THE incidence and prevalence of diabetes in Kuwait are alarmingly high. Dr Faisal Al Refaei, Director of Clinical Services at Dasman Diabetes Institute, in this interview to the Arab Times takes us through the various aspects of the disease, and the challenges involved in its treatment and management. Education, he stresses, is the most important weapon to fight the disease.

Question: It is said that the incidence of diabetes in Kuwait is very high. Is that true?
Answer: If you look at the research in terms of prevalence Kuwait is definitely part of the top ten countries in the world. In fact all the six Gulf countries in terms of incidence and prevalence are all part of the top ten. The last published data on this subject, I think is dependable. It is not based on forecasts. The last study done locally was in 1998. It involved two of our consultants here at Dasman Diabetes Institute.
Back then the incidence was 15 percent of the total population. That was back then, and today we think the incidence will be around 25 percent of the total population. That’s the estimate. Which means one in four Kuwaitis will have diabetes. To me that is an alarming figure. So, yes, we are definitely on top of the table, which is nothing to be proud of. It is a major issue.

Q: You say the rate of incidence was 15 percent of population in 1998, and now you estimate it at 25 percent. Based on what is this estimation. How do you assess the incidence to have grown at this rate?
A: Looking at the rate of how often we are getting to see new diabetic patients is alarming. Not only that, the age of the onset of type 2 diabetes in patients is getting lower. Patients coming with type 2 diabetes are younger in Kuwait compared to the rest of the world. So, if in the US we see type 2 diabetes present in patients around 14 or 15, which is the youngest there, we have actually seen type 2 diabetes patients below 10 years old.
This is actually very alarming because type 2 diabetes is not genetic, unlike type 1, which used to be called insulin dependent. Type 2 diabetes is caused due to environmental factors like food, obesity, lack of exercise etc. I think that part is very alarming.

Q: Why is the situation so bad in Kuwait? Are there any specific factors that contribute to the high incidence of this disease in this region?
A: There are two parts to the story, one is genetic and one is environmental. We think may be the genes are playing a role in that we are more amenable to diabetes than other populations. Here in Dasman Diabetes Institute we are trying to unravel the mysteries behind this disease, and we have got our own genetic centre here. There is research taking place currently.
But I think the biggest component is actually environment. It is the changes around you that affect how the disease comes about. Mainly it’s lifestyle and behaviour in that sense, and of course nutrition. When you say lifestyle it also includes exercise.
Our lifestyle is sedentary, meaning we are less active and less inclined to leave home and be involved in physical exercise. Partly due to the weather conditions, which is something we can’t control. And so people are comfortable sitting at home and relaxing. Exercise is the last thing on your mind, and you don’t actually want to move around much.
Moreover, we the society has transformed from a less affluent and traditional nature to a very rich and modern one in less than sixty years. With affluence comes extra help and the appeal of physical exercise is even less. Even the nature of our jobs has changed. Our jobs don’t involve much physical labour, and with the advent of technology, we are having to do lesser and lesser physical work. Most of our jobs involves sitting comfortable in our seats staring into computers.

Then there is the question of nutrition. With so many fast food chains and other eateries and processed food, our diet has undergone a massive change. We consume very low amounts of food prepared using natural produce. Our diets are very unhealthy. The food we eat is a major factor in diabetes in two ways. One is we eat more of carbohydrates and glucose rich diet, which has a direct bearing on diabetes, and then of course there is obesity which kicks in with overeating. Obesity is a major contributor to diabetes.
So, I think the alarming rate of diabetes in Kuwait is a result of all these factors, and the absence of a natural progression into it. The fast and sudden change in the lifestyle of the society has triggered the onset of the disease much faster.

Q: Is the problem tied to the inability of the society to cope with the sudden changes that has overwhelmed it in a very short span of time? How does this compare with the onset of diabetes in the affluent countries in the West?
A: The suddenness of the change has played an important role. And I think the new lifestyle has been taken for granted. I am not an advocate of the culture of having maids to do all your work. If you go to the West, they are rare. They are rare because the society there has realized that these are luxuries that should not be actually abused, but used in special situations.
What’s happening in Kuwait is that these are not seen as luxuries but as fundamental to living. Long working hours and cheap manpower... you really wonder about these things. I think it’s getting rich too fast that has caused us to believe that these things are beneficial to us. But I also believe that there is a trend emerging that is moving away from these luxuries slowly. And here at Dasman, one of our objectives is instilling that education in the public. We are very big on education. We emphasise a lot on education on diabetes. Education in lifestyle, behaviour modification and nutrition.
The focus is to prevent diabetes rather than managing it. Managing diabetes is costly, especially in cases where the patient has had diabetes for 15, 20 years, and suffers complications, which by the way are many. So, prevention is the best bet and changing lifestyle is essential for that.

Q: You have partly answered my next question, which is what’s Dasman Diabetes Institute doing to fight diabetes. Yes, education you said, but then how do you reach the people? How do you conduct your interventions?
A: There are three or four ways how we fight diabetes. Research is one of them. Education is another. Training, meaning professional training, is also part of it. We do that here in the institute. We train professional teams that work in the public sector. The intention is to look at national programs, which we are working on currently, for education and disease prevention. We are setting up an information centre. You will be able to call in and ask questions about diabetes.
As we are also a research institute, we will continue our efforts there, and we will have subjects where we will also include the families of patients. Although we have been around for five years, we have not gone all out in the media. It’s only recently, since our new DG took over that we have been looking at this option seriously. Prior to that it wasn’t moving along a clear path with a clear plan. Now it is, and things are picking up very fast.
A part of this is also linked to the Ministry of Health. We have got a post graduate degree program in collaboration with the University of Dundee that offers a post graduate certificate for a diploma, and there is potential for PhD.
As part of training, we are actually bringing in international experts for lectures and to train full teams. We are funding it fully. We think this sort of training for full teams is essential to manage diabetes in the community. Ultimately, we devise models here at Dasman Diabetes Institute to deliver diabetes care and how to deliver diabetes care.

We test the models, involve people from the community and the public healthcare sector and then roll them out so that they can replicate it. We are also using technology and information, informatics, to manage the disease. So we have devised an electronic medical record, distributed throughout the public office system. That spoke about diabetes and complications. Basically, we had guidelines and advice to help physicians make the right decisions. So each family physician becomes an expert in diabetes. Plus it is linked to us, so anyone can get guidance whenever needed. The idea is also to empower the patient to see his blood results and other records and get an idea about his own disease. That’s, however, for a later stage. We think it’s the individual who has to first take care of himself, and then the family... so you know take it upwards in a stepwise fashion, including the family doctor and then the hospital. And us should be the last in that chain. The focus is on that.
So that’s about management, and for prevention we have our own lifestyle centre here. We propagate good lifestyle and try and spread the word. We have walkathons every year, public initiatives. And we have a lot of lectures educating the public on how to eat, how to watch out for early signs. In diabetes you might go through a period we call glucose intolerance, when your glucose level is on the borderline. And there is time for you to act in that period and reverse the progression. So you might not be there yet, but you are heading there, and that’s something you can reverse. And usually it is things like exercise, food and things like that that make the biggest difference at that stage.

Q: Can you tell us a little more about lifestyle change? What sort of diet, how many minutes of exercise every day, what sort of exercise and all that.
A: About an hour, three times a week, of moderate exercise like brisk walking, biking, swimming etc, should be good enough. And the general guidelines on food are that you move away from fast food, fried food, extra carbohydrates and sugar. You need to have a balanced diet. Have less of processed food and more of natural food. And part of it is also looking out for calories, because you should also try not to put on weight. Because overweight is a risk factor.

Q: What are the complications that diabetes can lead to? You said that managing diabetes is costly, because the complications are many.
A: About 15 years ago, I actually did my elective on diabetes foot care. It’s alarming how people back then didn’t know what consequences diabetes can lead to. So, if you asked them could diabetes lead to blindness, they would say no, but it could. Now, blindness is actually a preventable complication of diabetes, but only if you tackle it. Only if you first realize that it can happen.
What diabetes can lead to is a lot of things. Heart disease is one. It can lead to neurological complications. That’s why we hear some patients saying that they can’t feel their legs properly and things like that. And it’s not just about not being able feel parts of your body, but you don’t realize when you get injured, and injuries take longer to heal. Kidney diseases is another thing. Diabetes can lead to chronic renal failure. Foot diseases is a major thing which we want to tackle. So tight glucose control is really the corner stone of diabetes management. The more you keep it in line with normal figures, the less likely it is for you to develop complications down the line.
There are examples in the US where people have lived for 40, 50 or even more years with diabetes. They lived natural lives, doing what they are supposed to do to keep it under control, whether it’s pills, insulin or exercise or a combination of things.

Q: What are the different types of diabetes?
A: There are two types of diabetes: type 1 and type 2. Type 1 is when insulin production ceases in the body and you need to inject insulin into your system. There is a genetic component to that. But there are sporadic cases too. Type 2 is the one that comes usually later in life, but as I said, we are seeing early onset of type 2 in the Kuwaiti population which is alarming. This is mostly due to environmental factors, and it means that the cells are not responding to the insulin production well enough. Some are also due to poor insulin production in the body.
Then there is gestational diabetes, which is the one that comes around pregnancy. It may stay in some cases, and may resolve after delivery.

Q: What are the latest developments in the treatment and care of diabetes?
A: There are developments going on all the time. There are new types of drugs coming up. We are involved in research here. But generally the focus has been on educating the patient on the existing knowledge that we have. Existing knowledge on not treatments, but on what to eat, how to live, which has the biggest impact, you know. Insulin pumps are something new, and so active insulin secretion is made possible. The patient actually controls how he gets insulin. Of course, he needs to be a very aware and informed patient to be able to deal with that.
There are surgical procedures such as pancreatic islet cell transplantation, and whole pancreas transplantation. Pancreas is the place where the insulin is being produced. And islet cells are the ones responsible for that. The islet cell transplantation is currently under clinical trial, and so is neither a proven treatment or management technique. But there have been cases of patients going from insulin dependence to insulin independence after the surgery. Some with medicines and some even without. But they are recent, and so we haven’t seen the longer effects of that kind of surgical treatment.
And of course, islet cell transplantation is much simpler than whole pancreas transplantation, in which case finding donors with the right match and so on are difficult. And of course there are always more patients than there are donors, and so it is not as viable an option as you would want it to be.
Q: Don’t you have this problem of finding donors in the case of islet cell transplantation?
A: Yes, islet cells are from the pancreas of a deceased donor. But you can get more cells from a single donor and treat many patients.

biography

Dr Faisal Hamed Al-Refaei is currently the Director for Clinical Services at the Dasman Diabetes Institute in Kuwait. He is also being increasingly more involved in the Kuwait-Scotland Health Innovation Network. Dr Al-Refaei has an interest in quality improvement in healthcare from his years in the public sector in both Scotland and Kuwait, and is also interested in the biotechnology and biosciences industry through his private sector experience.
Dr Al-Refaei received his Bachelor’s degree in Medicine and Surgery (MBChB) from Aberdeen University in Scotland, for which he received the Amiri Honorary Medal for Scientific Achievement from the Kuwaiti government. Subsequently, he completed his Master’s degree in Healthcare Management with Distinction at the University of Wales, Swansea.

Prior to joining DDI, Dr Al-Refaei was the Regional Director for the Middle East at Amphion Innovations plc and focused on turning world-class research and intellectual property into successful and thriving businesses. With the absence of a local environment that promotes such endeavours, he developed an interest in promoting entrepreneurship and health innovation in the region. As such he is a member of the Arab Science and Technology Forum, the Arabian Knowledge Economy Association, the Gulf Venture Capital Association and is the Education Chair for the Kuwait Chapter of the Young President’s Organisation.
Before that, Dr Al-Refaei was the head of Quality Assurance and Accreditation offices for various health regions in Kuwait and was part of the team that designed and launched the Ministry of Health Hospital Accreditation Program in Kuwait. He is also a founding member of the Quality Assurance Physicians Society and is the founding treasurer of the Kuwait Society for Quality and Excellence.
Dr Al-Refaei has a research interest in physician job satisfaction and health reform.