 187 632, 858 454, 345 290, 239 2. 415, 627 38, 471 33, 363 33, 041 25, 949 15, 852 146, 676 Number of mini clinics 7 6 10 7 4 34 Number of Drs. (Diabetologists) PHC 18 20 17 13 11 79 Registered Diabetic Patients

Diabetes Services in Kuwait • The mini diabetes clinics provide all the services & Insulins OHAs Free of charge • This system was not functioning properly for many years, for different reasons !!!

Diabetes Services Barriers • Attitude barrier - decision makers - professionals • Lack of Multidisciplinary team Approach • Lack of diabetic educators • Lack of standardized educational programs • Lack of screening programs for complications

What has been done? • Increase policy makers awareness • Kuwait Diabetes Society 1996 • National Diabetes Program (NDP) 2000 • Tertiary Diabetes Center (by NGO) 2006

Governmental awareness • Continuous campaigning to demonstrate the effectiveness of education, training and awareness in reducing the burden of diabetes. • Ministers, MPs, Media, Other NGOs

National Diabetes Program (NDP 2000) • Political will • Chaired by under- secretary MOH • Members: - Diabetologists - PHC - Nurse, health educator - Dietitian - Ophthalmologist -Surgeon - Education and awareness dep. In MOH • Sub-committees with: - Ministry of information - Ministry of education (school) - Kuwait diabetes society (DKS)

National Strategies • Action targeted across the continuum of care • Action targeted at the primary prevention of diabetes • Action targeted early detection of diabetes • Action targeted the care of people with diabetes

Programs 1. Organization and improvement of diabetes care delivery system: • • • PHC (mini diabetes clinics) Secondary care (Diabetes units in hospitals) Foot care program Eye screening program Children Care 2. Training and education programs for diabetes care team 2. Diabetes care programs in PHC 4. Programs for patients education and increase public awareness 5. Prevention programs

Diabetic Retinopathy screening Until the end of 1987 NO screening activities, at any level, were performed.

The Screening for Diabetic Retinopathy, Capital Health Region • First step - Evaluate data from variety of sources (ophthalmic care services, diabetes clinic and hospitals) - To know the basal situation (pilot study) • Second step - build on the existing strength

Diabetic Fundus Clinic - Amiri Hospital • Started 1987 • Run by diabetologists • Methodology: • Ophthalmoscopy • Fundus photography • Ophthalmology opinion and referral, when needed • Patients from Capital area (3 mini diabetes clinics in PHC)

Results of the First Year • 1050 patients • 536 (50. 1%) --- different grades of DR • 287 (53%) --- had Ophthl. Treatment • 1008 (96%) --- first eye check

Diabetic Retinopathy Screening Services • A training program for doctors in diabetic clinics, was started 1993. • training at Diabetes Unit and Ophthalmology Dep. • Training on how to detect sight threatening DR by ophthalmoscope • screening done at diabetes mini clinics using ophthalmoscopes only

Result

NDP 2000 • Diabetic Retinopathy Screening services for the whole country 2002 Committee: – Diabetologists – Ophthalmologisits – Administration • Screening clinic in the mini diabetes clinics (34)

General Principles • • • Diabetes Registry Call & recall system Training of diabetologists and PHC doctors Education for patients and public Create the link with Ophthalmology for easy referral and treatment • Identify the recourses (MOH, public funds)

What has been achieved? • Registry, call and re-call system (mini diabetes clinic) • Training and development of screening service (PHC Drs) in ophthalmology center and diabetes unit in hospitals • Digital Cameras in 20 of the diabetes clinic • Referral for ophthalmologists (treatment center) • Periodic assessment by Ophthalmologist

Conclusion • There is no well structured program for diabetic retinopathy, however there is established clinical services for screening in most of the primary care diabetes clinics and hospitals (digital cameras, training) • We are in process of developing an accepted protocol of action between the screening services and the treating center • We are in process of establishing the teleophthalmology services

The Diabetic Foot • A neglected complication of diabetes in Kuwait until 1994 • A retrospective study of 86 in-patient cases in 1989, showed: • high amputation rate (55%) • long hospital stay (66 days) • `A foot care clinic and team was formed

Foot care program • First diabetic foot clinic Amiri hospital 1994 • Team • diabetologist • surgeon • nurses • foot wear specialist • Podiatrist (2000) • Lab, X-ray, Vasc. Lab • referrals from capital area clinics • Daily

The Diabetic foot Clinic-Amiri Hospital Patients from Capital Area

NDP 2000 Diabetic foot care program • 5 diabetic foot clinic (one in each general hospital) • 2 podiatrists • Continuous nurses training to do the job of podiatrists • International diabetic foot conferences • Diabetic foot workshops

NDP What have been achieved 1. Organization and improvement of diabetes care delivery system: – 34 mini diabetes clinics in PHC – 3 diabetes units in 3 general hospital (secondary level) – Children care in 3 hospital – Eye screening program – Foot care program ( 5 foot clinics)

What else have been achieved ? 2. Training and education programs for diabetes care team (MOH, Faculty of medicine, KDS) For Doctors • Diploma in diabetes (UCD), 27 candidates • Continuous CME courses for all health care professions by MOH, faculty of medicine and KDS (diabetes clubs monthly) • Regular training for pediatricians in diabetes care in pediatric diabetes unit • Fellowship in diabetes ( 2 years post graduate fellowship) 2006 by MOH and faculty of medicine For nurses • Educate the educator courses, workshops for one week by help of IDF and WHO and others

3. Patients education (Kuwait Diabetes society) • Children club - Twice/ month, for child and the family with the diabetic team (25 -30 families/ week)

Patients education (regular at KDS) • Diwania (Adult club) - twice monthly , (40 -50 pt/ w) - Hb. A 1 c, foot care, fundus exam, dietary advice - Group education or one by one • Pregnancy advice - once weekly for diabetic control • Diet advice - Twice weekly • Glucometers & strips: 50 -60% discount • Sponsor a child with diabetes

4. Increase public awareness (KDS) • Local media : press release, radio and TV • Daily messages in newspapers • School (obesity and fast food) • Marathons ( yearly ) • KDS website (www. kdskw. org) • Educational materials • Participations in other social activities

SMS messages

Diabetes Care Program Main Objective Improve the quality of diabetes care in the PHC

Main Interventions Development and distribution of Clinical practice guidelines Training courses Participation in patients’ education Suggestion of drugs to be available Kuwait Diabetes Care Programme Determination and distribution of Monitoring and Evaluation Surveys Standards of care Implementation of standards

Dasman Diabetes Centre • Prevention programs • Training of health care providers • Patient education • Increase public awareness • Research

Promising Initiatives • GGSD - Annual workshops for health care providers - Biannual conference in each GCC country • Gulf committee for the National Diabetes Planning in the GCC region to adopt the same strategies and sharing experience

GCC Declaration on Diabetes 16 May 2007 • All ministers of health in the Gulf cooperation council states signed a declaration which recognizes diabetes as a chronic debilitating and costly disease, associated with sever complication that poses sever risks for families, member states and entire world. • Give all the commitments for putting plans and strategies that reduces the burden of diabetes • Copy was send to IDF president and will be distributed to all members

GCC strategic plan for diabetes prevention Goals • Primary prevention • Secondary prevention • Improvement of medical services in all level • Empowerment of methods of surveillance and follow up • Support researches • Empowerment of patients and their families role in the control of diabetes

• Each country should have operational action plans in a time bound program • Each goal have specific objectives, strategies, implementation stages and several standard and indicators to assess the success

Conclusion • Diabetes is a major healthy problem in Kuwait • Some promising achievements • Lots of efforts are needed • With clear objectives & vision and a dedicated team more and more can be achieved

Thank you

Thank you

Future plans • Prevention programs - Early detection of diabetes and its risk factors - Community-based healthy lifestyle programs, aiming for prevention of type 2 DM • More Diabetic educators and qualified dietitians • Foot care specialists (podiatrists) • Research

Thank you

NDP Objectives 1. Increase public awareness of the seriousness of diabetes, its risk factors, complications. 2. Improve understanding of diabetes and its control and promote self-management behaviours among diabetics. 3. Improve health care providers’ understanding of diabetes and its control and promote an integrated approach to care. 4. Promote health care policies that improve quality of and access to diabetes care. 5. Set strategies for early detection and prevention of diabetes and its complications

Patients education (regular at KDS) • Diwania (Adult Club) - twice monthly - Hb. A 1 c, foot care, fundus exam, dietary advice - Group education or one by one • Pregnancy advice - once weekly for diabetic control • Diet advice - Twice weekly Glucometers & strips: 50 -60% discount