1. In The name of God

2. Diabetes epidemiology: Reflecting your clinic?

3. Question #1 Approximately what percentage of your T2 diabetes patients are obese (>30 kg/m 2 ) * ? 1.<10% 2.25% 3.50% 4.75% 5.>90% *WHO Diabetes Fact Sheet No. 311. September 2006

4. Epidemiological transition” in newly industrialised nations Cockram CS 2000. HKMJ; 6 (1): 43-52 Mohan et al 2007. Indian J Med Res; 125: 217-230 Adapted from IDF Diabetes Atlas 4 th ed., 2009 Aging population Dietary changes Reduced physical activity Urbanisation Unhealthy lifestyle choices

5. Urbanisation, Western dietary habits linked to obesity rates Emergence of obesity linked to lifestyle changes associated with urbanisation, modernisation Population adopts Western dietary habits, decreased physical activity etc. Chiarelli and Marcovecchio 2008. EJE; 159: S67-S74 Yach et al 2006. Nature Medicine; 12(1): 62-66 1970 2000

6. Methods: Conducted in 2007 5,287 Iranian citizens included Sample size aged 15–64 years Results: 8.7% Diabetes 8.7% 26.6% Hypertension26.6% 22.3% Obesity22.3% 53.6% Central obesity53.6% Female Male Prevalence of Diabetes and its risk factors in Iran Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009 May 29;9:167 2.5 million Iranian

7. Obesity contributes to increase in prevalence of T2DM Obesity 2-fold increase in the odds of developing diabetes for 40-55 yr age group over a 30 year period Physical inactivity Increase in the number of individuals > 65 years Fox CS et al. The Framingham Offspring Study. Circulation 2006;113:2914–8 Normal weightOverweight Obese 1970s1980s1990s 0 5 10 15 20 8 year rate (%)

8. Diabetes epidemic: 54% increase in diabetes from 2010 to 2030 Adapted from IDF Diabetes Atlas 4th ed., 2009 World2010 = 285 million 2030 = 439 million Increase 54% North America Europe Middle East and North Africa Africa South and Central America Western Pacific Southeast Asia

9. Diabetes: from the globe to your clinic Assume you are a physician in the Asia/Western Pacific region, where the diabetes prevalence level is approximately 5-7% If you oversee a group of 200 patients, then: 14 will have diabetes (7%) 11 of these 14 remain undiagnosed (75%) Screen for high risk groups Only 2 of these people are undergoing optimal treatment Only 1 of these people have their diabetes properly controlled IDF Diabetes Atlas 4 th ed., 2009 Asia-Pacific Type 2 Diabetes Policy Group. Practical Targets and Treatments 4 th Ed. 2005.

10. Poor glucose control is associated with increased risk of complications Stroke Retinopathy and blindness Heart disease Kidney disease Neuropathy Diabetic foot disease Peripheral vascular disease Erectile dysfunction International Diabetes Federation. Diabetes Atlas, 2006

11. Retinopathy and Neuropathy Prevalence of Retinopathy and Neuropathy in Type 2 diabetic patients in Iran compared to other countries Study Location Prevalence of Retinopathy (%) Qazvin51.1 Isfahan45.4 Germany16.1 Australia21.9 Egypt32.1 Study location Prevalence of Neuropathy (%) Isfahan75.1 Islamshahr33.3 Diabetes Atlas, 3 rd edition, International diabetes federation, 2006 France28.8 Australia13.1 Egypt21.9

12. How well are diabetic risk factors controlled in Iran? 6.4% 1.1% 25.7% NA HbA 1c Measured in the previous year Patients at goal Lipids Delaveri A.,Archives of Iranian Med 2009;12:492-495

13. Question #3 What do you think is the greatest obstacle to improving diabetes care in Iran? 1.Lack of infrastructure/healthcare training 2.Patient compliance towards diet and exercise 3.Physician attitude 4.Resistance of patients to medication 5.Difficulty managing diabetic complications 6.Other

14. Question #4 Approximately what percentage of patients do you treat with insulin? 1.5% 2.10% 3.15% 4.20% 5.>20%

15. Antidiabetic treatment use: OHA’s favoured, insulin used infrequently International Diabetes Federation. Diabetes Atlas. 2006: 273-287.

16. Suboptimal care results in diabetic complications Assume you are a physician overseeing a group of approximately 50 patients diagnosed with diabetes If your clinic is in Iran: 38 patients will have suboptimal control of HbA 1c Approximately 4 patients (8%) will be treated with insulin; 28 patients will be treated with OADs only and 18 patients will be treated with diet only 6 patients (11.3%) will suffer from renal failure as a complication of their diabetes IDF Diabetes Atlas 4 th ed., 2009 Novo Nordisk. Changing Diabetes Barometer. 2009 International Diabetes Federation. Diabetes Atlas. 2006: 273-287.

17. Local insulin usage: human insulin preferred vs. analogues in Iran Insulin Usage (%) Prevalence of Diabetes in Iran in 2007 was 8.7% * In Iran, insulin is prescribed to less than 7.5% of diabetic patients Uncontrolled blood sugar = increased risk of complications 99% 1% *Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and Dyslipidemia. BMC Public Health 2009, 9:167 ** National Pharmaceutics Statistics, Ministry of Health, 2009,Iran **

18. Question #5 Which of the following factors do you feel is most important to improving diabetes care in your region in the future? 1.Diabetes prevention via education programmes 2.Patient lifestyle changes (diet and exercise) 3.Treatment advances/new drugs 4.Improved training for clinicians 5.Political will/government investment in diabetes care 6.Other

19. Age at diagnosis First major complications *Average risk reduction Better treatment extends and improves lives First minor complications Baseline (HbA 1c = 7.0%) Earlier Diagnosis + Enhanced Treatment 69-71 71 ”Mr. Lee" Age at diabetes diagnosis 52 65-6852 25-40%*25-65%* 71 years 5266-68 68 years Baseline (HbA 1c = 9.1%) ”Mr. Kim" Age at diabetes diagnosis 52 60-62 UKPDS Risk Engine: modelled data based on newly diagnosed cohort at age 52

20. Taking action now can have a positive impact Mr. Kim Mr. Lee Age at diagnosis52 Detection By coincidence after first minor symptoms occurred Through GP monitoring before first minor symptoms occurred Treatment Random visits to doctor and limited monitoring Quarterly consultations with well educated diabetes team and consistent monitoring HbA 1c 9.1%7.0 Life expectancy from diagnosis1619 Years free of complications from diagnosis 813 UKPDS Risk Engine: modelled data based on newly diagnosed cohort at age 52