The Curse of Wealth – Middle Eastern Countries Need to Address the Rapidly Rising Burden of Diabetes

The energy boom of the last decade has led to rapidly increasing wealth in the Middle East, particularly in the oil and gas-rich Gulf Cooperation Council (GCC) countries. This exceptional growth in prosperity has brought with it rapid changes in lifestyles that have resulted in a significant rise in chronic disease. In particular the number of people diagnosed with diabetes has increased dramatically and health system capacity has not kept pace. In this article, we summarize the current literature to illustrate the magnitude of the problem, its causes and its impact on health and point to options how to address it.

In 2002, the WHO warned that obesity was an important determinant of health that could lead to adverse metabolic changes including increased levels of resistance to insulin and in turn raise the risk of type 2 diabetes mellitus (8). Accordingly, the rise in obesity in the GCC countries is likely to have substantially contributed to the rise of diabetes prevalence with an annualized rate of change of 4% in Saudi Arabia (between 1993 and 2000) and of 2% in Oman (between 1991 and 2000) (3).

Type 2 diabetes -a growing public health concern
Such trends have led to type 2 diabetes becoming a major public health problem in the region. In 2012, four GCC countries (Kuwait, Saudi Arabia, Qatar, and Bahrain 4 ) were among the 10 countries with the highest diabetes prevalence rates in the world (9) 5 . While this paper focuses on GCC countries, as shown in Figure 1 below, the trend in the GCC follows that of the whole Middle East and North Africa (MENA) region 6 , where estimates for 2013 suggest approximately 34.6 million adults suffer from diabetes (9.2% of the population), and an additional 25 million people (6.7% of the population) are at high risk of developing diabetes from impaired glucose tolerance 7 . Even in less affluent countries, such as Egypt and Lebanon, the prevalence of diabetes is 17% and 15% respectively, and in low-income 4. The comparative prevalence numbers are calculated by assuming the same age profile (the age profile of the world population) for every country. This approach allows for appropriate comparison across countries by reducing the effect of age.
countries, such Sudan and Yemen, 8 to 10% (10). The burden of diabetes is expected to surge over the next decades, as the Middle East will face the greatest increase in prevalence of type 2 diabetes worldwide, with 60 million diabetics in 2030 (11). The high prevalence of diabetes contributes to mortality due to complications, including eye disease (retinopathy), kidney failure, vascular diseases such as myocardial infarction and stroke, and neuropathy. For example, diabetic men are twice and women four times as likely to suffer from Coronary Heart Disease (CHD); the risk of stroke increases by a factor of three and the risk of amputation by a factor of 25, and diabetic retinopathy is the most common cause of blindness amongst 30-69 year olds (12). Numbers for select GCC countries put the prevalence of diabetic retinopathy in diabetics at 14% for Oman and 31% for Saudi Arabia. Statistics from Saudi Arabia also illustrate the striking increase in lifetime risk for diabetics to require dialysis for end stage renal disease, from 4% in the early 1980s to 40% in the late 1990s (13).

This diabetes epidemic is driven by a complex multitude of factors
This rise in chronic disease prevalence has been linked to a multitude of factors including dietary and lifestyle changes brought about by rapid economic development, increased urbanization, and the transition to a sedentary lifestyle (14).

A shift towards more Western diets
The dietary regime in the GCC region has moved away from "predominantly consuming dates, milk, fresh vegetables and fruit, whole wheat bread and fish to mostly foods rich in high saturated fats and refined carbohydrate diets coupled with a low dietary fiber intake" (13). In general, prosperity has led to greater consumption of meat; in Saudi Arabia for example, the per capita consumption of meat had increased on average by 2.2% per year between 1993 and 2003, while cereal consumption had declined during the same time period by an annual 0.1% (15). The proliferation of Western fast food chains may also have played a role in facilitating the dietary transition. Cultural norms have likely further reinforced the impact of this dietary transition: The hospitality culture where food is at the center of social interactions and refusing offered food could be seen as offensive to the host, and the fact that displaying some overweight is seen as a sign of wealth, exacerbate unhealthy nutrition patterns.

Lower levels of physical activity
Low levels of physical activity aggravate the impact of nutritional changes ( Figure 2) (13). Decreased physical activity has likely been supported by greater availability of cars and mechanic appliances, cheap migrant workers, access to television, as well as computers and computer games. A more sedentary lifestyle may have been reinforced by cultural impediments to physical exercise and sports (e.g. requirement for women to be accompanied by a male family member and wear traditional dresses like abayas when going outside pose significant barriers to physical activity in some settings). While the Quran encourages physical activities to take care of the body, the misinterpretation of the belief that "illness and wellness are God's will" may lead to fatalism with respect to health conditions (16,17). Some regional health authorities have tried to engage the respective religious authorities, but even explicit support of healthy conduct does not guarantee the desired individual behavior. For example, in spite of a fatwa (a The physical environment may also play a role; urban planning is often not supportive of physical activities and exercise facilities are frequently not available or expensive (20). In addition, climatic conditions present a major obstacle to outdoor activities, as Figure 3 illustrates.
Genetic predisposition for diabetes Furthermore, Middle Eastern populations appear to have a higher genetic risk for diabetes (21). For example, a recent study of Middle Eastern immigrants in Sweden found that the immigrants had a two to threefold higher risk of type 2 diabetes than native Swedes (22).
In sum, there are many factors, from changes in activity and nutrition patterns to genetic predisposition that are likely to contribute to the high prevalence of type 2 diabetes in the GCC countries.

The current impact on the healthcare budgets is just the beginning Diabetes represents a large burden on healthcare budgets
The Aggravating, the region has copied many flaws of the traditional Western healthcare system, concentrating on high-end curative rather than primary care and health promotion: 40-70% of national healthcare budgets in most Arab countries are allocated to hospitals (27)(28)(29)(30). This underinvestment in health promotion, prevention and primary care suggests the lack of a "medical home 9 "-a healthcare delivery model that provides the continuous, integrated-, and comprehensive care that diabetes requires, in a more cost-effective way.

GCC countries underinvesting in healthcare
Despite their high levels of GDP per capita, the GCC countries underinvest overall in healthcare (see Figure 4). In 2011, 8. This confirms earlier findings of the EPIDIAR study (which included 12,243 diabetics from 13 Islamic countries) in which 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes were fasting at least 15 days during Ramadan (19). 9. A Patient-Centered Medical Home (PCMH) "is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes" (31).
Kuwait, the UAE, and Qatar's per capita health expenditures were 1,500, 1,640, and 1,776 US dollars, respectively, compared to an average of 4,593 US dollars in OECD countries 10 (32).

Human resources for health are inadequate
Additionally, human resources for health are not adequate and contribute to the fact that some GCC countries sent up to 10% of patients for emergency care treatments abroad (33). There are 10 physicians per 10,000 population in the Eastern Mediterranean Region 11 compared with 32 in Europe and 19 in the Americas; and 15 nurses and midwives per 10,000 population compared to 79 in Europe and 49 in the Americas (30). A study in Saudi Arabia found that only 8% of primary healthcare centers were staffed with health educators-an important component in selfmanagement of chronic illnesses (34).

As a result, quality of healthcare is suboptimal
Ultimately, these factors are reflected in suboptimal quality of care; a recent systematic review of diabetes care in the GCC countries found that the management of type 2 diabetes based on the three major intermediate outcome measures (glycemic, blood pressure, and lipid control indicators) was suboptimal and that in almost all cases, less than 50% of patients met clinical outcomes targets (35). Too often primary care services are lagging particularly in providing appropriate diagnoses and referrals; according to Al-Ahmadi and Roland (34) "despite a high prevalence of diabetic retinopathy, only 40-68% of diabetic patients (in Saudi Arabia) were referred to eye clinics". Reasons for this sub-optimal diabetes management are manifold and include next to the underfunding, primary care physicians that are often not trained to deal with diabetes, diabetes educators that are rarely reimbursed or evaluated based on their results, and the lack of specialized training and certification of diabetes educators. This situation will be further challenged considering that a McKinsey study projected a 323% increase in treatment demand for diabetes-related ailments in the GCC countries by 2025 (36).

But awareness of the problem is rising in the region
The good news is that awareness of non-communicable diseases (in particular diabetes) is rising in the region. Acknowledging predicted 1. 12. Of note is also that although many GCC countries have a large expatriate population (often composed by a smaller share of western knowledge workers and a significantly larger share of low paid nationals from developing countries

The opportunity for advanced diabetes services
This mismatch between the growing demand for diabetes care and the inadequate setup of local healthcare systems in the GCC countries implies the need for creative solutions. Beyond cross-sectoral health promotion efforts to curb obesity and related non-communicable diseases (37)(38)(39) including the framing of specific diabetes policies and action plans, there are opportunities for health insurers, investors (e.g. sovereign wealth funds and venture capitalists), pharmaceutical companies, and healthcare delivery organizations to fill the gap by providing integrated care across the full continuum of patient needs in dedicated diabetes centers 13 . Such centers could capture the whole care continuum from pre-diabetes to severe cases with end-organ damage under one roof, providing patients with convenient access to all related services while allowing for the volume necessary to realize who work in particular in the construction and service sector) many local health initiatives and public health systems cover only nationals.    economies of scale (see Figure 5). The centers would have a strong primary care component to promote early detection, tailored education, optimal self-management, and successful counseling on lifestyle changes. Centers would adopt a holistic approach integrating a team of diabetes educators, specialized nurses, dietitians, exercise physiologists, and psychologists, and social workers into the process. These would be complemented by specialty care offering comprehensive clinical services including cardiology, eye care, endocrinology, nephrology, and dialysis. For those cases that nonetheless require tertiary care, the centers would establish a network of affiliated hospitals. Finally, pharmacy and medication management services would be addressed by the center and allow for treatment optimization. Services would be provided in a manner consistent with local norms and attitudes, such as on gender roles, views on physical activity, and dietary habits. This design, building on state of the art knowledge, recognizes that diabetic complications like blindness, kidney failure, nerve damage, amputations, strokes or heart disease are not inevitable. These complications and their healthcare costs and societal cost 14 , can be significantly reduced or avoided. Such an evidence-based and holistic approach is more likely to also honor the tradition of Arab healers who have a long history of being guided by science rather than dogma. As early as in medieval times, when blood-letting was the standard of care in Europe, Arab medicine experimented with herbal remedies, developed surgical tools to perform operations, used animals to test the effects of substances, and built upon their knowledge of the human body (40).
Innovative payment schemes such as risk-adjusted capitation, gain-sharing models and pay-for-performance schemes based on health outcomes could be established. This would 14. Al-Maskari et al. (26) found that in their sample the direct treatment cost of patients with diabetes was 3.2 times higher than the per capita expenditure for healthcare in the UAE, and that these cost increased by 2.2 times for patients with diabetes-related microvascular complications; by 6.4 times for patients with diabetes-related macrovascular complications; and by 9.4 times for patients with both micro and macrovascular diabetes-related complications. This illustrates the steep increase of health expenditures when early intervention and selfmanagement are not successful and complications occur. Electronic copy available at: https://ssrn.com/abstract=2424128 allow payers to share gain from optimized management with integrated diabetes centers. Such an approach should not only result in cost savings, but also in substantive improvements to the quality of life of patients.
The need for innovation is clear. And while these centers could have a major impact on improving diabetes care, there is obviously a range of specific policies that would have to accompany any successful strategy to tackle diabetes in the region. These include research in particular with respect to people's motivations and behaviors to understand how to effectively communicate and drive the needed move towards a healthier lifestyle, dedicated financial support for high quality primary healthcare, training, licensing and design of attractive and outcome oriented compensation of diabetes educators, and last but not least dedicated and visionary leadership.

Ethical issues
Not applicable.