Diabetes is one of the leading causes of death in the world today. According to the World Health Organization, the number of people with diabetes has nearly quadrupled since 1980. While those diagnosed with the disease can live long with proper management, early detection and intervention is the starting point to take control of one’s health. In this interview, Dr Kashif Rizvi, Consultant Physician & Endocrinologist at Mazaya Clover Centre, discusses the many issues surrounding the disease in Kuwait.
Arab Times: How has Kuwait responded to the awareness of the high incidence of diabetes in the country over the years? What improvements have been made at personal, community and institutional levels?
Kashif Rizvi: I think the answer to your question would be a simpler one if it was about an infectious disease or a vector borne disease like hepatitis or malaria. Kuwait has successfully contained and eradicated many such diseases due to a vigilant identification and management systems. Diabetes on the other hand is a very complex issue as it is deeply embedded into the cultural, social and institutional fabric here. Type 2 diabetes is mainly driven by the lifestyle of ‘obesogenic food consumption and masterly inactivity’ and it has to be a gradual process to raise awareness and deal with the consequences of this complex and deadly syndrome. Having said that there is increasing awareness amongst people and health care providers to identify at risk cohorts of people, like in schools and workplaces, early diagnosis with primary care centres across the country and organised, structured tertiary care alongside good quality research. So we have made progress but still there is a long way to go to exact a social, cultural and institutional change. Conversations like this one especially on World Diabetes Day are part of this ever so important dialogue.
AT: What is the current prevalence of diabetes in Kuwait? How does it compare according to age, gender and demographics?
KR: The answer to this question, in reality is another challenge, as collecting robust data is difficult in Kuwait. There are a wide variety of people here from different backgrounds, who seek healthcare sporadically or never. Diabetes on the other hand is of several types, some forcing people to get to a doctor, the others requiring general awareness due to the paucity of symptoms.
The data available is nonetheless a fair assessment into the scale of the problem. There are close to 3 million people living here out of which 400,000 or 15% of adult population are known to have been diagnosed and one could safely say there would be a similar number undiagnosed or in the so called ‘pre diabetes’ area. There used to be a time when Type 1 diabetes was considered to be affecting people younger than 40 years and Type 2 older age groups but unfortunately this boundary is now blurred and we see very young people with Type 2 diabetes as well. Kuwait features in top 5 countries with diabetes consistently.
Perhaps a better way to look at it is to not focus so much at the surrogate marker of mishandled glucose by the body but central obesity, which is commonly known as waist circumference. If you are a man whose waist is approached 38 inch or a lady with waist 32 inch it’s better to get yourself checked and alter your lifestyle to ‘eat less and walk more’ plus watching blood pressure and quitting smoking. This is easy to remember for individual people and does not require a visit to a clinic. So remember the words ‘watch your weight and watch your waist’, please.
AT: You mentioned that diabetes in children has become a cause for worry in Kuwait. Can you tell us more about this?
KR: Diabetes in children is of course worrisome as it has the added dimensions of enormous parental burden (parents literally living the diabetes of their child) effect on child’s psychology and hence quality of life, and the perceived length of the disease as children by default live the longest by the will of God and one has to protect them from complications of diabetes much more robustly and follow up in a structured pattern. Although most kids have Type 1 diabetes which as a disease entity is different in its cause and is a result of the body’s immune system misfiring on the insulin producing cells. This diabetes remains relatively constant around 10% of total diabetics. The worry you are referring to is the onset of Type 2 diabetes in children which is directly linked with inactivity and fast food reliance resulting in obesity in kids. One very important message for kids is to reduce ‘screen time’ when kids are just staring at a screen i.e. TV, computer, handheld device, Play Station etc to not more than an hour a day
AT: Is it true that genetic make-up presents high risk for children? What does that mean for Kuwait’s future incidence seeing that we already have an alarming prevalence today?
KR: Genetic makeup plays a larger part in Type 2 diabetes, the menace we are facing and much less so in Type 1. These genes are so called ‘thrifty’ i.e. know how to store energy so if we fall into the trap of eating energy dense foods like fast foods, starches, which is rice and bread mainly as staple and add the crucial element of inactivity then these genes will deliver an obese, with increased waistline, Type 2 diabetes person in due course. So we have to raise awareness on a continual basis.
AT: As we mark World Diabetes Day on Nov 14, what should people know about the risk factors and prevention of the disease?
KR: I think it depends on basic understanding of diabetes and then its prevention, identification and management should follow within an individual. As these people talk to within their immediate community a group is created and then the larger societal awareness is produced. The following is a brief description:
Diabetes mainly is of two types. Type 1 and Type 2. Type 1 is a relatively constant disease in terms of its incidence, because it is caused by what we call autoimmunity, the body’s defence system attacking its own tissues in the pancreas gland, and the body is unable to produce insulin. So it has to be treated with insulin at the outset.
The problem now that countries like Kuwait and virtually the whole world is facing is with Type 2 diabetes. Type 2 diabetes is a very simple problem but it leads to very complex situations. This epidemic of the last 50 to 60 years is relatively new although the disease always existed before but in small numbers.
It is mainly driven by consequences of industrialisation and of urbanization, as populations moved into big cities in pursuit of their sustenance from an economic perspective. This urbanization coupled with industrial revolution and affluence, where people got more resources, led to an environment which is conducive to becoming overweight. This obesogenic environment is partially a result of bombardment of advertising from fast food industry. You drive around and you see the logos of various fast food joints, which you can even drive through. They create a sense of convenience and also create a sense of family fun around them by installing climbing frames, slides or monkey houses adjacent to these outlets of food. As a result they become synonymous with a day out, fun evening etc.
Additionally there is also easy general availability of food, and there is an emphasis on starch-based foods like bread and rice. In Kuwait, like other Middle Eastern countries, we have a hospitable culture which revolves around food, so food is not eaten just for nutritional purposes, but for entertainment, socializing and at times to combat boredom or to celebrate. So there are many aspects of consumption of food and decrease of energy consumption. For example, you don’t have many pavements, public pathways or parks or places where people can go and exercise. It is not easy to walk because of the traffic. It’s a car-based society. The nature of the weather is another factor that contributes to a sedentary lifestyle.
AT: What is fundamental to management of diabetes to ensure the best quality of life?
KR: Like in most chronic disease, follow up is essential as there are usually no symptoms in Type 2 diabetes and patients feel relatively well for a number of years and unfortunately within this period of time there body is being damaged by the combination of glucose, BP, cholesterol and smoking if applicable. This damage manifests itself at the back of the eyes, kidneys and nerves of the feet due to leakage of small blood vessels or decrease in bone density due to concurrent lack of vitamin D and inactivity or a threat of a looming heart attack, stroke or erectile dysfunction due to the blockages of major and large blood vessels. This follow up enables the doctor to keep all parameters within normal to minimise the above threat. As the condition is usually not curable but ‘manageable’ so please attend regularly for follow up at your diabetic clinics.
AT: How will the hike in medical fees across the public sector in Kuwait impact treatment options for people and the level of care they receive?
KR: There are two ways of looking at it. No country can provide a bottomless pit for healthcare and you see even advanced societies reeling from this burden, so it’s good to wrap a structure around the cost to discourage misuse but at the same time it must remain affordable for the vast majority of population as the sufferers of diabetes and its complications are scattered across all segments of society. Additionally, it is vital to invest in preventative measures like parks, walkways, avoidance of fast foods and smoking plus encouraging follow up at primary care level as once a person becomes riddled with complications the cost to look after them rises exponentially.
AT: In your opinion, how early does prevention for diabetes start?
KR: That’s a good question indeed. I think it’s very early on when habits are instilled in a child. Simple things like encouraging playtime, healthier eating, and avoidance of screen time should start at home and school. The human body has this so called ‘metabolic memory’ where it tends to retain information from long time ago and reverts to the same pattern of behaviours accounting for the failures of yo-yo dieting and drastic dietary regimes later in life. So, sooner the better.
AT: What is the biggest change in care of Type 1 treatment? Has there been a change in the way we treat Type 2 diabetes as well?
KR: In type 1 diabetes there is promising research on many fronts. Monitoring is moving away from painful finger pricks to CGM (continuous glucose monitoring) devices and management ranging from newer safer insulins plus insulin pumps sometimes combined with automated monitoring, the so called artificial pancreas and also stem cells regeneration of insulin producing cells in the body. We feel that due to a clearly identifiable defect Type 1 diabetes holds promises in the future for its treatment.
Type 2 diabetes also benefits from better understanding of causation hence safer, newer drugs are now available to modify disease rather than just manage its symptoms, which also enable central weight loss which reduces BP, cholesterol as well as sugar. There are long acting i.e. once a month injections in the pipeline as well.
AT: What is the most promising research being done in the field today?
KR: I think the stem cells are where the most promising research is, as it offers a tangible cure for Type 1 diabetes. A word of caution as well in remembering that it is early days yet and often the medicines required for the success of stem cells are stronger than the consequences of diabetes in the long term so a patient must approach this with caution and under guidance from their doctors. Also, kindly beware of falsified information that some unregulated place in countries like China or Russia etc. could ‘fix’ your diabetes. Only approach internationally recognisable and reputed centres for advice as many people fall prey to a false promise causing big financial and health loss.
AT: How is technology being leveraged to manage the disease? What is the usage of such devices/applications in Kuwait?
KR: We have excellent continuous glucose monitoring systems becoming available without painful finger pricks and in the future mobile phone applications could be downloaded to monitor sugar from afar which would be great for parents of kids in school etc. Additionally telemedicine is being developed to be able to conduct consultations with senior physicians abroad on Skype etc to name a few.
AT: What is your outlook for the future?
KR: I think these things go a full circle, once people’s awareness and management of the condition improves, things will improve. The society on a larger scale has to play a part. It’s within us all to stop the progress of obesity and Type 2 diabetes with simple avoidance of energy dense foods like rice, bread, potatoes, fizzy sugar laden drinks and walk for 30 minutes daily. We as health care providers have to remain optimistic and hopeful for the future. There are better drugs and better equipment to deal with diabetes at the primary secondary and tertiary levels so in time we will see improvement which is visible. Discussions like this are important as we need to reach all parts of the society to influence positively.
We at our centre at Clover provide a multidisciplinary approach addressing all aspects of this disease and focus on preventing its complications enhancing quality of life and productivity of our clients.
Dr Kashif Rizvi
MD, FRCP, CCST (UK dual board certified)
Consultant Physician & Endocrinologist
Mazaya Clover Centre
Former Director New Mowasat Hospital Diabetes & Medical Centre, Kuwait.
Former Head of Department of Endocrinology and Diabetes — Kettering, UK
Certificate of Completion of Specialist Training — UK
Accredited Physician, Endocrinologist & Diabetologist
Teaching Faculty University of Leicester / Wales, UK
Editor, Journal of Endocrinology & Human Metabolism, California USA
Specialist Register, General Medical Council — UK
Member of Royal College of Physicians (London — UK)
Member of British Diabetes Association
Member of British Endocrine Society
Member of Association of British Clinical Diabetologists
Author of Several Peer Reviewed Research Papers
Tutor of Royal College of Physicians
Online appointments www.kuwaitdiabetes.com
By Cinatra Fernandes – Arab Times Staff