Keywords:
Diabetes mellitus - obesity - sociocultural factors - urbanization
Introduction
The State of Qatar is an oil-rich country that lies halfway along the West Coast of
the Arabian Gulf. It is a peninsula that covers 11606.8 Sq. Km., with a desert climate
of hot summer and warm winter. In the last four decades, population growth rate has
been very fast and in 2011 were 1,951,591. [1]
[2]
[3] This article aims to highlight evidence- and experience-based effects of some important
socio-cultural factors that considerably contribute to the prevalence of diabetes
mellitus in Qatar.
Urbanization, sedentary life style, and obesity in relation to type 2 DM (DM2)
According to the International Association for the Study of Obesity, Qatar has the
6th highest rate of obesity among boys in the Middle East and North Africa region. It
is also ranked 5th for having the highest percentage of people between 20 and 79 with diabetes.[4]
Recently, the overall prevalence of metabolic syndrome in adults in Qatar according
to the revised criteria of the National Cholesterol Education Program Adult Treatment
Panel III (NCEP ATP III) and the International Diabetes Federation (IDF) was 26.5%
and 33.7% (P < 0.001). This prevalence of the metabolic syndrome in the State of Qatar is about
10–15% higher than in most developed countries. The prevalence of metabolic syndrome
by ATP III and IDF increased with age and body mass index (BMI), whereas it decreased
with higher education and physical activity. Among the components of metabolic syndrome,
central obesity was significantly higher in the studied subjects. Multivariate logistic
regression analysis (ATP III and IDF) showed that age and BMI were significant contributors
for metabolic syndrome. Additionally, there was a steady increase in the prevalence
of metabolic syndrome (MetS) through the decades, independent of the definition. The
prevalence of MetS was higher among females. Among the components of MetS, the prevalence
of central obesity was significantly higher in studied subjects.[5]
In 2009, the overall prevalence of diabetes mellitus among adult Qatari population
was high (16.7%) with diagnosed DM (10.7%) and newly diagnosed DM (5.9%). The impaired
glucose tolerance was diagnosed in 12.5%, while impaired fasting glucose was in 1.3%
with a total of (13.8%). The proportion of DM was higher in Qatari women (53.2%) than
in Qatari men (46.8%), and it peaked in the age group 40–49 years (31.2%). Risk factors
were significantly higher in diabetic adult Qatari population: Central obesity (P < 0.001), hypertension (P < 0.001), triglyceride (P < 0.001), HDL (P = 0.003), metabolic syndrome (P < 0.001), heart diseases (P – 0.001). Smoking habits and family history of DM were the major contributors for
diabetes disease. The central obesity was associated with higher prevalence of DM
and IFG among Qatari men and women.
One reason for the obesity trend is the lack of exercise and poorly designed pedestrian-friendly
cities. ≪Like other oil-rich nations, Qatar has leaped across decades of development
in a short time, leaving behind the physically demanding life of the desert for air-conditioned
comfort, servants, and fast food.”[6] In addition, urbanization has occurred rapidly and has been accompanied by new technologies
that promote sedentary lifestyles. Due to accessibility of private cars, television,
and household appliances, the hot damp weather outdoors and the deficiency of designed
pedestrian-friendly cities, the population as a whole is engaging in less physical
activity. Although the type of food eaten has changed, the cultural traditions surrounding
food have not. Food is often consumed communally, making it nearly impossible to ensure
proper portions. A person who does not eat when food is offered is seen as offensive
and shameful. The presence of foreign workers has introduced many new foods from all
over the world. Qatar′s cuisine has been influenced by close links to Iran and India
and more recently by the arrival of Arabs from Lebanon, Syria, and North Africa. In
recent years, restaurants and fast-food franchises have increasingly opened. It is
also normal within Qatari society to be obese.[7]
[8]
[9]
[10]
In children, obesity is associated with a number of co-morbidities in childhood[5] and with increased risk of adult disease, particularly DM2.[6] In Qatar, a randomly selected cluster sample of 38070 students aged 6-18 years,
the prevalence of overweight (BMI > 85th centile) and obesity (BMI > 95th centile) were 11.6% and 14.7%, respectively (total 26.3% above 85th % for BMI). Obesity among Qatari children (15.8%) was higher than among non-Qatari
children (13.2%). The mean BMI crossed above and became progressively higher than
the mean for CDC by the age of 8 years in Qatari girls and by the age of 10 years
in Qatari boys.[11] These results are in accordance with those reported from Kuwait (prevalence of 26.5%
(BMI > 90%) among children aged 6-13 years and from the KSA (1996) with prevalence
of overweight and obesity among Saudi boys age 6-18 years was 11.7% and 15.8%, respectively.[12]
[13] Before 2007, DM2 has not been reported in Qatari children; however, consequent to
this epidemic of obesity, DM2 has been increasingly reported among Qatari children
and adolescents. [Table 1] [Figure 1]All children with type 2 DM were obese (BMI > 95th centile), and all had family history of DM2 in first- or second-degree relatives.[11] In a random sample of obese children and adolescents in Qatar, using continuous
glucose monitoring system (CGMS) for 3 days, revealed that 69% of them had either
impaired fasting glucose (36%) or impaired glucose tolerance (69%) denoting markedly
disturbed glucose homeostasis.[14]
Table 1
Incidence of type 1 DM and type 2 DM in children (1-16 years) in Qatar
|
Year
|
Type 1 incidence/100,000
|
Type 2 incidence/100,000
|
|
2006
|
18.63
|
0
|
|
2007
|
30.64
|
0
|
|
2008
|
21.64
|
0.33
|
|
2009
|
22.91
|
1.43
|
|
2010
|
21.22
|
1.47
|
|
2011
|
23.64
|
1.47
|
|
2012
|
26.33
|
2.66
|
Figure 1 Mean body mass index for Qatari children (6-12 years) (boys and girls) versus mean
for centers for disease control and prevention CDC standard
Vitamin D Deficiency and Diabetes in Qatar
Vitamin D deficiency has been shown to alter insulin synthesis and secretion in both
humans and animal models. Glycemic control and insulin resistance are improved when
vitamin D deficiency is corrected and calcium supplementation is adequate. Children
and adults need at least 1000 IU of vitamin D per day to prevent deficiency when there
is inadequate sun exposure.[15]
[16]
[17] The prevalence of vitamin D deficiency (VDD) is high in Qatari children (49.8% of
males and 50.2% of females), adults (91%) including pregnant women. Rickets and osteomalacia
are still reported. This vitamin D deficiency appears to result from a combination
of limitations in sunlight exposure and a low oral intake of vitamin D. Women are
completely covered because of religious factors, and humid hot weather outdoors most
of the year leads to no or low duration of time spent outdoors. In addition, breast
feeding less than 6 months and decreased physical activity are significant predictors
for vitamin D deficiency in Qatari children.[18]
[19]
[20]
[21]
[22]
[23]
Epidemiological studies suggest a link between vitamin D deficiency in early life
and the later onset of DM1. A case-control study has been designed to find the association
between vitamin D and DM1 then to study the difference in the level of vitamin D in
T1DM and healthy subjects, and to determine the associated environmental risk factors
in young Qatari DM1 children and healthy subjects below 16 years. The study revealed
that VDD was considerably higher in T1DM children compared to non-diabetic children,
and the mean value of vitamin D was lower in DM1 versus non-diabetic children (P = 0.009). Family history of vitamin D deficiency was considerably higher among DM1
children (35.3%) versus non-diabetic children (22.9) (P = 0.012). Vitamin D supplement with breast milk was very poor in diabetic children
compared to non-diabetic children. Multivariate logistic regression analysis revealed
that low vitamin D level, less physical activity, low duration of time under sun light,
and breast feeding less than 6 months were considered as the main factors associated
with the DM1.[24]
[25]
Diabetic ketoacidosis: Relation to social issues
The incidence of diabetic ketoacidosis (DKA) is still high in Qatar (11% of the diabetic
children suffer an attack of DKA per year). Analysis of causes of DKA in diabetic
children revealed that, apart from the known causes of DKA, among the important factors
behind this is the decreased family role in the management and support of diabetic
children, due to high rate of divorce (41.0% in 2009, 46.8% in 2010, and 39.7% in
2011).[26] However, the incidence of DKA at first presentation has decreased significantly
from 47% to 32%, and the degree of severe acidosis decreased from 41% to 20% of cases
in the last 10 years. These significant changes are attributed to increased awareness
for early symptoms for diagnosis through the extensive education programs adopted
by the Qatari Diabetes Association through all forms of media (TV, newspapers, magazines),
camps, and conferences.
Consanguinity, smoking, education level and housing and DM
The association between consanguineous marriages and genetic and environmental factors
and NIDDM in the adult Qatari population has been studied in a total of 338 randomly
selected diabetic patients. The diabetic population was found to have a significantly
lower educational level and a tendency to live in houses with less room. Diabetics
were significantly higher among the subjects with consanguinity, and this effect was
even more significant in first degree consanguinity. Diabetics were also seen to consume
more fruit and less fish/chicken. Logistic regression analysis identified consanguinity,
smoking, level of education, number of children, high BMI and systolic blood pressure
as risk factors to be considered for NIDDM. It appears that the high prevalence of
diabetes in the Qatari population could be attributed to an interaction of these environmental
and socio-cultural factors with the genetic factors.[27]
In 2011, a national diabetes survey was conducted in Qatar to explore the general
population awareness levels of diabetes, its causes, and complications. The survey
revealed that, 53% believe that diabetes is less serious than heart disease, and diabetes
does not lead to stroke. On the same time, 37% are at risk of developing diabetes,
and 93% of them have never been informed of that risk. These results reflect the fact
that diabetes is very common disease, which makes people get acquainted with it and
not take it too seriously.[28]
Fasting Ramadan and control of DM2
Although Muslim patients with type 2 diabetes may be exempt from fasting during Ramadan
for medical reasons, a high proportion of them fast. Results a recent study in Iran
showed that fasting during Ramadan deteriorated the glycemic control in type 2 diabetes
patients. This was more evident in patients using oral hypoglycemic medication than
in diet-controlled patients. However, Ramadan fasting had small positive effects on
lipid profile and body weight.[29] In keeping with this, two large epidemiological studies conducted in 13 Islamic
countries on 12,243 diabetic individuals who fasted during Ramadan showed a high rate
of acute complications.[30]
[31] Patients with type 1 diabetes are discouraged to fast Ramadan. However, those who
fast are at increased risk for development of diabetic ketoacidosis, particularly
if their diabetes is poorly controlled before Ramadan.[29] In addition, the risk for DKA may be further increased due to excessive reduction
of insulin dosages based on the assumption that food intake is reduced during the
month. In Qatar, the prevalence of DKA in adolescent with DM1 who fast against medical
advice is almost doubled in Ramadan compared to other months of the year that is confirmed
in other Arab countries.[31]
[32] A recent study from another Gulf country showed that fasting during Ramadan deteriorated
the glycemic control in type 2 diabetes patients.[29]
The government in its effort to build the welfare state is providing all the health
services free of charge (including diabetes clinic visits (including diabtologists,
diabetes educators, dietitians, and foot care clinics), insulin pens, insulin pumps
and disposables, glucometers, and glucostrips). However, in many patients, this led
to a negative attitude of dependency on the government and hospital without taking
their role for self-monitoring and control.
Conclusion
In conclusion socio-cultural factors can profoundly influence diabetes control in
diabetic patients. In Qatar, important socio-economic factors that lead to rapid urbanization,
excessive consumption of fast food, sedentary life style that led to an epidemic of
obesity, increased rate of divorce, and vitamin D deficiency appear to have negative
influence on diabetes control.
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