Diabetes mellitusDiabetes mellitusorganization of organization of

carecarethe experience of Syriathe experience of Syria

Bassam ABDULMASSIH MDBassam ABDULMASSIH MD

EndocrinologistEndocrinologist

Istanbul Friday ,April 27 Istanbul Friday ,April 27 20072007

Syria

Epidemiology of DM in Epidemiology of DM in Damascus 1999 ( 24y – 64y)Damascus 1999 ( 24y – 64y)

التوزيعالنسبيلإلصابةبالسكريحسبفئاتالسن ) مستوىسكرالدمالفموي (

0.8 1.1

9.0 11.5 12.5

30.0

36.0

12.3

43.5

0

5

10

15

20

25

30

35

40

45

50

24-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

المجموع

فأكثر ( حسبفئاتالسن التوزيعالنسبيلمستوىسكرالدمالصيامي ) 140

0

5

10

15

20

25

30

35

40

45

50

ذكور إناث مجموع

فئاتالسن

24-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

malemale female all

Age group

Percentage of subject having glycemia >140mg\%ml

NCD in SyriaNCD in Syria in Syria a survey was conducted and it was a in Syria a survey was conducted and it was a

part of series of similar surveys conducted in part of series of similar surveys conducted in different country in the word backed up by the different country in the word backed up by the WHO .WHO .

the objectives of the study are to measure the objectives of the study are to measure NCD risk factors and to evaluate the NCD risk factors and to evaluate the distribution of these diseases in the Syrian distribution of these diseases in the Syrian population.population.

a total of 9184 individuals between 15-64 years a total of 9184 individuals between 15-64 years old , males and females, were chosen randomly old , males and females, were chosen randomly and were collected from 1002 clusters from all and were collected from 1002 clusters from all communities according to their population  .communities according to their population  .

NCD in Syria (continue)NCD in Syria (continue)

half of those individuals gave a half of those individuals gave a sample of blood for analysis ..sample of blood for analysis ..

the survey was carried out during the survey was carried out during 2003-2004 and the result was 2003-2004 and the result was published in 2005 by the report published in 2005 by the report (NCD distribution and risk factors in (NCD distribution and risk factors in the SAR lama hamish MD and the SAR lama hamish MD and all2005)all2005)

smokingsmoking

Alcohol consumptionAlcohol consumption

ObesityObesity

Physical activityPhysical activity

Nutritional habitsNutritional habits

HypertensionHypertension

DiabetesDiabetes

HyperlipidemiaHyperlipidemia

NCD in SyriaNCD in Syria

The average of glycemiaThe average of glycemia

قيمةسكرالدمعلىالريق

0 20 40 60 80 100 120 140 160

لبنان

ايران

االمارات

فرنسا

سوريا

لةدو

ال

/100ملليتر قيمةسكرالدمبالملغم

أنثى

ذكر

Syria

France

EAU

Iran

Lebanon

Fasting blood sugar

Mg \%ml

Fm

ResultResult

--in the 4742 individuals fasting blood in the 4742 individuals fasting blood test was donetest was done

22.9% of males and22.9% of males and

18% of females  and 18% of females  and

19.8% of the whole population had 19.8% of the whole population had a FPG >110mg%ml . a FPG >110mg%ml .

- the percentage of dysglycemia is - the percentage of dysglycemia is different according to the age group , different according to the age group ,

Result (2)Result (2)   in the group aged 15-19y 13.8% of males in the group aged 15-19y 13.8% of males

and 7.6% of females were hyperglycemic.and 7.6% of females were hyperglycemic. It increased gradually to reach 40.4% in It increased gradually to reach 40.4% in

male and 45.1% in female between 60-64y .male and 45.1% in female between 60-64y . from the questionnaire 4.8% of the from the questionnaire 4.8% of the

population answered by yes that they are population answered by yes that they are diabetics.(4.7% male ,4.9% female)diabetics.(4.7% male ,4.9% female)

this percentage is different according to the this percentage is different according to the age group (0.2% in the group 15-19y –age group (0.2% in the group 15-19y –increased up to 22.2% between 60-64y).increased up to 22.2% between 60-64y).

Epidemiology of DMEpidemiology of DM

15.6% of the individuals that were not aware to 15.6% of the individuals that were not aware to have diabetes, showed FPG >110 mg\dl (there have diabetes, showed FPG >110 mg\dl (there is no data about the percentage of those who is no data about the percentage of those who are between 110-125 mdl and those who are are between 110-125 mdl and those who are >126mg\dl)>126mg\dl)

in the diabetic population, to the question (did in the diabetic population, to the question (did you monitor your blood glucose the last year ?) you monitor your blood glucose the last year ?) 85% answer yes (93% in the urban area 71.3% 85% answer yes (93% in the urban area 71.3% in the rural area) so 15% of diabetics in Syria in the rural area) so 15% of diabetics in Syria don't have any follow up for there diabetes and don't have any follow up for there diabetes and specially in the rural area (28.7%) specially in the rural area (28.7%)

the treatmentthe treatment

in the question about the treatment in the question about the treatment the survey showed that the majority the survey showed that the majority of patient (79.6%) were treated of patient (79.6%) were treated orallyorally

specially in the rural area the use of specially in the rural area the use of insulin is limited comparing with the insulin is limited comparing with the urban population (the use of insulin urban population (the use of insulin is 4 time more in urban  than in is 4 time more in urban  than in rural area?!!) rural area?!!)

Glycemic control in diabetic Glycemic control in diabetic patientspatients

the average of FPG was 179.4mg\dl the average of FPG was 179.4mg\dl (the majority had uncontrolled (the majority had uncontrolled glycemia), (Hb a1c was not tested) glycemia), (Hb a1c was not tested)

plasma glucose tested in the diabetic plasma glucose tested in the diabetic population showed that 20.4% of population showed that 20.4% of them had a FPGthem had a FPG

of <110mg\dlof <110mg\dl

ConclusionsConclusions

the percentage of dysglycemia is the percentage of dysglycemia is elevated and in the next decades we elevated and in the next decades we will assist a greater number of will assist a greater number of diabetics .diabetics .

  in the rural area we need more in the rural area we need more continuous medical education to continuous medical education to stimulate doctors to have better stimulate doctors to have better follow up for our diabetic patientsfollow up for our diabetic patients

Diabetes care in SyriaDiabetes care in Syria

National program (ministry of National program (ministry of health)health)

this program offers all servicesthis program offers all services

free-of-charge.free-of-charge. Other public health services.Other public health services. Private sector.Private sector.

National diabetes National diabetes programprogram

Started in 1987 Started in 1987 The first diabetic clinic opened in The first diabetic clinic opened in

Deirelzor.Deirelzor. Actually there is 105 clinics that cover Actually there is 105 clinics that cover

all regionsall regions There is a central clinic in each There is a central clinic in each

department (14).department (14). The patients are referred to them The patients are referred to them

yearly.yearly.

Central clinic

clinic

clinic

clinic

clinicclinic

clinicclinic

clinic

Distribution of the diabetic Distribution of the diabetic clinicsclinics

Damascus : 10 Damascus sub. : 18 Damascus : 10 Damascus sub. : 18 Aleppo : 10 latakie : 6Aleppo : 10 latakie : 6 Tartous : 5 raka : 4Tartous : 5 raka : 4 Daraa : 10 soueda : 6Daraa : 10 soueda : 6 Hasake : 4 deirelzor : 4Hasake : 4 deirelzor : 4 Homs : 13 hama : 10Homs : 13 hama : 10 Idleb : 4 konetra : 5Idleb : 4 konetra : 5

Number of patients Number of patients registered in each registered in each

departmentdepartment : :

Central clinicCentral clinic Diabetic consultationDiabetic consultation Eye clinic : fluorescence and laser Eye clinic : fluorescence and laser

treatment .treatment . Cardiologic clinic equipped with EKG Cardiologic clinic equipped with EKG

and echo.and echo. Diabetic foot clinic.Diabetic foot clinic. laboratory .laboratory . Education.Education. Social clinic.Social clinic. In some cases the patient is referred to In some cases the patient is referred to

the hospital for further evaluationthe hospital for further evaluation

Several programs are Several programs are included in the diabetes included in the diabetes

programprogram Education programEducation program Diabetic foot programDiabetic foot program Blindness reduction program.Blindness reduction program. Children care program.Children care program. Nutrition program.Nutrition program.

Education programEducation program

Started in 1997Started in 1997 Courses for patient.Courses for patient. Duration : 6weeksDuration : 6weeks Individual educationIndividual education Collective educationCollective education

Diabetic foot programDiabetic foot program

Started in 1999Started in 1999 To teach doctors the basis of foot To teach doctors the basis of foot

care .care . Actually there are 26 doctors trained Actually there are 26 doctors trained

and are working in 12 diabetic foot and are working in 12 diabetic foot clinics in different provincesclinics in different provinces

Diabetic children care Diabetic children care programprogram

Started in 2000.Started in 2000. Summer camps in different regionsSummer camps in different regions Educational courses to children Educational courses to children

using drawing and puppet theater .using drawing and puppet theater . Excursion and participation in social Excursion and participation in social

activity.activity.

Reduction of blindness Reduction of blindness programprogram

Started in 2001Started in 2001 Follow up of each patient every 6 Follow up of each patient every 6

month.month. Fluorescent fundography.Fluorescent fundography. Laser treatment if neededLaser treatment if needed

Nutritional programNutritional program

Started in 2004.Started in 2004. 4 courses for nurses .4 courses for nurses .

What do we need?What do we need?

Majority of physician are part time.Majority of physician are part time. The outcome in each center is The outcome in each center is

related to the physician ….related to the physician …. More resources to afford all lab. Test More resources to afford all lab. Test

in a regular basis.in a regular basis. Invest in the prevention of DM .Invest in the prevention of DM .