Salah Abusnana

Novel approach to systematic random sampling in population surveys: lessons from the United Arab Emirates National Diabetes Study (UAEDIAB)

The prevalence of diabetes has risen rapidly in the Middle East, particularly in the Gulf Region. However, some prevalence estimates have not fully accounted for large migrant worker populations and have focused on minority indigenous populations. The objectives of the UAE National Diabetes and Lifestyle Study are to: (i) define the prevalence of, and risk factors for, T2DM; (ii) describe the distribution and determinants of T2DM risk factors; (iii) study health knowledge, attitudes, and (iv) identify gene–environment interactions; and (v) develop baseline data for evaluation of future intervention programs.

Self-reported hypoglycemia in insulin-treated patients with diabetes: Results from an international survey on 7289 patients from nine countries

AIMS Hypoglycemia constitutes a significant barrier to achieving glycemic control with insulin in both type 1 and type 2 diabetes. Historically, it has been difficult to accurately verify the rates of hypoglycemia within a clinical setting and there is a need for high-quality, real-world data to ascertain the true rates of hypoglycemia in clinical practice. The global Hypoglycemia Assessment Tool (HAT) study was designed to assess the global incidence of hypoglycemia in patients with insulin-treated diabetes, and the results have indicated that the overall incidence of hypoglycemia is high, with large variations between geographical regions. METHODS The International Operations HAT (IO HAT) study retrospectively and prospectively assessed the incidence of hypoglycemia in patients with insulin-treated diabetes in Bangladesh, Colombia, Egypt, Indonesia, Philippines, Singapore, South Africa, Turkey, and United Arab Emirates. RESULTS During the prospective period, hypoglycemic events were reported by 97.4% of patients with type 1 diabetes and 95.3% of those with type 2 diabetes, with an estimated rate of 6.86 events per patient per month (PPPM) for patients with type 1 diabetes and 2.37 events PPPM for patients with type 2 diabetes. CONCLUSIONS These results represent the first patient-reported dataset on hypoglycemia in the participating countries and confirm that hypoglycemia is under-reported and more widespread than previously believed. Although the incidence of hypoglycemia was variable among patients on different treatment regimens, there were substantial impacts on both productivity and healthcare utilization following an episode of hypoglycemia. This trial is registered at clinicaltrials.gov: NCT02306681.

The FTO rs9939609 “A” allele is associated with impaired fasting glucose and insulin resistance in Emirati population

BACKGROUND Fat mass and obesity-associated protein gene variants have shown diverse influence on body weight and metabolism across different populations. Overweight, obesity and metabolic syndrome are multifactorial major health problems in the UAE and worldwide. Insulin resistance represents the link between overweight and development of metabolic syndrome and type 2 diabetes mellitus. We investigated two (FTO) variants in Emirati population, in relation to insulin resistance and different parameters of metabolic syndrome. METHODS We recruited 259 Emiratis through the UAE National Diabetes and Lifestyle Project. Ethical approval was obtained. Besides basic data collection, venous blood samples were collected. Fasting blood glucose, Lipid profile, and insulin levels were measured. Genotyping for (FTO) rs9939609 (A>T) and rs9930506 (G>A) were performed using real time-PCR. Insulin resistance were identified using HOMA2-IR calculation; with a cut-off point of 1.4 for female and 1.18 for male subjects. RESULTS The study included 259 Emiratis (age range 30-53 years, mean 41.76 years, 54.4% females), 24.5% are diabetic and 30.8% are hypertensive, with body mass index of 28.4 ± 5.9 and 28.7 ± 5.7 kg/m2 in female and male subjects, respectively. Homozygous A of rs9939609 showed significantly higher fasting glucose compared to other genotypes (p = 0.04) with a trend of higher insulin level and HOMA-2IR. The A/A diabetic patients (n = 13) showed significantly higher insulin levels compared to other genotypes. G allele of rs9930506 showed a trend of higher fasting glucose and HOMA-2IR, but lower insulin level and HbA1c. No association of genotypes was detected with other components of metabolic syndrome. CONCLUSION There is an association of FTO rs9939609 A/A genotype and impaired fasting glucose and insulin resistance. Homozygous A genotype diabetic patients may be more vulnerable to blood glucose fluctuation. Focused genotyping can help the health care providers to identify high risk groups of both normal population and diabetic patients to intervene accordingly.

High prevalence of diabetes among migrants in the United Arab Emirates using a cross-sectional survey

In 2011, the United Arab Emirates (UAE) had the 10th highest diabetes prevalence globally, but this was based on data that excluded migrants who comprise 80% of the population. This study assessed diabetes prevalence across the UAE population. A random sample of migrants was recruited from the visa renewal centers. Data were collected using interviews, anthropometric measurements and fasting blood for glucose, lipids and genetic analyses. 2724 adults completed the questionnaires and blood tests. Of these, 81% were males, 65% were ≤40 years old and 3% were above 60 years. Diabetes, based on self-report or fasting plasma glucose ≥7.0 mmol/l, showed a crude prevalence of 15.5%, of whom 64.2% were newly diagnosed. Overall age- and sex-adjusted diabetes prevalence, according to the world mid-year population of 2013, was 19.1%. The highest prevalence was in Asians (16.4%) and non-Emirati Arabs (15.2%) and lowest in Africans and Europeans (11.9%). It increased with age: 6.3% in 18–30 years and 39.7% in 51 to 60 years. Lower education, obesity, positive family history, hypertension, dyslipidemia, snoring, and low HDL levels, all showed significant associations with diabetes. The high diabetes prevalence among migrants in the UAE, 64% of which was undiagnosed, necessitates urgent diabetes prevention and control programs for the entire UAE population.

Statin-induced myopathy SLCO1B1 521T > C is associated with prediabetes, high body mass index and normal lipid profile in Emirati population

BACKGROUND Statin-induced myopathy has been linked to the C allele of a single nucleotide polymorphism (SNP) (rs4149056) of SLCO1B1 gene. This effect is more significant, but not restricted to simvastatin. Many studies have included European, American, African and Southeast Asian ancestries, but few were carried out on Middle Eastern population. AIM To detect the prevalence of SLCO1B1 rs4149056 (521T > C) in Emirati population. METHOD We recruited 282 Emiratis through the UAE National Diabetes and Lifestyle Project. Ethical approval was obtained before the study starts. Besides basic data collection, venous blood samples were collected. Fasting blood glucose, Lipid profile, and insulin levels were measured. Genotyping for rs4149056 (521T > C) was tested in triplicates through Real Time-PCR using TaqMan® Drug Metabolism Genotyping Assay. rs2306283 (388A > G) was analyzed for comparison. In addition, presence of minor alleles of both SNPs define stronger association with statin-induced myopathy. RESULTS The study included 282 individuals, 52.8% were males with median age of 39.5 years. 10% had Diabetes Mellitus and 23% were hypertensive. Median of body mass index (BMI) was 27.68 kg/m2 in males and 28.38 kg/m2 in females. One-hundred ninety-seven (69.9%) showed abnormal lipid profile (either increased LDL-cholesterol or triglycerides or both). For rs4149056, C allele was present in 21.3% (2.8% homozygous C and 18.4% heterozygous CT). Although homozygous C genotype prevalence was low, compared with Caucasians (4%) and Africans (0%), C allele was associated with a trend of having higher BMI and abnormal lipid profile. C allele subjects were all pre-diabetics with mean glycated hemoglobin above 6%. Mean BMI in CC, CT, and TT genotypes was 30.91 ± 4.4, 29.48 ± 4.2, 27.96 ± 5.5 kg/m2 respectively, with lack of such a trend observed with the different genotypes of the rs2306283 (used for comparison). Abnormal lipid profile was observed in 7/8(87.5%), 38/52(73.1%) and 152/222(70%) of the CC, CT, and TT genotypes respectively. CONCLUSION There is lower prevalence of statin-induced myopathy-linked C allele of rs4149056 in SLCO1B1 gene in Emirati population, compared to Caucasians and Africans. However, there is a trend of higher glycosylated hemoglobin and BMI associated with normal lipid profile in patients having this allele.

Diabetes risk score in the United Arab Emirates: a screening tool for the early detection of type 2 diabetes mellitus

Objective The objective of this study was to develop a simple non-invasive risk score, specific to the United Arab Emirates (UAE) citizens, to identify individuals at increased risk of having undiagnosed type 2 diabetes mellitus. Research design and methods A retrospective analysis of the UAE National Diabetes and Lifestyle data was conducted. The data included demographic and anthropometric measurements, and fasting blood glucose. Univariate analyses were used to identify the risk factors for diabetes. The risk score was developed for UAE citizens using a stepwise forward regression model. Results A total of 872 UAE citizens were studied. The overall prevalence of diabetes in the UAE adult citizens in the Northern Emirates was 25.1%. The significant risk factors identified for diabetes were age (≥35 years), a family history of diabetes mellitus, hypertension, body mass index ≥30.0 and waist-to-hip ratio ≥0.90 for males and ≥0.85 for females. The performance of the model was moderate in terms of sensitivity (75.4%, 95% CI 68.3 to 81.7) and specificity (70%, 95% CI 65.8 to 73.9). The area under the receiver-operator characteristic curve was 0.82 (95% CI 0.78 to 0.86). Conclusions A simple, non-invasive risk score model was developed to help to identify those at high risk of having diabetes among UAE citizens. This score could contribute to the efficient and less expensive earlier detection of diabetes in this high-risk population.

Management of Diabetes during Ramadan Fasting: A Comprehensive Survey of Physicians’ Knowledge, Attitudes and Practices

Background: Physicians play a role in informing patients’ choices to fast or not and also in education and support of those diabetic patients who choose to observe the Ramadan fast. Objectives: To ascertain physicians’ knowledge, attitudes, and practices regarding practical management of diabetes during Ramadan. Subjects and Methods: A cross-sectional Internet-based survey of a convenience sample of physicians, mostly practicing in UAE, was included. The survey questionnaire was developed de novo to address the objectives of this exercise. Responses were collected completely anonymously and were summarized using descriptive statistics. We report here the responses from 236 physicians who submitted adequately completed questionnaires. Results: General management knowledge varied widely. Over 90% recognized the importance of Ramadan-focused education, 75.1% valued the importance of glycemic control at night time, and 71.2% were aware of the exemption of T1DM. 69.0% were familiar with the time of highest risk of hypoglycemia, and 62.0% knew the rulings regarding exemption of pregnant women with diabetes. There was an awareness of the advantages of DDP-IV inhibitors over sulphonylureas, but many thought that all sulphonylureas carry the same hypoglycemic risk potential. Many physicians would maintain metformin and pioglitazone in the same daily doses and use SGLT2 inhibitors carefully in certain groups. Nearly two-thirds of respondents were aware of the traditional adjustments of doses and timing of sulphonylureas. Most (>90%) of respondents recognized the importance of prompt management of hypoglycemia, the need and permission to monitor blood glucose during the day and that potential for the use of GLP1 therapy is supported by experimental evidence. About three quarters recognized the usual practice of reversing the insulin doses when premixed insulin between day and night but only thirds recognized the possible need to reduce basal insulin to avoid hypoglycemia. Attitude: Perceived level of self-confidence, 71% of the respondents stated that they are fully confident or somewhat confident in the management of diabetes during Ramadan. There was a wide variation in recognition of relevant concerns and risks associated with fasting during Ramadan in people with diabetes. Hypoglycemia was the most highly recognized risk (96%) followed by dehydration (85%). About two-thirds of respondents’ associated increased risk of hyperglycemia and diabetic ketoacidosis with fasting. Less than half of respondents recognized the increased risks in pregnancy and of thromboembolic disease. Forty- one percent of respondents followed the ADA workshop of 2005 and its updates. Its risk scale was thought to be the most practical by 34% of respondents. Risk stratification practices were stated to be undertaken consistently, often or occasionally (80%, 15%, and 5% of respondents respectively). 78% confirmed formal stratification using one of the published guidelines. Clinical management practices during the previous month of Ramadan, a total responded positively in high proportions to almost all the questions with no particular differences between the issues nor between the care settings and facilities. Younger doctors were not especially competent as their more senior colleagues. Conclusions: Physicians demonstrated variable levels of knowledge about care of patients with diabetes during Ramadan. Reported self-reported competence was not matched by actual knowledge and treatment practices. Continued education, mentoring and support schemes are needed with regular assessments before Ramadan fast on an annual basis.