Earl V. Dunn

An Update on the Etiology and Epidemiology of Diabetes Mellitus

Abstract:  Diabetes mellitus is one of the most common endocrine disorders affecting almost 6% of the worlds population. The number of diabetic patients will reach 300 million in 2025 (International Diabetes Federation, 2001). More than 97% of these patients will have type II diabetes. The projected increase in the number of diabetic patients will strain the capabilities of healthcare providers the world over. Thus it is of paramount importance to revisit the causes and epidemiology of diabetes mellitus. Diabetes mellitus is caused by both environmental and genetic factors. The environmental factors that may lead to the development of diabetes mellitus include physical inactivity, drugs and toxic agents, obesity, viral infection, and location. While type I diabetes is not a genetically predestined disease, an increased susceptibility can be inherited. Genetic susceptibility plays a crucial role in the etiology and manifestation of type II diabetes, with concordance in monozygotic twins approaching 100%. Genetic factors may have to be modified by environmental factors for diabetes mellitus to become overt. An individual with a susceptible gene may become diabetic if environmental factors modify the expression of these genes. Since there is an increase in the trend at which diabetes prevail, it is evident that environmental factors are playing a more increasing role in the cause of diabetes mellitus. The incidence of type I diabetes ranged from 1.9 to 7.0/100,000/yr in Africa, 0.13 to 10/100,000/yr in Asia, ∼4.4/100,000/yr in Australasia, 3.4 to 36/100,000/yr in Europe, 2.62 to 20.18/100,000/yr in the Middle East, 7.61 to 25.7/100,000/yr in North America, and 1.27 to 18/100,000/yr in South America. The epidemiology of type II diabetes is equally bleak. The prevalence of type II diabetes ranged from 0.3 to 17.9% in Africa, 1.2 to 14.6% in Asia, 0.7 to 11.6% in Europe, 4.6 to 40% in the Middle East, 6.69 to 28.2% in North America, and 2.01 to 17.4% in South America.

The determinants of breast cancer screening behavior: a focus group study of women in the United Arab Emirates.

PURPOSE/OBJECTIVES To explore perceptions, knowledge, attitudes, and beliefs about breast cancer and its screening among Emirati national women in Al Ain, United Arab Emirates. DESIGN A qualitative study using focus group methods. SETTING Primary healthcare centers and a community-based womens association in the United Arab Emirates. SAMPLE 41 women, aged 25-45 years. METHODS Four 90-minute focus group discussions exploring perceptions, knowledge, attitudes, beliefs, and practices regarding breast cancer were audiotaped, transcribed, translated, and analyzed. MAIN RESEARCH VARIABLES Social and cultural themes related to breast cancer and its screening. FINDINGS Focus group methodology worked well in this setting. The womens perceptions, knowledge, attitudes, and beliefs regarding cancer and screening, together with aspects of the healthcare system and social milieu, appeared to strongly influence the womens preventive practices. Some of these factors had an encouraging effect on the womens practices, and others had a deterring effect. The encouraging factors included feelings of susceptibility, high levels of knowledge in some women, attitudes and beliefs about personal responsibility for health, and a supportive social milieu. Deterring factors included anxiety and fear leading to denial; lack of knowledge about cancer and the screening program; fear, embarrassment, and mistrust of health care; and belief in predestination. CONCLUSIONS Health planners and healthcare providers must capitalize on encouraging factors and minimize deterring factors to optimize breast cancer screening practices among these women. IMPLICATIONS FOR NURSING Identifying and accounting for the factors that encourage or deter women in their breast cancer screening practices will help to optimize screening programs.

The prevalence and determinants of health care-seeking behavior for urinary incontinence in United Arab Emirates women.

Abstract: The aim of this study was to determine the prevalence and sociodemographics of urinary incontinence (UI) in women in the United Arab Emirates (UAE). Women at risk, such as multiparous and climacteric women, were selected from the community (n= 200) and health-care centers (n= 200) and interviewed about inappropriate urine loss in the past 12 months, using a structured and pretested questionnaire. Of these, 81 (20.3%) admitted UI; only 25 of these (30.9%) had sought medical advice. The reasons were embarrassment (38.2%), choice of self-treatment because of low expectations from medical care (38.2%), and preferring to discuss the matter with friends, assuming that UI is normal (23.3%). Sufferers were troubled by their inability to pray (90%) and to have sexual intercourse (33.3%). Perceived causes of UI were paralysis (45%), childbirth (35.4%) and old age or menopause (33.7%). UI is common yet underreported by UAE women because of cultural attitudes and inadequate public knowledge.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE: This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females. METHODS: A representative sample of multiparous United Arab Emirates females aged 20 years or older (N=450) were randomly selected from the community (n=225) and health care centers (n=225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire. RESULTS: Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P<0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent). CONCLUSIONS: Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

Quantitative ultrasound of the calcaneus in Arabian women: relation to anthropometric and lifestyle factors

OBJECTIVES To determine factors influencing quantitative ultrasound (QUS) parameters of the calcaneus in a population-based sample of United Arab Emirates (UAE) women, and to compare QUS parameters of the calcaneus for healthy young UAE women with the manufacturers reference ranges for other populations. METHODS All subjects completed a questionnaire on reproductive and life style factors. Height and weight were measured, and body composition was determined by bioelectric impedence. Estimated bone mineral density (BMD), Speed of sound (SOS), broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) of the right calcaneus were determined by Sahara ultrasound. RESULTS In premenopausal women (n=330), age, weight, body mass index (BMI), lean weight, fat weight, education, age at menarche, and number of pregnancies, correlated significantly with QUS parameters. Multiple regression analysis showed that age at menarche, number of pregnancies, and BMI, were the best predictors of QUS parameters although these factors explained only small amounts of the variance (R(2)=0.05). In postmenopausal women (n=81), age, BMI and physical activity were the best predictors of BUA (R(2)=0.35), SOS (R(2)=0.39), and QUI (R(2)=0.43). Mean estimated BMD, QUI and SOS for healthy young UAE women were significantly lower than the manufacturers reference ranges for U.S. Caucasian, European Caucasian, and Chinese Asian healthy young women of the same age range (P<0.001 for all comparisons). Mean BUA was not significantly different, however. CONCLUSIONS Menopausal status, age, BMI and physical activity are strong predictors of QUS parameters of the calcaneus in Arabian women. Healthy young Arabian women have lower estimated calcaneal BMD compared with the manufacturers reference ranges for other populations.

A clinical trial of chronic care diabetic clinics in general practice in the United Arab Emirates: a preliminary analysis.

Control of diabetes mellitus is a high priority for primary health care systems. One innovative method of diabetes care delivery is the use of structured diabetes care in primary care. This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care. There is limited experience with this model in non-Western settings. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf. The study design used was a controlled before-after methodology. Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls. A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics, a diabetic flow chart, and educational programs for clinic nurses and doctors and patients. The study intervention took place over a period of 18 months with three diabetic outcomes (fasting blood glucose, blood pressure and cholesterol) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period. Knowledge and satisfaction questionnaires were also administered to intervention and control subjects at the end of the study. In this study, 219 subjects were enrolled (130 males and 89 females). They had a mean age of 51.6 years and a mean of 3.1 years of formal education. Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics. Subjects had diabetes for a mean of 7.8 ± 4.8 years and the majority was treated with pharmacological therapy. Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age (p = 0.01) and a trend for more males (p = 0.06) in the intervention clinics. There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied (fasting blood glucose, blood pressure and cholesterol) both in comparison to the control group before and after and within the intervention group. However most changes noted were in the expected direction of improvement; six of the seven guidelines were statistically improved in the intervention group when compared with the control group. Within the intervention group, adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement (fasting blood glucose measurements (p = 0.07) and urine determinations for protein (p = 0.07)). Knowledge questionnaire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group. The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care. The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement. The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries.

The health status of community based elderly in the United Arab Emirates

Little is known about the elderly in the United Arab Emirates (UAE), a country with both developing country features (high fertility rate, few elderly, strong traditional culture) and developed country characteristics (high-income economy, urbanized population, high growth rate of people aged 65+ years). In this cross sectional survey of 184 randomly chosen community based people aged 65+ years, the mean age was 71.8 +/- 6.3, 52% were female, 76% were married, 11% were literate, 89% lived in multi-generational households, 85% lived in households with servants and 15% had a personal servant. Health status was largely independent of age. Compared with the ambulatory aged USA population, the rate of functional independence in activities of daily living (ADL) (83%) was similar and chronic medical problems were less frequent, with the notable exception of diabetes (37% UAE, 10-12% USA). Almost all (95%) participants in this study rated their health as satisfactory or higher, compared with 82% of US ambulatory elderly. There appeared to be a significant under-diagnosis of psychological problems. In the presence of a high regard for traditional values, close family ties, universal practice of religion and high economic resources, the elderly in the UAE have a high level of health, which they maintain into their later years. There may be a need to substantially increase health care resources for aged care in the near future due to the high prevalence of diabetes, amount of hidden psychological morbidity and known demographic trends. Encouraging families to continue to provide home based long-term care may minimize the need for government intervention in this area.

Validation of additional domains in activities of daily living, culturally appropriate for muslims

Background: Measurement of activities of daily living (ADL) is an integral part of geriatric care. Prayer is a central part of the life of practicing Muslims. Objectives: To validate additional domains of ADL based on the functional capacity of Muslims to perform prayer, a culturally appropriate measure for those practicing the Islamic faith. Methods: Functional capacity was measured using 2 scales: an 8-domain scale (ADL-8) and a 3-component domain scale assessing the key components of Islamic prayer: washing for prayer, physical motion during prayer and the words spoken. A randomly selected sample of 132 community-based practicing Muslim people from Arabic-speaking countries, aged 65+ years were assessed. Results: The mean age ± standard deviation was 72.6 ± 7.0 with a female to male ratio of 0.97. The correlation between the summation scores for the prayer ADL and the ADL-8 was r = 0.922 (p < 0.001), while correlation with prayer ADL and each of the 8 components in the ADL-8 ranged from r = 0.806 (p < 0.001) to r = 0.906 (p < 0.001). There was a high level of construct validity with the reliability coefficient for the 3 components of the prayer ADL being 0.933 with a standardized item α of 0.935, with a range of 0.746–0.896 for the subscales. Conclusion: The prayer ADL domains provide an additional valid, short, simple and culturally orientated functional assessment for those of the Islamic faith.

Diabetes Mellitus and its Complications in a Hungarian Population

The aim of this study was to examine the disease characteristics and complications of diabetes mellitus in patients in a Hungarian rural community. Data relating to age, sex, date of onset of diabetes, fasting blood glucose values and all diseases associated with diabetics were retrieved from the medical records of patients. Almost six percent (5.7%) of the population has diabetes mellitus. The percentage of Type I diabetic patients in this population was 5.8 percent. The prevalence of diabetes was slightly but not significantly higher in females than in males. The mean age of the diabetic population was 52.1 ± 11.3 for male and 53.47 ± 15.7 for the female patients. The peak age of onset of diabetes mellitus was in the sixth decade of life. The mean fasting blood sugar value was 10.64 ± 0.6 and 10.57 ± 0.5 mmol L−1, in male and female diabetic patients (n = 103), respectively. Diabetic patients presented with many signs and symptoms in the general practice setting. The findings of this study showed that diabetics present with many disease conditions and signs and symptoms in the general practice setting. Many of these conditions are known to be associated with diabetes while others are not. As a result of the adverse effects of diabetes mellitus on the cardiovascular system and on body metabolism as a whole, the damage and morbidity caused by diabetes mellitus may have been underestimated. The results of this study have shed light on the unrecognised complications of diabetes mellitus.

Dietary fat reducing behaviours of Arab women with type 2 diabetes mellitus

To identify dietary fat reducing behaviours of Emirati women with type 2 diabetes, based on 5 eating patterns (subscales) associated with a low fat diet. Responses from a cross-sectional questionnaire survey of 172 women were used to calculate means for the 5 subscales and summary scores. A low score indicated a desirable behaviour. Multiple regression analysis was used to determine the predictors of the subscale and summary scores. Based on a 5-point scale, the mean scores (s.d.) of the subscales were as follows: substituting for lower fat milk products 3.70 (1.53), modifying meats 1.46 (0.70), avoiding frying 2.63 (0.88), replacing high-fat foods with lower fat foods 3.14 (1.09) and avoiding fat as flavouring or spread 2.62 (0.68). The values for the summary and mean scores were 2.64 (0.60) and 2.52 (0.55), respectively. Nutrition education programs should focus on dietary fat behaviours these women were less successful in changing.