Optimising the medical management of hyperglycaemia in type 2 diabetes in the Middle East: pivotal role of metformin.

AIMS: Increases in the prevalence of type 2 diabetes will likely be greater in the Middle East and other developing countries than in most other regions during the coming two decades, placing a heavy burden on regional healthcare resources. METHODOLOGY: Medline search, examination of data from major epidemiological studies in the Middle Eastern countries. RESULTS: The aetiology and pathophysiology of diabetes appears comparable in Middle Eastern and other populations. Lifestyle intervention is key to the management of diabetes in all type 2 diabetes patients, who should be encouraged strongly to diet and exercise. The options for pharmacologic therapy in the management of diabetes have increased recently, particularly the number of potential antidiabetic combinations. Metformin appears to be used less frequently to initiate antidiabetic therapy in the Middle East than in other countries. Available clinical evidence, supported by current guidelines, strongly favours the initiation of antidiabetic therapy with metformin in Middle Eastern type 2 diabetes patients, where no contraindications exist. This is due to its equivalent or greater efficacy relative to other oral antidiabetic treatments, its proven tolerability and safety profiles, its weight neutrality, the lack of clinically significant hypoglycaemia, the demonstration of cardiovascular protection for metformin relative to diet in the UK Prospective Diabetes Study and in observational studies, and its low cost. Additional treatments should be added to metformin and lifestyle intervention as diabetes progresses, until patients are receiving an intensive insulin regimen with or without additional oral agents. CONCLUSIONS: The current evidence base strongly favours the initiation of antidiabetic therapy with metformin, where no contraindications exist. However, metformin may be under-prescribed in the Middle East.

Serum homocysteine concentration is related to diabetes mellitus, but not to coronary heart disease, in Saudi Arabians.

INTRODUCTION: Plasma homocysteine (HCYS) concentration is believed to be an independent risk factor for atherosclerosis. METHODS: HCYS was measured in a cohort of 584 Saudi Arabians participating in a national screening study of coronary heart disease (CHD) risk factors. A total of 173 subjects (114 men and 59 women) had clinical CHD, of whom 82 (47.4%) had type 2 diabetes mellitus (56 men and 26 women). A further 127 subjects (60 men and 67 women) also had type 2 diabetes mellitus but no CHD. A total of 284 individuals (120 men and 164 women) were recruited as healthy controls, and had no previous history of CHD or diabetes. Serum HCYS was measured by high-performance liquid chromatography (HPLC) with electrochemical detection. RESULTS: Univariate analysis showed HCYS concentrations were significantly lower in those with diabetes mellitus (DM) than in controls, for both men [8.7 (4.2-18.6) vs. 10.5 (4.5-20.5) mmol/l, median (5th-95th percentiles, p = 0.009] and women [6.3 (3.3-24.0) vs. 8.1 (4.0-17.9) mmol/l, p = 0.049]. Stepwise multivariate regression analysis indicated a relationship between HCYS concentration and age, sex and the presence of DM, but not with CHD. CONCLUSIONS: In the Saudi Arabian population, serum HCYS is not a risk factor for CHD, but is lower in patients with DM.

Family practice in Saudi Arabia: chronic morbidity and quality of care.

Over a one-year period, 2990 patients attended a primary health care practice in urban Riyadh, Saudi Arabia. Of these, 33.5% had chronic disorders. Clinically significant obesity (BMI > 29.9 Kg/m2) was present in 24.5% of those with chronic disorders. Musculoskeletal disorders, diabetes mellitus (DM), digestive disorders and cardiovascular disease accounted for 38%, 36%, 24% and 22% of encounters respectively. Uncontrolled DM was encountered in 7.1% while uncontrolled systolic hypertension was present in 28.8% of patients with these disorders. A significant proportion (42%) of patients with bronchial asthma required emergency management. Symptomatic relief was obtained in 57% of patients with irritable bowel and 87% of patients with osteoarthritis of the knees. The results point to a trend of morbidity similar to that encountered in developed nations with affluence and sedentary life style. There is a need to focus on obesity, life style measures that reduce weight would be expected to positively influence diabetes, hypertension and osteoarthritis of the knees. Monitoring of outcome measures would help identify areas of improvement and preventive measures.

The prevalence of obesity among saudi males in the Riyadh region.

Attendees of 15 health centers in urban and rural areas in the Riyadh region were screened for obesity during May and June 1994. Systemic selection yielded 1580 Saudi males for analysis. The mean age was 33.6 +/- 13.5 years and body mass index (BMI) was 26.9 +/- 5.7 kg/m(2). Only 36.6% of subjects were their ideal weight (BMI < 25 kg/m(2)), while 34.8% were overweight (BMI 25-29.9 kg/m(2)), 26.9% were moderately obese (BMI 30-40 kg/m(2)) and 1.7% were morbidly obese (BMI > 40 kg/m(2)). Middle age, lower education and joblessness predicted a higher risk for obesity. Patients living in a rural areas had greater BMIs than those living in urban areas (P <0.01). Forty percent of overweight participants did not think they were so. The high prevalence of obesity and the lack of awareness among those afflicted emphasizes the need for community-based programs for preventing and reducing obesity, since weight control is effective in ameliorating most of the disorders associated with obesity, such as Type II non-insulin-depedent diabetis mellitus, hypertension, stroke, heart disease, sleep apnea syndrome and osteoarthritis of the knees. Young parents who are at risk of developing obesity and who play a central role in perpetuating it in their offspring should be the target of obesity-prevention programs.

Hospitalization patterns of diabetic patients: A six year experience at King Khalid University Hospital.

To determine the pattern of hospitalization of patients with diabetes mellitus (DM), the computer stored data on admission with DM as the primary or secondary diagnosis to King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia over six years (1986 to 1991) were analyzed. There were 3037 admissions of 2299 patients with diabetes mellitus (2.6% of all hospital admissions), occupying 33,253 hospital bed days (3.5% of all hospitalization days). Twenty-four percent of admissions were recurrent, 4% were frequent (more than once a year) and 6% were prolonged (more than four weeks). DM was the primary diagnosis in 39%, secondary to other illness in 47% and related to diabetes in pregnancy in 14%. Diabetes-related admissions contributed 54% of all hospital bed-days used by patients with DM and were for acute metabolic complications (and hence potentially avoidable) in only 10.6% of these admissions. These patients spent an average 3.26 days per year in hospital, which is double the published expected rates. Pregnancy-related admissions of females with diabetes are short in duration. When diabetes is a secondary diagnosis, the reasons for admission are mostly related to degenerative diseases similar to those in the nondiabetic population. Patients admitted to KKUH with DM are more likely to stay longer and be admitted more often than when DM is a secondary diagnosis. The majority of diabetes-related admissions are nonacute and potentially avoidable. Identification of risk factors for and prevention of lengthy recurrent admissions should be a priority in health care resource allocation.

Hypercholesterolemia in healthy adult males - A public survey in central Saudi Arabia.

To describe hypercholesterolemia in an urban community in Saudi Arabia, total serum cholesterol (TSC) was measured in 966 apparently healthy males (475 Saudi Arabs, 351 other Arabs and 140 non-Arabs) using a portable analyzer (Boehringer Model[R]). Mean age was 35.9 years (SD+/-9.1) and mean body mass index (BMI) was 26.2 kg/m(2) (SD+/-3.4) with a mean TSC of 5.20 mmol (SD+/-1.21). Mean TSC was significantly higher among non-Arabs at 5.74 mmol/L (SD+/-1.48) than in Saudi Arabs at 4.93 mmol/L (SD+/-1.11), P<0.001 mmol/L. TSC was higher than 5.20 mmol/L in 44.3% and higher than 6.80 mmol/L in 6.9% of the population. TSC was higher than 6.80 mmol/L in 3.6% of Saudi Arabs, 8.0% in other Arabs and 15.7% in the non-Arabs. This calls for cholesterol screening of the indigenous male population for hypercholesterolemia and other coronary heart disease risk factors at every opportunity. Among expatriate males, a mass screening strategy might be appropriate. The health care system needs appropriate adjustment to deal with this growing health problem.

High prevalence of clinical obesity among Saudi females: a prospective, cross-sectional study in the Riyadh region.

A cross-sectional study of 1385 Saudi females attending 15 health centres in urban and rural areas in the Riyadh region was conducted during September and October 1992 to determine the prevalence of obesity and its associated factors. The mean age was 32.2 +/- 11.7 years and body mass index (BMI) 29.2 +/- 7.0 kg m-2. Only 26.1% of subjects were their ideal weight (BMI < 25 kg m-2), while 26.8% were overweight (BMI 25-29.9 kg m-2), 41.9% were moderately obese (BMI 30-40 kg m-2) and 5.1% were morbidly obese (BMI > 40 kg m-2). High-risk groups for obesity were mostly middle aged, multiparous housewives. Patients living in rural areas had greater BMIs than those living in urban areas (P < 0.01). Thirty per cent of overweight participants did not think they were overweight. The study emphasizes the need for community based programmes for preventing and reducing obesity since weight control is effective in ameliorating most of the disorders associated with obesity such as Type 2 non-insulin dependent diabetes mellitus, hypertension, stroke, heart disease, sleep apnoea syndrome and osteoarthritis of the knees. The focus of efforts should be directed towards young mothers who are at risk of developing obesity and who play a central role in perpetuating it in their offspring.

Blood lipid concentrations and other cardiovascular risk factors among Saudis.

A study of 1005 family practice attenders at King Fahad National Guard Hospital was conducted during February 1993 to determine the prevalence of hyperlipidaemia and its association with participants' sociodemographic characteristics and clinical problems. The percentage of patients with total serum cholesterol concentration (TSCC) of 5.2-6.8 mmol/l was 39.3%, while those with TSCC exceeding 6.8 mmol/l was 9.5%. Hypertriglyceridaemia (TG > 2.5 mmol/l) was found in 5%. TSCC increased progressively with age up to the seventh decade. TSCC was higher among obese and diabetic patients than others. Obesity body mass index (BMI) > 29.9 kg/m2 was found in 32.8%, diabetes mellitus in 24.2%, hypertension in 11.1% and both diabetes and hypertension in 6.4%. There is an urgent need to equip primary health care teams with training and resources to help them give proper dietary advice, modify the local lifestyle and screen at least high-risk groups for hyperlipidaemia and other coronary risk factors.