Epidemiology of type 2 diabetes in the Middle East and North Africa: Challenges and call for action

Table 1 Gender specific prevalence of type 2 diabetes in % (CI) in 20 Middle East and North Africa countries in 2000 and 2014 as reported by the World Health Organization[1] and for Palestine[144]

Country	2000		2014
	Men	Women	Men	Women
Afghanistan	8.1 (5.3-11.5)	8.5 (5.7-11.9)	11.6 (6.4-18.2)	12.2 (6.8-18.8)
Algeria	8.6 (6.0-11.8)	9.2 (6.5-12.3)	12.3 (7.4-18.8)	12.6 (7.7-18.9)
Bahrain	10.6 (7.6-14.2)	9.9 (7.1-13.5)	12.0 (7.0-18.5)	10.6 (6.1-16.7)
Egypt	10.8 (7.5-14.7)	13.3 (9.6-17.5)	16.0 (10.0-23.6)	19.8 (12.9-28.2)
Iran	7.4 (5.5-9.4)	8.5 (6.4-10.7)	11.4 (7.2-17.2)	12.9 (8.4-18.8)
Iraq	11.5 (8.2-15.4)	12.4 (9.1-16.2)	17.2 (10.7-25.3)	17.5 (11.1-25.4)
Jordan	12.0 (8.8-15.9)	14.0 (10.5-18.0)	16.5 (10.5-24.0)	17.2 (11.3-24.6)
Kuwait	15.3 (11.2-20.3)	15.6 (11.4-20.4)	19.7 (12.8-28.1)	19.6 (12.9-27.7)
Lebanon	9.0 (5.7-13.1)	8.4 (5.3-12.2)	14.5 (8.7-21.8)	12.2 (7.4-18.5)
Libya	10.7 (7.9-14.1)	12.2 (9.1-15.8)	15.2 (9.5-22.5)	16.6 (10.7-23.8)
Morocco	9.0 (6.2-12.4)	9.2 (6.4-12.6}	14.0 (8.4-21.5}	13.4 (8.1-20.5}
Oman	10.2 (7.6-13.6)	9.9 (7.3-13.1)	14.3 (8.6-21.7)	12.3 (7.4-18.4)
Pakistan	9.1 (6.3-12.2)	9.0 (6.3-12.2)	12.6 (7.0-19.5)	12.1 (7.0-18.6)
Palestine	10.6 (7.8-14.0)	11.8 (8.9-15.2)	16.5 (10.3-24.3)	17.5 (11.4-24.9)
Qatar	13.7 (9.9-18.1)	14.2 (10.4-18.5)	18.9 (12.0-27.0)	18.8 (12.2-26.8)
Saudi Arabia	13.1 (9.8-17.1)	13.1 (9.8-17.0)	17.6 (11.5-25.4)	17.0 (11.1-24.4)
Syria	9.8 (7.0-13.2)	10.9 (8.1-14.2)	14.0 (8.5-21.0)	15.3 (9.6-22.4)
Tunisia	8.3 (6.0-11.1)	9.7 (7.2-12.7)	12.1 (7.4-18.3)	12.9 (7.9-19.0)
United Arab Emirates	11.8 (8.6-16.0)	12.4 (9.1-16.5)	15.0 (9.2-22.5)	15.4 (9.7-22.6)
Yemen	7.4 (4.5-11.3)	6.2 (3.6-9.4)	12.6 (6.7-20.6)	10.1 (5.3-17.0)

Table 2 Prevalence of prediabetes (%) in some Middle East and North Africa countries

Ref.	Country, yr	Age group (n)	Definition of prediabetes	Sampling technique	Prevalence of prediabetes % (95%CI)
					Male	Female	Total
Nasrallah et al[29]	Lebanon (Beirut area), 2014	≥ 18 yr (501)	IFG: FPG 5.6-6.9 mmol/L or A1c 5.8%-6.49%	Probability multistage random sampling	48.0 (40.6-55.4)	36.0 (30.7-41.3)	40.3 (36.0-44.6)
Mansour et al[38]	Iraq, 2011-2012	19-94 yr (5445)	IFG: FPG 5.7-6.9 mmol/L or A1c: 5.7%-6.4%	Population-based random sample	28.6	29.5	29.1
Al-Rubeaan et al[19]	Saudi Arabia, 2007-2009	≥ 30 yr (18034)	IFG: FPG 5.6-6.9 mmol/L	Random household national sample	26.4	24.7	25.5
Saadi et al[39]	United Arab Emirates (Al-Ain), 2005-2006	> 18 yr (2455)	IFG: FPG 5.6-6.9 mmol/l or IGT	Simple random sample	19.7	22.8	22.8
Alkandari et al[40]	Kuwait, 2014	18-69 yr (2561)	IFG: FPG 6.1-6.9 mmol/L	Random sample	19.3 (16.9-22.0)	19.5 (17.6-21.5)	19.4 (17.9-21.0)
Esteghamati et al[41]	Iran, 2011	25-70 yr (11867)	IFG: FPG 5.6-6.9 mmol/L	Randomized multistage cluster sample	15.45 (12.71-18.18)	13.74 (11.55-15.94)	14.6 (12.41-16.78)
Basit et al[34]	Pakistan, 2016-2017	≥ 20 yr (10834)	IFG: FPG 6.1-6.9 mmol/L orIGT	Multistage clustering technique	NA	NA	14.4
Bener et al[42]	Qatar, 2007-2008	> 20 yr (1117)	IFG: FPG 5.6-6.9 mmol/L or IGT	Multistage stratified cluster sampling	NA	NA	13.8
Gunaid et al[43]	Yemen, 2000	≥ 35 yr (250)	IFG: FPG 5.6-6.1 mmol/L or IGT	Multistage random sampling	5.7 (2.8-8.6)	10.9 (7.1-14.7)	9.0 (6.0-12.0)
Albache et al[30]	Syria (Aleppo), 2006	≥ 25 yr (806)	IFG: FPG 6.1-6.9 mmol/L	Random sampling	10.4 (4.7-21.0)	6.8 (2.9-15.1)	8.6 (3.8-18.1)
Al-Lawati et al[44]	Oman, 2000	≥ 20 yr (5838)	IFG: FPG 6.1-6.9 mmol/L	Multistage stratified probability sampling	7.1 (6.2-8.1)	5.1 (4.4-6.0)	6.1 (5.5-6.8)
Bouguerra et al[45]	Tunisia, 1996-1997	≥ 19 yr (7860)	IFG: FPG 6.1-6.9 mmol/L	National cross-sectional sample	4.58	4.91	NA

IFG: Impaired fasting glucose according to specified glucose range; FPG: Fasting plasma glucose; IGT: Impaired glucose tolerance (using World Health Organization definition, glucose ≥ 7.8 but < 11.1 mmol/L, 2 h after 75 gm oral glucose load); CI: Confidence interval; NA: Not available; A1c: Hemoglobin A1c.

Table 3 Mortality from high glucose and cardiovascular disease extracted from the World Health Organization country profile data site for 2016[75]

2016	Total population (million)	Age-standardized mortality rate for NCD per 100000	Diabetes deaths (n)	Diabetes mortality per 10000	CVD deaths (n)	CVD mortality per 10000
Afghanistan (LIC)	32527000	805.3	7056	2.17	51244	15.75
Algeria (MIC)	39667000	430.7	8390	2.12	69173	17.44
Bahrain (HIC)	1377000	430.1	404	2.93	775	5.63
Egypt (MIC)	91508000	711.8	17851	1.95	245904	26.87
Iran (MIC)	79109000	532.5	14842	1.88	160823	20.33
Iraq (MIC)	36423000	604.5	7279	2.00	51593	14.16
Jordan (MIC)	7595000	542.4	2347	3.09	13384	17.62
Kuwait (HIC)	3892000	541.4	326	0.84	4552	17.62
Lebanon (MIC)	5851000	516.4	1886	3.22	17814	30.45
Libya (MIC)	6278000	567.0	1292	2.06	11638	18.54
Morocco (MIC)	34378000	483.9	10645	3.10	69457	20.20
Oman (HIC)	4491000	404.6	903	2.01	4047	9.01
Pakistan (MIC)	189000000	681	44666	2.36	411569	21.78
Qatar (HIC)	2235000	425.5	359	1.60	1054	4.72
Saudi Arabia (HIC)	31540000	508.5	3737	1.18	42440	13.46
Syria (MIC)	18502000	594.7	1322	0.71	37885	20.48
Tunisia (MIC)	11254000	460.6	3523	3.13	31987	28.42
UAE (HIC)	9157000	460	707	0.77	5970	6.52
Yemen (MIC)	26832000	819.7	3854	1.44	56793	21.17

NCD: Noncommunicable diseases; CVD: Cardiovascular disease; LIC: Low income countries; MIC: Middle income countries; HIC: High income countries.

Table 4 Select studies reporting on diabetic foot ulcer and macrovascular complications of diabetes for the Middle East and North Africa region

Complication	Ref.	Country	Sample size (% male)	Setting	Duration of diabetes (yr)	Method of assessment	Prevalence %
Diabetic foot ulcer	Assaad-Khalil et al[88], 2015	Egypt (Alexandria)	2000 (50.0)	Diabetes Foot Clinic	11.7 ± 8.3	Physical exam	8.7
	Al-Rubeaan et al[89], 2015	Saudi Arabia	62681 (52.4)	Saudi National Diabetes Registry	13.3 ± 8.1	Chart review	2.1
	Yazdanpanah et al[92], 2018	Iran (Ahfaz)	605 (42.8)	Diabetes Clinic	9.2 ± 7.1	Physical exam	6.4
	AlAyed et al[93], 2017	Jordan	1000 (48.2)	Diabetes Clinic	57.1% ≥ 5	Physical exam	5.3
Peripheral vascular disease	Akram et al[90], 2011	Pakistan	830 (49.0)	Outpatient Clinic	8.1 ± 6.2 low ABI; .4 ± 6.4 normal ABI	ABI below 0.9	31.6
Coronary artery disease	Saeedi et al[4], 2020	Iran (Kurdistan)	400 (18.0)	Diabetes Clinic	14.6 ± 4.1	Angiography or physician	21.7 (5.75 CABG, 3.75 angioplasty)
	Abu Al-Halaweh et al[81], 2017	Palestine	1308 (35.9)	Primary Care Centers	7.1 ± 6.3	Questionnaire	12.2 (myocardial infarction)
	Afsharian et al[80], 2016	Iran (Tehran)	1198 (42.1)	Community-based	NA	Physician assessment	23.4

ABI: Ankle brachial index; NA: Not available; CABG: Coronary artery bypass grafting.

Table 5 Select studies reporting on microvascular complications of diabetes in the Middle East and North Africa region

Complication	Ref.	Country	Sample size (% male)	Setting	Duration of diabetes (yr)	Method of assessment	Prevalence %
Retinopathy	Al-Rubeaan et al[89], 2015	Saudi Arabia	50464 (56.0)	Saudi National Diabetes Registry	13.4 ± 8.2	Chart review	19.7 (10.6 PDR)
	Macky et al[101], 2011	Egypt	1325 (28.5)	Hospital-based	48% for 5-15	Slit lamp	20.5 (2.3 PDR)
	Jammal et al[104], 2013	Jordan	127 (63.8)	Clinic-based	Newly diagnosed	Slit lamp	7.9
	Uddin et al[99], 2018	Pakistan	958 (56.0)	Multi-Clinics	Newly diagnosed	Slit lamp	15.9
	Abu Al-Halaweh et al[81], 2017	Palestine	1308 (35.9)	Primary Care Centers	7.1 ± 6.3	Digital retinal photo	21.8
	Elshafei et al[97], 2011	Qatar	540 (360/540)	Community-based	12.9 ± 9.1	Slit lamp	23.5
	Heydari et al[98], 2012	Iran	1022 (40.2)	Clinic-based	11.2 ± 8.2 DR; 5.8 ± 5.4 no DR	Slit lamp	23.6
	Arej et al[96], 2019	Lebanon	2205	Community-based	9.1 ± 7.1	Digital retinal photo	12.6
	Kahloun et al[102], 2014	Tunis	2320 (39.8)	Hospital-based	7.6	Slit lamp	26.3 (3.4 PDR)
Nephropathy	Al-Rubeaan et al[107], 2018	Saudi Arabia	54670 (51.2)	Saudi National Diabetes Registry	13.6 ± 8.1	ACR and GFR	10.8 (1.2 micro; 8.1 macro; 1.5 ESRD)
	Uddin et al[99], 2018	Pakistan	958 (56.0)	Multi-Clinics	Newly diagnosed	ACR	24.0
	Zakkerkish et al[110], 2013	Iran	350 (32.0)	Diabetes Clinic	4.6 ± 5.5	ACR	20.6 (5.1 macro)
	Shahwan et al[108], 2019	Palestine (Ramallah)	550 (54.7); Age above 35 yr	Diabetes Clinic	8.9 ± 6.8	ACR	34.6 (5.8 macro)
	Ali and Al Lami[109], 2016	Iraq	224 (58.9)	Diabetes Clinic	23.2 % ≥ 9	ACR (2 out of 3)	16.1
Neuropathy	Khedr et al[22], 2016	Egypt (Qena)	9303 (51.1); 837 with diabetes	Community	NR	MNSI, then ENG	18.5
	Ghandour et al[114], 2018	Palestine (Ramallah)	517 (32.0)	Primary Health Clinic	9.0 ± 7.5	Monofilament test	38.2
	Chahbi et al[115], 2018	Morocco	300 (50.7)	Diabetes Clinic	10.6 ± 7.4	Diabetic Neuropathy Score	15.4 (DN4 painful)
	Garoushi et al[112], 2019	Libya	450 (50.2)	Diabetes Clinic	15.1± 7.1	Diabetic Neuropathy Score	42.2 (s-LANSS ≥ 12 pain)
	Kiani et al[113], 2013	Iran	521 (NR)	Diabetes Clinic	9.2 ± 7.4	NSS and NDS	49.3

NR: Not recorded; MNSI: Michigan neuropathy screening instrument, ENG: Electroneurogram; PDR: Proliferative diabetic retinopathy; ACR: Albumin to creatinine ratio; S-LANSS: Leeds assessment of neuropathic symptoms and signs; NSS: Neuropathy symptom score; NDS: Neuropathy disability score; DR: Diabetic retinopathy; GFR: Glomerular filtration rate; ESRD: End-stage renal disease.