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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 5 | Page : 81-84
Availability and accessibility of diabetes-related technologies in IDF-MENA Region
Erum Ghafoor1, Shabeen N Masood2, Jamal Belkhadir3, Mohamed Sultan4, Mohammad Sandid5, Shehla Baqai6, Nadima Shegem7
1 Department of Diabetology & Endocrinology, Baqai Institute of Diabetology & Endocrinology, Karachi, Sindh, Pakistan
2 Department of Obstertrics and Gynecology, Isra University, Hyderabad, Pakistan
3 Department of Diabetes and Endocrinology, International Diabetes Federation, Regional Chair of Middle East North Africa
4 Department of Obstetrics and Gynecology, Tripoli University, Diabetic Pregnancy Unit, 5 Aljalaa Maternity Hospital, Tripoli, Libya
5 Department of Diabetes and Endocrinology, Lebanese Diabetes Association, LMC, Saida, Lebanon
6 Department of Obstetrics and Gynecology, CMH Lahore Medical College, National University of Medical Sciences, Rawalpindi, Punjab, Pakistan
7 Department of Endocrinology and Diabetes, Jordanian Society for the Care of Diabetes, Amman, Jordan
Correspondence Address:
Prof. Shabeen N Masood
Department of Obstetrics and Gynecology, Isra University, Hyderabad
Pakistan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_117_22
Diabetes is a global epidemic and public health emergency, which leads to long-term health problems, cardiovascular diseases, diabetic retinopathy, stroke, blindness, dementia, limb loss, cd cancers across the globe. Diabetes not only leads to chronic complications but also compromises the quality of life. Diabetes-related deaths totaled 6.7 million in 2021, with health expenditure reaching USD 966 billion. Diabetes technologies are new novel modalities for the management of diabetes to create ease in the life of people living with diabetes, improve glycemic control and increase life expectancies. The Middle East and North Africa (MENA) Region consists of countries that are diverse not only in terms of culture, norms, practices, and financial and socioeconomic status. The high-income countries in this region have better access to new technologies such as insulin pumps, continuous glucose monitoring (CGM) systems, and integrated self-management applications. Some of these modalities have government support systems, reimbursement, and subsidy policies for people with diabetes (PWD). In contrast, PWD from low- and middle-income countries still find it difficult to access diabetes-related innovations due to lack of awareness, high out-of-pocket costs, lack of trained healthcare providers, weak healthcare infrastructure, absence of reimbursement health policies, universal coverage and lack of health insurance. Diabetes care management in the MENA Region is still deprived of modern diabetes care technologies.
Keywords: CGM, continuous glucose insulin infusion, continuous glucose monitoring, diabetes innovations, diabetes technologies, insulin pumps
Despite many public health measures and the involvement of global bodies, the epidemic of diabetes is not showing any reversal signs.[1] According to the World Health Organization (WHO), the prevalence of diabetes has increased to 80% from 1980 to 2014 globally, causing diabetes-related deaths totaled 6.7 million in 2021, with health expenditure reaching USD 966 billion. Technological new novel modalities for the management of diabetes may make a difference in health and life expectancies of people with diabetes.[2],[3],[4] The International Diabetes Federation estimated that 537 million people (aged 20–79 years) suffered from diabetes worldwide, with an expected increase to 644 million by 2030.[5]
There is much evidence that shows that integration of technologies in diabetes care management not only improves health outcomes, helps healthcare providers (HCPs) to better monitor and manage the disease, and also reduces the cost of diabetes-related complications.[6] It is important to understand diabetes technologies are not just electronic gadgets of automatic insulin delivering and blood glucose monitoring, these are also data-driven clinical management, software, application clinical decision support systems, and health economics. Diabetes technologies also embrace hybrid devices that do mutual functions, like monitoring blood glucose and delivery of insulin. More recently, integrated applications are part of these medical devices. It is important and safe to use only those devices which are approved by US Food and Drug Administration (FDA). The most commonly used diabetes-related technologies are flash glucose monitors, continuous glucose monitors, and insulin pumps. Flash glucose monitors possess a sensor and a reader (older versions scan the sensor via a reader). Newer versions circumvent this, connecting to a mobile app through Bluetooth. The person with diabetes wears the sensor externally on the back of their upper arms that sense the blood glucose level through interstitial fluid.[7]
The continuous glucose monitoring (CGM) systems are commonly used and considered more accurate. CGM systems consist of a sensor and transmitter which can transmit blood glucose levels to the insulin pump through Bluetooth technology. CGMs can be used standalone. In standalone CGMs the sensor constantly measures the blood glucose level and the transmitter transmits the blood glucose level every five minutes to a connected mobile app and can be checked on the cellphone.[8] Newer versions also provide alerts, predictive alarms, and five care link partners which send automatic SMS to connected partners in case of any adverse event such as hypoglycemia and hyperglycemia through the observation of blood glucose trends. The predictive alert systems are such an amazing feature of this novel modality. This algorithm-based feature predicts expected hypoglycemia and hyperglycemia and sends alerts, reducing the number of hospitalizations.[9] Similarly, insulin pumps are another new advancement; they are also called the artificial pancreas. The system consists of the insulin pump, insulin reservoir, and infusion set. An insulin pump provides continuous delivery of short-acting insulin 24/7. The insulin pump removes the requirement for long-acting insulin. Insulin pumps substitute the need for multiple daily injections (MDIs) with a continuous subcutaneous infusion and also help to improve blood glucose and quality of life.[10],[11],[12] There are numerous more devices available in different parts of the world but their accuracy and safety are still not validated.
Most of the Middle East and North Africa (MENA) states have weak or no healthcare infrastructure. There are several other factors that create hurdles in the implementation of diabetes-related technologies, such as lack of resources and funds, unavailability of health coverage/insurance by the government, lack of trained HCPs to sustain patient motivation, assist in day-to-day handling of the latest novelties such as CGM systems, insulin pumps and advance self-management applications. It is interesting to know that even HCPs are resistant to the use of technology in diabetes care management. A study has shown that junior and younger HCPs possess more adaptive attitudes toward the use of diabetes-related technologies.[13]
Initially, the use of technology such as insulin pumps and CGM systems was focused on people with type 1 diabetes but later its benefits were accepted in the management of people with type 2 diabetes as well as among women with gestational diabetes who are insulin dependent. A survey was conducted to identify the barriers and evaluate the use of CGMs and insulin in South East Asia, Africa, and Middle East, and North Africa countries. The survey was sent to healthcare professionals providing care to young people with diabetes (PWD). The responses from 28 countries show that half of the respondents use such innovations. Fifty percent of HCPs have 10% of PWD on CGM and 5% on insulin pumps. Approximately, 70% of HCPS declared that major challenge includes out-of-pocket cost, lack of funding, and support programs in the implementation of technologies. The other barriers are the unavailability of trained staff mainly diabetes health educators, fear and stress among users, the complexity of devices, lack of sale competition as manufacturers prefer to operate in high-income countries, and cultural barriers.[14]
The MENA Region is diverse in terms of economy and resources. There are few high-income countries such as Qatar, Kuwait, Saudi Arabia, and UAE benefiting from oil-dominant economies. Qatar has seen swift economic growth and showed a marked reduction in infant mortality and an increase in life expectancy.[15] The government of Qatar has declared diabetes prevention and treatment as a national priority.[16] Closed-loop insulin pumps and glucose monitoring sensors are reimbursed at different levels; Qatari nationals can be fully reimbursed, insurance holders can be partially reimbursed, and a support system for others, including low socio-economic groups, exists.[17] The clinical data is very limited in regards to use of these new technologies. However, some studies among Qatari children with type 1 diabetes and adolescents showed the improvement of long-term glycemic control with CGM and continuous subcutaneous insulin infusion (CSII) or insulin pumps.[18] Similarly, the government of Kuwait provides insulin pumps at government healthcare facilities but monitoring innovations such as CGM system or glucometer and testing strips are not supported. On the contrary, some NGOs and other organizations support and provide subsidies on the latest monitoring devices, which reduce the out-of-pocket burden of diabetes among the Kuwaiti population. The RCT study diabetes and telecommunication (DATES) from Kuwait shows the mobile phone-based support of self management for people with T2D and this can be replicated in low resource settings.[19] A single-center clinical audit in Kuwait has revealed that there was no significant difference in A1C among children with type 1 diabetes who were using CSII as compared with those who were on MDIs over the period of 1 year, but glycemic improvement was observed among those children who had poor glycemic levels in the past. It was also observed that, despite the reimbursement support system, patient motivation and positive family participation are also essential to gain full benefit.[20] The Kingdom of Saudi Arabia is also providing insulin pumps for free to almost all people with type 1 diabetes and further policies and support programs are on the charter of the Saudi government.[21]
A case-control study conducted among Saudi adults in 2019 showed that insulin pump therapy provides better glycemic control. However, with no significant impact on reduction of hypoglycemia and diabetic ketoacidosis (DKA) episodes among study participants was seen as compared to MDI. These findings point towards the vital role of training of HCPs and structured diabetes education with the availability of new modalities.[22] Likewise, the provision of diabetes technologies is not vastly different in the UAE for nationals under the age of 18.[23] An interesting study on Emirati children with type 1 diabetes showed significant improvement in glycemic control with the use of CGM system and insulin pumps compared to those who were on MDIs and manual monitoring. At the same time, there was no evident difference in reduction of hypoglycemic events as well as DKA, which proves that structured counseling and diabetes education are also mandatory to achieve comprehensive outcomes.[24] Another patient experienced analysis identified reasons behind underusage of CGM in the same region despite the provision of good glycemic control. It was observed that skin allergies related to adhesive strips of CGM, alarm lassitude, frequent loss of connectivity, accuracy discrepancies in comparison of capillary blood glucose levels and intrusion with daily activity also contribute to the stagnation of such innovations.[25]
The needs of PWD are similar across the globe but provision of care is largely different due to many factors. The scenario is upside down in low- and middle-income countries (LMICs).
According to the International Diabetes Federation, the prevalence of diabetes in Egypt is 18.4%,[26] which is high; new innovations and advances are not available at Egypt and neither are HCPs trained for them.[27] In contrast, the private sector is introducing CGM devices in Yemen, though insulin pumps are not yet available, nor is any governmental support.[28] The situation is not much different in other LMICs including Tunisia, Jordan, Algeria, Iran, Lebanon, Libya, Syria, and Pakistan. The private sector is working on diabetes-related innovations in some of these countries but most of them are manufacturers, a major reason behind the high cost of these tools and devices. As mentioned above, very few studies have been conducted in LMICs s of the MENA Region; therefore, the scientific evidence of diabetes technologies’ impact is limited. A patient experience study from Libya has shown positive outcomes in terms of achieving good glycemic control; patient interaction with diabetes care team, continuous education, and support are the main components in solving that matrix.[29] A thought-provoking survey was published in 2021 from Pakistan about use of diabetes mellitus technology (DMT) among people with Type-1 and Type-2 Diabetes. It was observed that 80% of participants believed that use of diabetes technologies improves overall diabetes care; 55% of study participants opinioned that it reduces the risk of chronic complications and approximately 38% of participants were concerned about the increased cost of diabetes care. Of interest was that 40% of participants stated that HCPs never discussed such modalities, whereas 27% of contributors showed their aversion towards it as they did not like to wear them 24/7. Due to scarcity of the data, limited scientific evidence is available from many countries, especially from LMICs.
ConclusionIt is important to understand that use of diabetes-related technologies is inconsistent in the MENA Region due to variable levels of income among countries. A public health shift, strong infrastructure, government support, local production, and manufacturing to reduce the cost, mass training of HCPs and targeted healthcare policies are needed to increase the use of technologies among PWD in this region to improve their glycemic control and quality of life as a whole.
Acknowledgement
The authors acknowledge Mr. Karim Anani, an award-winning writer, translator, and editor for his in-depth review and editing of the manuscript. The authors also acknowledge Ms. Safina Abdul Razzak (Research Associate, International Center for Clinical Research, Pakistan (ICCRP) for her technical IT support.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
References
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