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Diabetes in the Middle East and North Africa

      Abstract

      Aims

      Even though the Middle East and North Africa (MENA) region had the highest comparative prevalence of diabetes in 2012, little is known about the nuances of diabetes risk and capacity to address the burdens. To provide a comprehensive overview, we reviewed the literature on diabetes in the MENA region.

      Methods

      We conducted a systematic search in PubMed between January 1990 and January 2012 for studies on diabetes in the MENA region without language restriction.

      Results

      There was a paucity of country-specific epidemiology data in the region. Diabetes prevalence varied widely across studies, from 2.5% in 1982 to 31.6% in 2011. Older age and higher body mass index were the most strongly associated risk factors for diabetes. Among people with diabetes, over half did not meet recommended care targets. In addition, macrovascular and microvascular complications were observed in 9–12% and 15–54% of diabetes population, respectively.

      Conclusions

      This review suggests a need for more representative surveillance data in this noteworthy focal point of the global diabetes epidemic. Such actions will not only help to understand the actual burden of diabetes but also motivate actions on design and implementation of diabetes prevention and control programs.

      Abbreviations:

      WC (diabetic neuropathy symptom), WHR (high waist-to-hip ratio), NSS (neuropathy symptom score), NDS (neuropathy disability score), VPT (vibration perception threshold), ACR (albumin-creatinine ratio)

      Abbreviations:

      DNS (diabetic neuropathy symptom), DNE (diabetic neuropathy examination), NSS (neuropathy symptom score), NDS (neuropathy disability score), VPT (vibration perception threshold), ACR (albumin-creatinine ratio)

      Abbreviations:

      WC (diabetic neuropathy symptom), WHR (high waist-to-hip ratio), NSS (neuropathy symptom score), NDS (neuropathy disability score), VPT (vibration perception threshold), ACR (albumin-creatinine ratio), DNS (diabetic neuropathy symptom), DNE (diabetic neuropathy examination), NSS (neuropathy symptom score), NDS (neuropathy disability score), VPT (vibration perception threshold), ACR (albumin-creatinine ratio), FPG (fasting plasma glucose), OGTT (oral glucose tolerance test), IFG (impaired fasting glucose), IGT (impaired glucose tolerance), NR (not reported), WHO 1985 (the World Health Organization definition of diabetes in 1985), WHO 1999 (the World Health Organization definition of diabetes in 1999), ADA 1997 and ADA 2003 (the American Diabetes Association definition of diabetes in 1997 and 2003)

      Keywords

      1. Introduction

      The Middle East and North Africa (MENA) region has drawn attention in recent years due to their geopolitical significance, and also because of important demographic (e.g., increased life expectancy), lifestyle (e.g., reduced physical activity), and health transitions (e.g., decreased perinatal mortality). The MENA region had the highest comparative prevalence of diabetes in the world in 2012, with four countries in the region among the top ten in terms of prevalence. The International Diabetes Federation (IDF) estimates that 32.8 million adults are affected by diabetes in the MENA region, and by 2030, this number will double to 59.9 million [
      • Whiting D.R.
      • Guariguata L.
      • Weil C.
      • Shaw J.
      IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030.
      ]. Also, 10% of deaths in MENA region were attributable to diabetes and the cumulative spending to treat diabetes in 2012 amounted to $12 billion [
      • Whiting D.R.
      • Guariguata L.
      • Weil C.
      • Shaw J.
      IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030.
      ,
      • International Diabetes Federation
      The diabetes atlas.
      ].
      Little is, however, known about the nuances of type 2 diabetes risk and the capacity (detection, preventive services, disease management) to address this rapidly emerging chronic condition in MENA. There is heterogeneity across MENA countries in terms of level of development and urbanization, ethnicity, cultural and religious backgrounds, and income distribution within nations. These variations may influence the epidemiology, clinical presentation, quality of care, and health and economic outcomes related to diabetes in the region. Also, while diabetes in Asia and Africa has been well reviewed [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • et al.
      Diabetes in Asia: epidemiology, risk factors, and pathophysiology.
      ,
      • Mbanya J.C.
      • Motala A.A.
      • Sobngwi E.
      • Assah F.K.
      • Enoru S.T.
      Diabetes in sub-Saharan Africa.
      ] little is known about these facets of diabetes in MENA. As such, this systematic review is aimed to address the deficits, providing a comprehensive overview of diabetes in the region.

      2. Methods

      2.1 Search strategy and selection criteria

      We searched Pubmed for articles related to diabetes mellitus in the MENA region published from January 1990 to January 2012 without language restriction. We used a combination of search terms (Appendix A) related to diabetes and all MENA countries classified by the World Bank.
      Two reviewers independently identified articles and sequentially screened abstracts for inclusion. Disagreements were resolved through discussion with a third author.
      The following types of studies were eligible for inclusion: (1) studies reporting diabetes prevalence, incidence, or both; (2) those reporting on risk factors for diabetes (e.g., age, family history, ethnicity, urbanization and migration, adiposity, lifestyle patterns, genetic susceptibility, socioeconomic status (SES), or developmental origins [low birth weight, early life events]); (3) studies investigating pathophysiological mechanisms of diabetes (e.g., insulin resistance, pancreatic beta-cell dysfunction); (4) studies describing diabetes-related microvascular (retinopathy, neuropathy, nephropathy) or macrovascular (cardiovascular and peripheral vascular disease) complications; and (5) studies characterizing quality of diabetes care, patient-reported quality of life, and costs.
      Full-texts of eligible articles were retrieved for detailed assessment. Reference lists of selected articles were also manually scanned for additional eligible studies.
      Although clinic-based studies have limitations with regard to the representativeness of the sample populations, we included these from studies with multiple clinical settings as the data do offer some meaningful and potentially generalizable insights.
      We excluded: studies focused on type 1 diabetes, gestational diabetes, or any uncommon forms of diabetes (e.g., diabetes secondary to chronic pancreatitis); studies with self-reported prevalence data or those that did not define diabetes using standard definitions (World Health Organization or American Diabetes Association); studies based in single clinics/hospitals; studies using non-random sampling; or studies exclusively investigating specific ethnic- or age- groups (e.g., children; elderly).
      Two reviewers independently extracted data using standardized data collection spreadsheets and assessed study quality. We also excluded studies that used inappropriate statistical methods and those with response rate <75%.
      Given the complexity and the heterogeneity of studies included (spanning clinical, pathophysiology, and public health literatures), we conducted a narrative synthesis of the evidence and findings are presented within each category of interest.

      3. Results

      Searches yielded 6765 publications, of which 1205 were selected for full-text review. A total of 101 cross-sectional and 9 cohort publications from all the 22 countries of the MENA region were eligible for inclusion.
      There was wide variation in the number of studies conducted in each of the MENA countries. Furthermore, available studies used different research methods and surveyed populations with different age-sex distributions and level of representativeness. As such, caution is advised when trying to compare data across studies.

      3.1 Prevalence and incidence

      Diabetes prevalence largely differed across the available studies and ranged from 2.5% in Saudi Arabia, 1982 to 31.6% in that country in 2011. High estimates were recorded in studies in recent years – for example, among urban residents of Riyadh, Saudi Arabia (31.6%) [
      • Al-Daghri N.M.
      • Al-Attas O.S.
      • Alokail M.S.
      • Alkharfy K.M.
      • Yousef M.
      • Sabico S.L.
      • et al.
      Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (riyadh cohort 2): a decade of an epidemic.
      ], a national census of Bahrain (28.1%) [
      • Al-Mahroos F.
      • McKeigue P.M.
      High prevalence of diabetes in Bahrainis. Associations with ethnicity and raised plasma cholesterol.
      ], employees surveyed in Kuwait (21.4%) [
      • Al Khalaf M.M.
      • Eid M.M.
      • Najjar H.A.
      • Alhajry K.M.
      • Doi S.A.
      • Thalib L.
      Screening for diabetes in Kuwait and evaluation of risk scores.
      ], urban dwellers in Jordan (17.1%) [
      • Ajlouni K.
      • Khader Y.S.
      • Batieha A.
      • Ajlouni H.
      • El-Khateeb M.
      An increase in prevalence of diabetes mellitus in Jordan over 10 years.
      ], health care center users in Qatar (16.7%) [
      • Bener A.
      • Zirie M.
      • Janahi I.M.
      • Al-Hamaq A.O.
      • Musallam M.
      • Wareham N.J.
      Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar.
      ] and a representative sample of Beirut, Lebanon (15.8%) (Table 1) [
      • Hirbli K.I.
      • Jambeine M.A.
      • Slim H.B.
      • Barakat W.M.
      • Habis R.J.
      • Francis Z.M.
      Prevalence of diabetes in greater Beirut.
      ]. There were very few data regarding rural diabetes prevalence in the region. However in a recent systematic review focused on rural areas of low-middle income countries, the MENA region had the highest pooled prevalence (7.7%; 95% CI: 6.2–9.3), substantially higher than the global average (5.6%; 95% CI: 4.6–6.6) [
      • Hwang C.K.
      • Han P.V.
      • Zabetian A.
      • Ali M.K.
      • Narayan K.M.
      Rural diabetes prevalence quintuples over twenty-five years in low- and middle-income countries: a systematic review and meta-analysis.
      ].
      Table 1Diabetes prevalence in the Middle East and North Africa region.
      Author and yearYear of surveySamplingAge (years)% FemalesDiagnosisDiabetes prevalence % (95% CI)IFG and/or IGT prevalence % (95% CI)Age-adjusted
      FrameStrategyResponse rate (%)SizeMethodCriteria
      Algeria
      Zaoui et al., 2007
      • Zaoui S.
      • Biemont C.
      • Meguenni K.
      Epidemiology of diabetes in urban and rural regions of Tlemcen (Western Algeria).
      NRLocal/urban and ruralRandomNR7656≥ 264Venous FPGWHO 198514.2NRNo
      Malek et al., 2001
      • Malek R.
      • Belateche F.
      • Laouamri S.
      • Hamdi-Cherif M.
      • Touabti A.
      • Bendib W.
      • et al.
      Prevalence of type 2 diabetes mellitus and glucose intolerance in the Setif area (Algeria).
      1985Local/urban and ruralRandom90145730–6451OGTTWHO 19999.08 (50% were undiagnosed)7.5 for IGTNo
      Bahrain
      Al-Mehrooz et al., 1998
      • Al-Mahroos F.
      • McKeigue P.M.
      High prevalence of diabetes in Bahrainis. Associations with ethnicity and raised plasma cholesterol.
      1995–1996National censusSystematic sampling59–70212840–6941.5FPG, OGTT, previously known diabetesWHO 198528.117.43 for IGTNo
      Egypt
      Herman et al., 1995
      • Herman W.H.
      • Ali M.A.
      • Aubert R.E.
      • Engelgau M.M.
      • Kenny S.J.
      • Gunter E.W.
      • et al.
      Diabetes mellitus in Egypt: risk factors and prevalence.
      1991–4Rural censusRandom726052≥20NRFPG, OGTTWHO 19854.9 for newly diagnosed; 9.3 for both diagnosed and undiagnosedNRNo
      Iraq
      Al-Kasab et al., 1979
      • Al-Kasab F.M.
      • Alkafajei A.M.
      • Medbigh S.H.
      The prevalence of diabetes mellitus in a rural community in Iraq.
      NRLocal/ruralMutistage systematic56228≥1567OGTTWHO19794.8NRNo
      Mansour et al., 2008
      • Mansour A.A.
      • Wanoose H.L.
      • Hani I.
      • Abed-Alzahrea A.
      Diabetes screening in Basrah, Iraq: a population-based cross-sectional study.
      2007Local/ruralSystematicNR3176≥2056.8Capillary FPGADA 20037.42.02 for IFG
      Iran
      Esteghmati et al., 2008
      • Esteghamati A.
      • Gouya M.M.
      • Abbasi M.
      • Delavari A.
      • Alikhani S.
      • Alaedini F.
      • et al.
      Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non-Communicable Diseases of Iran.
      2005National/urban and ruralMultistage probability cluster sampling75.47098125–64NRVenous FPGWHO 19997.7 (7.5–7.9)16.8 (16.4–17.2) for IFGYes
      Azimi-Nezhad et al., 2008
      • Azimi-Nezhad M.
      • Ghayour-Mobarhan M.
      • Parizadeh M.R.
      • Safarian M.
      • Esmaeili H.
      • Parizadeh S.M.
      • et al.
      Prevalence of type 2 diabetes mellitus in Iran and its relationship with gender, urbanisation, education, marital status and occupation.
      NRLocal/urban and ruralCluster-stratified samplingNR377815–6451Venous FPGADA5.52.5No
      Hadaegh et al., 2008
      • Hadaegh F.
      • Bozorgmanesh M.R.
      • Ghasemi A.
      • Harati H.
      • Saadat N.
      • Azizi F.
      High prevalence of undiagnosed diabetes and abnormal glucose tolerance in the Iranian urban population: Tehran Lipid and Glucose Study.
      1999–2001Local/urbanMultistage cluster random sampling91.59489≥2058OGTTADA 20034.9 (4.5–5.3) for undiagnosed; 9.1 (8.5–9.7) for known diabetes7.3 (6.8–7.8) for isolated IFG; 6.7 (6.2–7.2) for isolated IGT and 4.2 (3.8–4.6) IFG and IGTYes
      Israel
      Stern et al., 1988
      • Stern E.
      • Blau J.
      • Rusecki Y.
      • Rafaelovsky M.
      • Cohen M.P.
      Prevalence of diabetes in Israel. Epidemiologic survey.
      1986Local/urbanEmployees of the manufacture (representative cross-section of the Israeli population)NR466030–6519.6FPG, OGTT, A1CWHO 19854.1 (3.6% for known diabetes)NRNo
      Rennert et al., 2001
      • Rennert G.
      • Peterburg Y.
      Prevalence of selected chronic diseases in Israel.
      1998Insurees of the largest HMO in countrySystematic30–88 in different districts1409705≥20NRPhysician-diagnosedClassifi-cation of Health Problems in Primary Care (CHPPC codes)6.1NRYes
      Jordan
      Ajlouni et al., 2008
      • Ajlouni K.
      • Khader Y.S.
      • Batieha A.
      • Ajlouni H.
      • El-Khateeb M.
      An increase in prevalence of diabetes mellitus in Jordan over 10 years.
      2004Local/urbanRandom sample941121≥2565Venous FPGADA17.1 (15.0, 19.1)7.8 (6.2, 9.4) for IFGYes
      Kuwait
      Abdella, et al., 1996
      • Abdella N.
      • Khogali M.
      • al-Ali S.
      • Gumaa K.
      • Bajaj J.
      Known type 2 diabetes mellitus among the Kuwaiti population. A prevalence study.
      1989–1990Urban/ruralAll Kuwaitis attending diabetes clinics in the two health regionsNR109051≥20NRMedical chart review: FPG or OGTTWHO 19857.6NRNo
      Al-Khalaf et al., 2010
      • Al Khalaf M.M.
      • Eid M.M.
      • Najjar H.A.
      • Alhajry K.M.
      • Doi S.A.
      • Thalib L.
      Screening for diabetes in Kuwait and evaluation of risk scores.
      2007Public sector employees SurveyMulti-stage cluster random samplingNR56236.2 (8.9)52.8FPG, random glucose, previously known diabetesADA 200321.412.3 for IFG (in 460 subjects)No
      Lebanon
      Hirbli et al., 1992
      • Hirbli K.I.
      • Gerges T.A.
      • Karam V.J.
      • Saikaly J.A.
      The estimation of the prevalence of diabetes mellitus in Lebanon.
      1989NationalInvitation via TV campaignNR436No limitNRFPGFPG ≥140 mg/dl1011No
      Hirbli et al., 2005
      • Hirbli K.I.
      • Jambeine M.A.
      • Slim H.B.
      • Barakat W.M.
      • Habis R.J.
      • Francis Z.M.
      Prevalence of diabetes in greater Beirut.
      NRLocal/urbanMultistage random sampleNR3000≥40NRVenous FPGADA 199715.8 (14.5–17.1)2.5 (1.2–3.9)No
      Lybia
      Kadiki et al., 2001
      • Kadiki O.A.
      • Roaeid R.B.
      Prevalence of diabetes mellitus and impaired glucose tolerance in Benghazi Libya.
      1998–1999Local/ruralMultistage cluster sampling86.6868≥2064OGTTADA 1997 and WHO 199914.1 (10.9–17.1)8.5 (5.8–11.3)Yes
      Morocco
      Rguibi et al., 2006
      • Rguibi M.
      • Belahsen R.
      Prevalence and associated risk factors of undiagnosed diabetes among adult Moroccan Sahraoui women.
      2001–2002Local/urbanRandom samplingNR249 (women only)≥ 15100Venous FPGADA 19976.4 for undiagnosed5.5 for IFGNo
      Tazi et al., 20032000NationalCensus90.11802≥2058.1FPGWHO6.6NRYes
      Oman
      Asfour et al., 1995
      • Asfour M.G.
      • Lambourne A.
      • Soliman A.
      • Al-Behlani S.
      • Al-Asfoor D.
      • Bold A.
      • et al.
      High prevalence of diabetes mellitus and impaired glucose tolerance in the Sultanate of Oman: results of the 1991 national survey.
      1991NationalMultistage cluster sampling932963All ages (33% 20–29%; <1% >80 years)NRFPG, OGTTWHO9.812.9 for IGTNo
      Al-Lawati et al., 2002
      • Al-Lawati J.A.
      • Al Riyami A.M.
      • Mohammed A.J.
      • Jousilahti P.
      Increasing prevalence of diabetes mellitus in Oman.
      2000NationalSystematic84583830–6450.2Venous FPGWHO 199916.1 (14.7–17.4)7.1 (6.2–8.1) for IFG of males; 5.1 (4.4–6.0) for IFG of femalesYes
      Al-Riyami et al., 2012
      • Al Riyami A.
      • Elaty M.A.
      • Morsi M.
      • Al Kharusi H.
      • Al Shukaily W.
      • Jaju S.
      Oman world health survey: part 1 – methodology, sociodemographic profile and epidemiology of non-communicable diseases in oman.
      2008Nationalmulti-stage stratified cluster sampling93.55000≥1848FPGWHO12.3NRNo
      Palestine
      Husseini et al., 2000
      • Husseini A.
      • Abdul-Rahim H.
      • Awartani F.
      • Jervell J.
      • Bjertness E.
      Prevalence of diabetes mellitus and impaired glucose tolerance in a rural Palestinian population.
      1996Local/semi-rural villageSystematic8550030–6558.2Capillary FBGWHO 19999.8 (7.3–12.3)8.6 (6.1–11.1)No
      Abdul-Rahim et al., 2001
      • Abdul-Rahim H.F.
      • Husseini A.
      • Giacaman R.
      • Jervell J.
      • Bjertness E.
      Diabetes mellitus in an urban Palestinian population: prevalence and associated factors.
      1998Local/urbanStratified cluster random59.249230–6561.4Capillary FBG/venous OGTTWHO13.94.2 for IGT
      Abu Sham’a et al., 2009
      • Abu Sham’a R.A.
      • Darwazah A.K.
      • Kufri F.H.
      • Yassin I.H.
      • Torok N.I.
      MetS and cardiovascular risk factors among Palestinians of East Jerusalem.
      2005Local/urbanRandom8734220–7456.4Venous FPGWHO12.611.1 for IFG
      Qatar
      Bener et al., 2009
      • Bener A.
      • Zirie M.
      • Janahi I.M.
      • Al-Hamaq A.O.
      • Musallam M.
      • Wareham N.J.
      Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar.
      2007–2008National/urban and semi-urbanMultistage stratified cluster sampling77.91117≥2049OGTTWHO 199916.7 (10.7% for diagnosed; 5.9% for newly diagnosed)12.5 for IGT; 1.3 for IFGYes
      Saudi Arabia
      Bacchus et al., 1982
      • Bacchus R.A.
      • Bell J.L.
      • Madkour M.
      • Kilshaw B.
      The prevalence of diabetes mellitus in male Saudi Arabs.
      NRRural Al-Kharj areaSurveyNR1385All age groups0 (all MALE)Venous FPG, OGTTWHO 19852.50.2No
      Fatani et al., 1987
      • Fatani H.H.
      • Mira S.A.
      • el-Zubier A.G.
      Prevalence of diabetes mellitus in rural Saudi Arabia.
      NRRural (Western region of Saudi Arabia)Household cluster sampling875222All age groups46.9FPG, OGTTWHO4.358 subjects were IGTNo
      Anukote,1990
      • Anokute C.C.
      Epidemiologic studies of diabetes mellitus in Saudi Arabia – Part I – Screening of 3158 males in King Saud University.
      1985–1987King Saudi UniversityScreening programNR3158≥150 (all male)FPGWHO 19856.0NRNo
      El-Hazmi et al., 1996
      • El-Hazmi M.A.
      • Warsy A.S.
      • Al-Swailem A.R.
      • Al-Swailem A.M.
      • Sulaimani R.
      • Al-Meshari A.A.
      Diabetes mellitus and impaired glucose tolerance in Saudi Arabia.
      199134 different areas of Saudi ArabiaRandom sampling>95%234932–70 years53.9Fasting whole blood glucose, OGTTWHO 19850.21 for Type 1 diabetes; 4.99 for Type 2 diabetes0.7 for IGTNo
      Al-Nuaim et al., 1997
      • Al-Nuaim A.R.
      Prevalence of glucose intolerance in urban and rural communities in Saudi Arabia.
      1990–1993Different urban-rural regionsRandomly selected from National Epidemiological Household Study for Chronic Metabolic DiseasesNR13177≥ 1548Random plasma glucose, OGTT, self-reportedWHO 1985Men [12 (11–13) urban, 7 (6.3–8.1) rural] Women [14 (13–15) urban, 8 (7–9) rural]10 (9–11) for IGT of urban males;8 (7–9) for IGT of rural males;11 (10–12) for IGT of urban females,8 (7–9) for IGT of rural femalesYes
      Al-Daghri et al., 2011
      • Al-Daghri N.M.
      • Al-Attas O.S.
      • Alokail M.S.
      • Alkharfy K.M.
      • Yousef M.
      • Sabico S.L.
      • et al.
      Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (riyadh cohort 2): a decade of an epidemic.
      NRRiyadh/urbancluster samplingNR91497–8041.4Capillary FBGWHO 199931.610.2 for IFGYes
      Al-Baghliet al., 2010
      • Al-Baghli N.A.
      • Al-Ghamdi A.J.
      • Al-Turki K.A.
      • Al Elq A.H.
      • El-Zubaier A.G.
      • Bahnassy A.
      Prevalence of diabetes mellitus and impaired fasting glucose levels in the Eastern Province of Saudi Arabia: results of a screening campaign.
      2004Eastern Province Of Saudi ArabiaScreening of all the residents99.8197681≥3067.6Fasting venous bloodFPG ≥  126 mg/dl (7.0 mmol/l), or when there was a history of a previous diagnosis17.2 (15.6% for known; 1.8% for newly diagnosed)2.7 for IFGNo
      Syria
      Albache et al., 2009 and 2011
      • Albache N.
      • Al Ali R.
      • Rastam S.
      • Fouad F.M.
      • Mzayek F.
      • Maziak W.
      Epidemiology of type 2 diabetes mellitus in Aleppo, Syria.
      ,
      • Al Benwan K.
      • Al Mulla A.
      • Rotimi V.O.
      A study of the microbiology of diabetic foot infections in a teaching hospital in Kuwait.
      2006Allepo/urbanTwo-stage cluster sampling92.11168≥2547.7FPG or A1C, self-reportedWHO 1999 and ADA6.5 based on FPG and 15.6 based on A1C8.6 for IFGYes
      Sudan
      Elbagir et al., 1998
      • Elbagir M.N.
      • Eltom M.A.
      • Elmahadi E.M.
      • Kadam I.M.
      • Berne C.
      A high prevalence of diabetes mellitus and impaired glucose tolerance in the Danagla community in northern Sudan.
      1992–1993Local/urban and ruralmulti-stage cluster samplingNR724≥2567OGTTWHO, 198510.4 (7.7–13.1)9.8 (7.1–12.4) for IGTYes
      Tunisia
      Bouguerra et al., 2007
      • Bouguerra R.
      • Alberti H.
      • Salem L.B.
      • Rayana C.B.
      • Atti J.E.
      • Gaigi S.
      • et al.
      The global diabetes pandemic: the Tunisian experience.
      1996–1997National/urban and ruralmultistage stratified cluster sampling85.13729>1966.6Venous FPGADA 19978.54.91 for IFG among those aged ≥ 20Yes
      Elasmi et al., 2009
      • Elasmi M.
      • Feki M.
      • Sanhaji H.
      • Jemaa R.
      • Haj Taeib S.
      • Omar S.
      • et al.
      Prevalence of conventional cardiovascular risk factors in the Great Tunis population.
      2004–2005Local/urbanTwo stage cluster random sampling99.6248335–7054.7FPGFPG ≥126 mg/dl or under treatment for diabetes15NRNo
      Gharbi et al., 1995
      • Gharbi M.
      • Belhani A.
      • Ben Aleya A.
      • Aouidet A.
      • Nasraoui A.
      • Achour A.
      • et al.
      Epidemiology of diabetes in Tunisia.
      1984Local/urbanRandom sample of the census6969235–5054FPG or self-reportedFPG > 7.8 mmol/l or known diabetes or medication6.3 (3/4 were known diabetes)NRYes
      United Arabs Emirates
      Saadi et al., 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      2005–2006Local/urbanMultistage random samplingNR2455≥1850OGTTWHO 199910.5 for diagnosed; 6.6 for undiagnosed20.2 for IFG and/or IGTNo
      Yemen
      Al-Habori et al., 2004
      • Al-Habori M.
      • Al-Mamari M.
      • Al-Meeri A.
      Type II Diabetes Mellitus and impaired glucose tolerance in Yemen: prevalence, associated metabolic changes and risk factors.
      NRLocal/urbansystematic samplingNR49825–6551OGTTWHO 19994.6 (7.4 in males and 2 in females)2 for IGT; 2.2 for IFGYes
      Gunaid et al., 2008
      • Gunaid A.A.
      • Assabri A.M.
      Prevalence of type 2 diabetes and other cardiovascular risk factors in a semirural area in Yemen.
      2000Local/semi-ruralMultistage random86.825035–9052Capillary FBG/OGTTWHO 1999 and ADA 19976.3 (5.4–7.2)9.0 (6.0–12) for IFG or IGTYes
      FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; IFG, impaired fasting glucose (fasting plasma glucose: 5.6 to 6.9 mmol/l); IGT, impaired glucose tolerance (2-h post challenge glucose: 7.8–11.0 mmol/l); NR, not reported; WHO 1985, the World Health Organization definition of diabetes in 1985 (FPG ≥ 7.8 mmol/l and/or 2-h post challenge glucose (2-h PG) ≥11.1 mmol/l.)
      • World Health Organization:
      Diabetes mellitus: report of a WHO study group.
      ; WHO 1999, the World Health Organization definition of diabetes in 1999 (FPG ≥ 7.0 mmol/l and/or 2-h PG ≥ 11.1 mmol/l)
      • World Health Organization
      Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO Consultation. Part 1. Diagnosis and classification of diabetes mellitus.
      ; and ADA 1997 and ADA 2003: the American Diabetes Association definition of diabetes in 1997 and 2003 (FPG ≥ 7.0 mmol/l and/or 2-h PG ≥ 11.1 mmol/l)
      Report of the expert committee on the diagnosis and classification of diabetes mellitus.
      .
      Very few studies reported the proportion of people with undiagnosed diabetes. The few data that are available show that one-fourth of those with diabetes in Tunisia [
      • Gharbi M.
      • Belhani A.
      • Ben Aleya A.
      • Aouidet A.
      • Nasraoui A.
      • Achour A.
      • et al.
      Epidemiology of diabetes in Tunisia.
      ] and half in Algeria and Egypt were undiagnosed until surveyed [
      • Malek R.
      • Belateche F.
      • Laouamri S.
      • Hamdi-Cherif M.
      • Touabti A.
      • Bendib W.
      • et al.
      Prevalence of type 2 diabetes mellitus and glucose intolerance in the Setif area (Algeria).
      ,
      • Herman W.H.
      • Ali M.A.
      • Aubert R.E.
      • Engelgau M.M.
      • Kenny S.J.
      • Gunter E.W.
      • et al.
      Diabetes mellitus in Egypt: risk factors and prevalence.
      ]. To understand whether diabetes prevalence in MENA countries has changed over time, we report data from the Global Burden of Disease study [
      • Danaei G.
      • Finucane M.M.
      • Lu Y.
      • Singh G.M.
      • Cowan M.J.
      • Paciorek C.J.
      • et al.
      National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants.
      ]. This systematic analysis of 370 country-years showed an upward trend in diabetes prevalence for most countries in the region, with the highest increase observed in Saudi Arabia (from year 1980 to year 2008: 9.4% to 22% in males; and 8.7% to 21.7% in females) (Fig. 1). There are concerns that diabetes prevalence will continue to increase for two main reasons. First, intermediate hyperglycemia (impaired fasting glucose [IFG] and/or impaired glucose tolerance [IGT]) notably affects large proportions of people, with prevalence of IFG reaching 16.8% in Iran [
      • Esteghamati A.
      • Gouya M.M.
      • Abbasi M.
      • Delavari A.
      • Alikhani S.
      • Alaedini F.
      • et al.
      Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non-Communicable Diseases of Iran.
      ]. Second, data suggest that type 2 diabetes prevalence may be high among children in the MENA region – for example, 30% of Kuwaiti 6- to 18-year-olds were affected by this condition [
      • Moussa M.A.
      • Alsaeid M.
      • Abdella N.
      • Refai T.M.
      • Al-Sheikh N.
      • Gomez J.E.
      Prevalence of type 2 diabetes mellitus among Kuwaiti children and adolescents.
      ].
      Figure thumbnail gr1
      Fig. 1Trends in the prevalence of type 2 diabetes from 1980 to 2008 in the Middle East and North Africa region.
      Incidence data were very limited. The longitudinal Tehran Lipid and Glucose Study (TLGS) demonstrated a 6.4% cumulative incidence of diabetes among urban Iranian adults over a 6 year follow-up [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ]. In Israel, 25.9% of a representative sample of normoglycemic people progressed to diabetes during 20 years follow-up [
      • Dankner R.
      • Abdul-Ghani M.A.
      • Gerber Y.
      • Chetrit A.
      • Wainstein J.
      • Raz I.
      Predicting the 20-year diabetes incidence rate.
      ]. These data suggest that the annual incidence of diabetes in the general population is just above 1%, a rate that is similar to the United States [
      • Boyle J.P.
      • Thompson T.J.
      • Gregg E.W.
      • Barker L.E.
      • Williamson D.F.
      Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence.
      ].

      3.2 Risk factors

      Diabetes is a multifactorial condition. Twenty studies investigated risk factors associated with diabetes, of which twelve were cross-sectional, seven were cohort studies, and one was a case control study. Obesity (BMI ≥ 30 kg/m2) was the most commonly reported risk factor with ten studies demonstrating strong associations with diabetes.
      Adiposity, in its various forms, appears to be a significant risk factor for type 2 diabetes in MENA region adults [
      • Wang Y.
      • Rimm E.B.
      • Stampfer M.J.
      • Willett W.C.
      • Hu F.B.
      Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men.
      ,
      • Narayan K.M.
      • Boyle J.P.
      • Thompson T.J.
      • Gregg E.W.
      • Williamson D.F.
      Effect of BMI on lifetime risk for diabetes in the U.S.
      ]. This has been demonstrated in numerous studies across the region (Table 2). As examples, although diabetes risk in Bahrain was higher among older adults (aged 50–79), in females, people with low or no literacy, and those currently married, obesity was still the strongest risk factor for diabetes when adjusted for all factors [
      • Musaiger A.O.
      • Al-Mannai M.A.
      Social and lifestyle factors associated with diabetes in the adult Bahraini population.
      ]. Among one million Israeli military enrollees, obesity was associated with elevated diabetes risk (odds ratio [OR] 5.56 for males and 4.42 for females) [
      • Levin A.
      • Morad Y.
      • Grotto I.
      • Ravid M.
      • Bar-Dayan Y.
      Weight disorders and associated morbidity among young adults in Israel 1990–2003.
      ]. Also, in villages in Israel, obesity was associated with higher risk and the disease appeared at earlier age and more commonly among people of Arab origin [
      • Abdul-Ghani M.A.
      • Kher J.
      • Abbas N.
      • Najami T.
      Association of high body mass index with low age of disease onset among Arab women with type 2 diabetes in a primary care clinic.
      ]. Over 3.6 years follow-up of Iranian men and women without diabetes, ORs for diabetes were higher among those with BMI ≥ 30 kg/m2 (OR: 2.4–5.3) and high waist-to-hip ratio (WHR)(OR: 2.6–3.5) [
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      The prospective association of general and central obesity variables with incident type 2 diabetes in adults, Tehran lipid and glucose study.
      ]. Secondary analyses of these data indicated waist-to-height ratio was a better predictor of diabetes than BMI in men [
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      Waist/height ratio as a better predictor of type 2 diabetes compared to body mass index in Tehranian adult men – a 3.6-year prospective study.
      ] and that height and hip circumference interact with WC in its link with diabetes among women [
      • Bozorgmanesh M.
      • Hadaegh F.
      • Zabetian A.
      • Azizi F.
      Impact of hip circumference and height on incident diabetes: results from 6-year follow-up in the Tehran Lipid and Glucose Study.
      ].
      Table 2Studies showing the relationships between obesity and diabetes in the Middle East and North Africa region.
      Design

      County, year (Ref.)
      SettingSample SizeAge
      Age is reported as mean±standard deviation or range (-).
      Male %AdipostiyObesity %DM%Odd ratio (CI 95%)
      Cross-sectional
      Egypt, 2008
      • Abolfotouh M.A.
      • Soliman L.A.
      • Mansour E.
      • Farghaly M.
      • El-Dawaiaty A.A.
      Central obesity among adults in Egypt: prevalence and associated morbidity.
      Primary care centers180057.38 ± 10.0042-WC Obese (M ≥100 cm/F ≥95 cm)

      24.13.6
      Diabetes prevalence according to the obesity percentile.
      <90th 2.1(0.6–6.9)
      -WHR Obese (M >0.95/F >0.85)28.78.8
      Diabetes prevalence according to the obesity percentile.
      >90th 5.4(1.5–18.9)
      3.6
      Diabetes prevalence according to the obesity percentile.
      <90th 1.1(0.5–2.7)
      4.6
      Diabetes prevalence according to the obesity percentile.
      >90th 1.4(0.5–4.2)
      Iran, 2010
      • Esteghamati A.
      • Ashraf H.
      • Khalilzadeh O.
      • Rashidi A.
      • Mohammad K.
      • Asgari F.
      • et al.
      Trends of diabetes according to body mass index levels in Iran: results of the national surveys of risk factors of non-communicable diseases (1999–2007).
      National Health Survey96,79025–6450.7BMI (25–29.9) kg/m29.9 ± 1.24.6
      Data only for diagnosed diabetes.
      1.05(1.01–1.09)
      Data only for diagnosed diabetes.
      BMI (30–34.9)12.5 ± 1.78.71.04(0.99–1.09)
      Data only for diagnosed diabetes.
      Israel, 2010
      • Levin A.
      • Morad Y.
      • Grotto I.
      • Ravid M.
      • Bar-Dayan Y.
      Weight disorders and associated morbidity among young adults in Israel 1990–2003.
      nominees for military service1,021,211175825< BMI ≤ 30 kg/m2M – 4.2M – 0.01–0.05
      Prevalence of diabetes in the entire population.
      M – 2.25(1.96–2.59)
      BMI (>30 kg/m2)F – 3.6F – 0.02–0.08
      Prevalence of diabetes in the entire population.
      F – 1.31(0.15–11.19)
      M – 2.25(1.96–2.59)
      F – 4.423.90–5.00)
      Israel, 2005
      • Abdul-Ghani M.A.
      • Kher J.
      • Abbas N.
      • Najami T.
      Association of high body mass index with low age of disease onset among Arab women with type 2 diabetes in a primary care clinic.
      Health services454552.18 ± 16.1248.9BMI (27–30) kg/m2M – 28; F – 107.1N/A
      BMI (>30 kg/m2)M – 42; F – 77.5
      Jordan, 2008
      • Zindah M.
      • Belbeisi A.
      • Walke H.
      • Mokdad A.H.
      Obesity and diabetes in Jordan: findings from the behavioral risk factor surveillance system, 2004.
      National survey334218 and older40.3BMI (≥30 kg/m2)34.816.9
      Prevalence of diabetes in the entire population.
      BMI(25–29) 2.17(1.07–4.39)
      BMI (≥ 30) 3.27(1.58–6.76)
      Oman, 2003
      • Al-Riyami A.A.
      • Afifi M.M.
      Prevalence and correlates of obesity and central obesity among Omani adults.
      National survey701120 and older50BMI (25–39.9) kg/m247.9BMI (25–29.9) 14.31.74(1.41–2.15)
      BMI (≥ 30) 16.22.04(1.61–2.58)
      Saudi Arabia, 2009
      • Almajwal A.M.
      • Al-Baghli N.A.
      • Batterham M.J.
      • Williams P.G.
      • Al-Turki K.A.
      • Al-Ghamdi A.J.
      Performance of body mass index in predicting diabetes and hypertension in the Eastern Province of Saudi Arabia.
      Residents of eastern province197,68130 and older51BMI (25–29.9) kg/m235.117.2
      Prevalence of diabetes in the entire population.
      M-3.35(2.87–3.92)
      BMI (≥ 30 kg/m2)43.8F – 4.50(3.76–5.39)
      Cohort
      Iran, 2007
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      The prospective association of general and central obesity variables with incident type 2 diabetes in adults, Tehran lipid and glucose study.
      Urban representative sample– F/U of 3.6 yrs447943.1 ± 13.641.34BMI kg/m2 (25–29.9)34.53.71.2(0.6–2.6)
      BMI (≥ 30)53.32.4(1.1–5.1)
      WC Obese (M – ≥102 cm; F – ≥88 cm)58.40.7(0.4–1.2)
      WHtR Obese (M – ≥0.95; F – ≥0.8)85.52.6(1.3–4.9)
      Israel, 2011
      • Tirosh A.
      • Shai I.
      • Afek A.
      • Dubnov-Raz G.
      • Ayalon N.
      • Gordon B.
      • et al.
      Adolescent BMI trajectory and risk of diabetes versus coronary disease.
      Staff Periodic Examination Center – F/U 17.4 yrs37,67417NRNRNREach elevated BMI unit is associated with 1.115 risk of diabetes in adultHazard Ratio 2.76 (2.11–3.58)
      Based on linear regression model for highest vs. the lowest decile.
      a Age is reported as mean ± standard deviation or range (-).
      b Prevalence of diabetes in the entire population.
      c Data only for diagnosed diabetes.
      d Diabetes prevalence according to the obesity percentile.
      e Based on linear regression model for highest vs. the lowest decile.
      Consistent associations between obesity/central adiposity (WHR) and diabetes were observed in Iraq [
      • Mansour A.A.
      • Al-Jazairi M.I.
      Predictors of incident diabetes mellitus in Basrah, Iraq.
      ], UAE (BMI ≥ 30 kg/m2) [
      • Baynouna L.M.
      • Revel A.D.
      • Nagelkerke N.J.
      • Jaber T.M.
      • Omar A.O.
      • Ahmed N.M.
      • et al.
      Associations of cardiovascular risk factors in Al Ain, United Arab Emirates.
      ], Egypt (WC)) [
      • Abolfotouh M.A.
      • Soliman L.A.
      • Mansour E.
      • Farghaly M.
      • El-Dawaiaty A.A.
      Central obesity among adults in Egypt: prevalence and associated morbidity.
      ], Iran (increased BMI), Jordan (increased BMI) [
      • Zindah M.
      • Belbeisi A.
      • Walke H.
      • Mokdad A.H.
      Obesity and diabetes in Jordan: findings from the behavioral risk factor surveillance system, 2004.
      ], and Oman (BMI ≥ 30 kg/m2 and WHR ≥ 90th percentile). The BMI threshold where diabetes risk escalates were largely reported from cross-sectional studies and were as low as 21 kg/m2 in one study from Saudi Arabia, 25 kg/m2 in an Iranian study [
      • Esteghamati A.
      • Ashraf H.
      • Khalilzadeh O.
      • Rashidi A.
      • Mohammad K.
      • Asgari F.
      • et al.
      Trends of diabetes according to body mass index levels in Iran: results of the national surveys of risk factors of non-communicable diseases (1999–2007).
      ] and predominantly 30 kg/m2 in most other studies.
      We found a single cohort from Israel examining the impact of adolescent BMI on diabetes incidence which noted a 9.8% increased risk for each unit increase in BMI over 17.4 years of follow-up [
      • Tirosh A.
      • Shai I.
      • Afek A.
      • Dubnov-Raz G.
      • Ayalon N.
      • Gordon B.
      • et al.
      Adolescent BMI trajectory and risk of diabetes versus coronary disease.
      ].
      Prevalence of obesity (BMI ≥ 30 kg/m2) among the available studies in the MENA region was 24.5% with a 0.6 (r2) correlation with diabetes [
      • Motlagh B.
      • O’Donnell M.
      • Yusuf S.
      Prevalence of cardiovascular risk factors in the Middle East: a systematic review.
      ]. The high prevalence of obesity in the MENA region might be related to high frequency of physical inactivity, as suggested by a large 2004 Behavioral Risk Factor Survey of 3334 Jordanian adults where 50% of participants reported no physical activity at all [
      • Zindah M.
      • Belbeisi A.
      • Walke H.
      • Mokdad A.H.
      Obesity and diabetes in Jordan: findings from the behavioral risk factor surveillance system, 2004.
      ].

      3.2.1 Socio-economic and demographic factors

      Older age was associated with increased prevalence of diabetes among Palestinian refugees attending primary clinics across Jordan, Gaza Strip, Lebanon, and Syria [
      • Mousa H.S.
      • Yousef S.
      • Riccardo F.
      • Zeidan W.
      • Sabatinelli G.
      Hyperglycaemia, hypertension and their risk factors among Palestine refugees served by UNRWA.
      ].
      In terms of gender, the prospective TLGS in Iran showed that age-adjusted incidence of diabetes was 30% higher in females compared with males [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ]. Lower socioeconomic status women were more likely to have diabetes despite weight status [
      • Maddah M.
      Association of diabetes with living area in Iranian women.
      ] and associations between low income or education and diabetes were similar to those observed in the U.S. [
      • Kanjilal S.
      • Gregg E.W.
      • Cheng Y.J.
      • Zhang P.
      • Nelson D.E.
      • Mensah G.
      • et al.
      Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971–2002.
      ], the U.K. [
      • Connolly V.
      • Unwin N.
      • Sherriff P.
      • Bilous R.
      • Kelly W.
      Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas.
      ] and India [
      • Mohan V.
      • Sandeep S.
      • Deepa R.
      • Shah B.
      • Varghese C.
      Epidemiology of type 2 diabetes: Indian scenario.
      ]. In line with these were Bahrain and Iran where higher education was associated with lower risk of developing diabetes [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ,
      • Musaiger A.O.
      • Al-Mannai M.A.
      Social and lifestyle factors associated with diabetes in the adult Bahraini population.
      ].

      3.2.2 Biochemical factors

      In MENA populations, as elsewhere [
      • Tabak A.G.
      • Herder C.
      • Rathmann W.
      • Brunner E.J.
      • Kivimaki M.
      Prediabetes: a high-risk state for diabetes development.
      ], IFG and IGT are precursors of diabetes [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ,
      • Dankner R.
      • Chetrit A.
      • Shanik M.H.
      • Raz I.
      • Roth J.
      Basal-state hyperinsulinemia in healthy normoglycemic adults is predictive of type 2 diabetes over a 24-year follow-up: a preliminary report.
      ]. In terms of pathophysiological mechanisms, hyperinsulinemia in normoglycemic Israeli adults predicted progression to diabetes [
      • Dankner R.
      • Chetrit A.
      • Shanik M.H.
      • Raz I.
      • Roth J.
      Basal-state hyperinsulinemia in healthy normoglycemic adults is predictive of type 2 diabetes over a 24-year follow-up: a preliminary report.
      ] while combinations of elevated triglycerides, total cholesterol, and low HDL-cholesterol predicted diabetes and increased diabetes risk by 23–27% [
      • Narayan K.M.
      • Boyle J.P.
      • Thompson T.J.
      • Gregg E.W.
      • Williamson D.F.
      Effect of BMI on lifetime risk for diabetes in the U.S.
      ].

      3.2.3 Lifestyle factors

      Three studies examined behavioral risks for diabetes in the MENA region [
      • Baynouna L.M.
      • Revel A.D.
      • Nagelkerke N.J.
      • Jaber T.M.
      • Omar A.O.
      • Ahmed N.M.
      • et al.
      Associations of cardiovascular risk factors in Al Ain, United Arab Emirates.
      ,
      • Midhet F.M.
      • Al-Mohaimeed A.A.
      • Sharaf F.K.
      Lifestyle related risk factors of type 2 diabetes mellitus in Saudi Arabia.
      ,
      • Azadbakht L.
      • Mirmiran P.
      • Esmaillzadeh A.
      • Azizi F.
      Dietary diversity score and cardiovascular risk factors in Tehranian adults.
      ]. Low diet quality, as measured by Haines et al's Diet Quality Index [
      • Haines P.S.
      • Siega-Riz A.M.
      • Popkin B.M.
      The Diet Quality Index revised: a measurement instrument for populations.
      ] was associated with lower prevalence of diabetes in Iran [
      • Azadbakht L.
      • Mirmiran P.
      • Esmaillzadeh A.
      • Azizi F.
      Dietary diversity score and cardiovascular risk factors in Tehranian adults.
      ]. Increased vegetable consumption was also protective compared with higher meat and carbohydrate consumption among Saudis [
      • Midhet F.M.
      • Al-Mohaimeed A.A.
      • Sharaf F.K.
      Lifestyle related risk factors of type 2 diabetes mellitus in Saudi Arabia.
      ].

      3.2.4 Genetics

      Family history of diabetes increased the risk of incident diabetes by 1.6, 1.8, and 2.4 times in studies among Palestinians, Iranians, and Kuwaitis, respectively [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ,
      • Mousa H.S.
      • Yousef S.
      • Riccardo F.
      • Zeidan W.
      • Sabatinelli G.
      Hyperglycaemia, hypertension and their risk factors among Palestine refugees served by UNRWA.
      ,
      • Moussa M.A.
      • Alsaeid M.
      • Refai T.M.
      • Abdella N.
      • Al-Sheikh N.
      • Gomez J.E.
      Factors associated with type 1 diabetes in Kuwaiti children.
      ]. In a case-control study investigating genetic factors, the K121Q polymorphism of the ENPP1 (involved in insulin down-regulation) was associated with type 2 diabetes in the presence of obesity among Moroccan adults aged ≥40 years [
      • El Achhab Y.
      • Meyre D.
      • Bouatia-Naji N.
      • Berraho M.
      • Deweirder M.
      • Vatin V.
      • et al.
      Association of the ENPP1 K121Q polymorphism with type 2 diabetes and obesity in the Moroccan population.
      ]. Single nucleotide polymorphisms (SNPs) such as carriers of homozygous TCF7L2 genotype, had 56% higher risks of diabetes than CC genotype carriers in Tunisia [
      • Ezzidi I.
      • Mtiraoui N.
      • Cauchi S.
      • Vaillant E.
      • Dechaume A.
      • Chaieb M.
      • et al.
      Contribution of type 2 diabetes associated loci in the Arabic population from Tunisia: a case-control study.
      ]. A smaller study of 48 patients in Gaza also reported that the presence of allele 2 (calpain-10-allele) in SNP-44 elevated the risk of type 2 diabetes by 2.7-fold [
      • Zaharna M.M.
      • Abed A.A.
      • Sharif F.A.
      Calpain-10 gene polymorphism in type 2 diabetes mellitus patients in the Gaza Strip.
      ]. A recent study in Bahrain showed that the homozygous genotype where angiotensin-converting enzyme gene is deleted was more frequent among people with diabetes than in healthy adults [
      • Al-Harbi E.M.
      • Farid E.M.
      • Gumaa K.A.
      • Masuadi E.M.
      • Singh J.
      Angiotensin-converting enzyme gene polymorphisms and T2DM in a case-control association study of the Bahraini population.
      ].

      3.3 Complications

      3.3.1 Macrovascular complications

      Data regarding macrovascular complications of diabetes in the MENA region are limited to one cohort study from Iran [
      • Hadaegh F.
      • Shafiee G.
      • Ghasemi A.
      • Sarbakhsh P.
      • Azizi F.
      Impact of metabolic syndrome, diabetes and prediabetes on cardiovascular events: Tehran lipid and glucose study.
      ] and cross-sectional studies from Yemen, Israel, and UAE [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of risk factors for diabetic foot complications.
      ,
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      ,
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      ]. Hypertension and dyslipidemia were common among people with diabetes in the MENA region with 25–53% and 35–60% having these co-existing risk factors, respectively [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of risk factors for diabetic foot complications.
      ,
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      ,
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      ].
      In Yemen, amongst people with diabetes with a median duration of 6.3 years, 25.4% had previous or current coronary heart disease (CHD), stroke, or peripheral vascular disease (PVD) [
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      ]. CHD prevalence among diabetes populations in the UAE (mean diabetes duration: 3 years) [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ], Yemen (6.3 years) [
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      ] and Iran (7.6 years) [
      • Janghorbani M.
      • Rezvanian H.
      • Kachooei A.
      • Ghorbani A.
      • Chitsaz A.
      • Izadi F.
      • et al.
      Peripheral neuropathy in type 2 diabetes mellitus in Isfahan, Iran: prevalence and risk factors.
      ] were 10.5%, 17.8%, and 28%, respectively. Further, diabetes increased the risks of myocardial infarction (MI) three-fold in an Israeli nationwide survey in 2003 [
      • Jonas M.
      • Reicher-Reiss H.
      • Boyko V.
      • Behar S.
      • Grossman E.
      Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension.
      ] and diabetes was present among 11.6–69.4% of patients with stroke in Arab countries [
      • Benamer H.T.
      • Grosset D.
      Stroke in Arab countries: a systematic literature review.
      ] as well as 55.7% in Iran [
      • Delbari A.
      • Salman Roghani R.
      • Tabatabaei S.S.
      • Rahgozar M.
      • Lokk J.
      Stroke epidemiology and one-month fatality among an urban population in Iran.
      ]. In Iranian people with diabetes, the hazard ratio of incident cardiovascular events was 2.9 (95% CI: 2.2–3.8) compared with those without diabetes [
      • Hadaegh F.
      • Shafiee G.
      • Ghasemi A.
      • Sarbakhsh P.
      • Azizi F.
      Impact of metabolic syndrome, diabetes and prediabetes on cardiovascular events: Tehran lipid and glucose study.
      ].

      3.3.2 Renal complications

      Data regarding renal complications of diabetes in the region are available from Iran, Jordan, UAE, Syria, and Egypt. The differences in measurement methods, terminology, and definitions across studies made it difficult to compare results. We grouped studies regarding microalbuminuria (MA) [an early indicator of diabetic nephropathy], diabetic nephropathy (more advanced chronic kidney disease (CKD)), and end-stage renal disease requiring dialysis or kidney transplantation.
      The prevalence of MA ranged from 21 to 61% among people with diabetes from Iran, UAE, and Egypt [
      • Al-Maskari F.
      • El-Sadig M.
      • Obineche E.
      Prevalence and determinants of microalbuminuria among diabetic patients in the United Arab Emirates.
      ,
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ,
      • Esteghamati A.
      • Ashraf H.
      • Nakhjavani M.
      • Najafian B.
      • Hamidi S.
      • Abbasi M.
      Insulin resistance is an independent correlate of increased urine albumin excretion: a cross-sectional study in Iranian Type 2 diabetic patients.
      ] based on different definitions of MA [some used ADA criteria [
      • Al-Maskari F.
      • El-Sadig M.
      • Obineche E.
      Prevalence and determinants of microalbuminuria among diabetic patients in the United Arab Emirates.
      ,
      • Esteghamati A.
      • Ashraf H.
      • Nakhjavani M.
      • Najafian B.
      • Hamidi S.
      • Abbasi M.
      Insulin resistance is an independent correlate of increased urine albumin excretion: a cross-sectional study in Iranian Type 2 diabetic patients.
      ] while others used albumin excretion ratio ≥100 mg/g] [
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ,
      • Latif Z.A.
      • Jain A.
      • Rahman M.M.
      Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008.
      ].
      Diabetic nephropathy (defined as an estimated Glomerular filtration rate (GFR) <60 ml/min and/or a urine albumin-to-creatinine ratio (ACR) ≥2.5 mg/mmol in males or ≥3.5 in females) was highly prevalent in people with diabetes for 3 years in the UAE (40.8%) [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ]. However, among Egyptians with diabetes, 7% had this disease defined as ACR ≥ 300 mg/g [
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ]. Diabetes was the second most common risk for CKD in Iran [
      • Chan J.C.
      • Malik V.
      • Jia W.
      • Kadowaki T.
      • Yajnik C.S.
      • Yoon K.H.
      • et al.
      Diabetes in Asia: epidemiology, risk factors, and pathophysiology.
      ] and a leading precursor among dialysis patients of Jordan, Iran, and Syria [
      • Al-Azzam S.I.
      • Abu-Dahoud E.Y.
      • El-Khatib H.A.
      • Dawoud T.H.
      • Al-Husein B.A.
      Etiologies of chronic renal failure in Jordanian population.
      ,
      • Abdallah S.
      • Ahmad A.T.
      • Batieha A.
      • Ajlouni K.
      Diabetes mellitus: the leading cause of haemodialysis in Jordan.
      ,
      • Malekmakan L.
      • Haghpanah S.
      • Pakfetrat M.
      • Malekmakan A.
      • Khajehdehi P.
      Causes of chronic renal failure among Iranian hemodialysis patients.
      ,
      • Moukeh G.
      • Yacoub R.
      • Fahdi F.
      • Rastam S.
      • Albitar S.
      Epidemiology of hemodialysis patients in Aleppo city.
      ].

      3.3.3 Eye complications

      Data regarding visual complications of diabetes in the MENA region were available from nine countries (Table 3). There was heterogeneity across study populations in terms of duration of disease, risk factor control, and methods of outcome assessment.
      Table 3Complications of diabetes in the Middle East and North Africa region.
      ComplicationsCountry, yearSample size (n)Duration of diabetesMethod of assessmentPrevalence (%)
      Coronary heart diseaseYemen, 2006
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      311Mean 6.3 (SD 6.5)History/EKG17.8
      UAE, 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      245Median 3 yearsHistory/EKG10.5
      Iran (cohort study)
      • Hadaegh F.
      • Shafiee G.
      • Ghasemi A.
      • Sarbakhsh P.
      • Azizi F.
      Impact of metabolic syndrome, diabetes and prediabetes on cardiovascular events: Tehran lipid and glucose study.
      4018NRHistory/EKG/laboratory tests, symptoms and examinations23.7% (incident after median 6.7 years follow-up)
      Cerebrovascular diseaseYemen, 2006
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      311Mean (6.3 (SD 6.5))History/CT/clinical symptoms5.8
      Cardiovascular diseaseIran (cohort study)
      • Hadaegh F.
      • Shafiee G.
      • Ghasemi A.
      • Sarbakhsh P.
      • Azizi F.
      Impact of metabolic syndrome, diabetes and prediabetes on cardiovascular events: Tehran lipid and glucose study.
      4018NRHistory/EKG/laboratory tests, symptoms and examinations27 (incident after median 6.7 years follow-up)
      Diabetic retinopathyIran, 2009
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      63433.9% <5 years; 57% 5–20 years; 9.1% >20 yearsFundoscopy37.9
      Saudi Arabia, 2010
      • Macky T.A.
      • Khater N.
      • Al-Zamil M.A.
      • El Fishawy H.
      • Soliman M.M.
      Epidemiology of diabetic retinopathy in Egypt: a hospital-based study.
      142Mean (8.6 (SD 5.9))Fundoscopy30
      Qatar, 2011
      • Elshafei M.
      • Gamra H.
      • Khandekar R.
      • Al Hashimi M.
      • Pai A.
      • Ahmed M.F.
      Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey.
      467NR
      Mean (SD) were 15.96 (7.41) in diabetes retinopathy (DR) and7.39 (6.6) in non DR.
      Photograph and/or fundoscopy (indirect)23.5 [Age-adjusted]
      19.7% mild non-proliferative diabetes retinopathy (NPDR); 7.8% moderate NPDR; 1% sever NPDR; 3.3% proliferative diabetes retinopathy (PDR).
      UAE, 2007
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      51379% ≥10 yearsFundus photographs19
      Oman, 2003
      • Khandekar R.
      • Al Lawatii J.
      • Mohammed A.J.
      • Al Raisi A.
      Diabetic retinopathy in Oman: a hospital based study.
      22499% <5 yearsFundoscopy (Indirect)16.2
      Egypt, 2011
      • Macky T.A.
      • Khater N.
      • Al-Zamil M.A.
      • El Fishawy H.
      • Soliman M.M.
      Epidemiology of diabetic retinopathy in Egypt: a hospital-based study.
      132532% 1–5 years; 48% 5–15 years; 10% >15 yearsFundoscopy20.5
      6.7% NPDR; 2.3% PDR.
      Egypt, 1998
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      364NRFundus photographs41.5
      UAE, 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      245Median 3 yearsFundus photographs54.2
      54.2% had background DR, none had PDR.
      NephropathyEgypet, 1998
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      364NRUrine ACR6.7
      Reported in diagnosed diabetes (6.8% in undiagnosed diabetes).
      UAE, 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      245NRGFR and/or urinary ACR40.8
      Oman, 2010–2011
      • Alrawahi A.H.
      • Rizvi S.G.
      • Al-Riyami D.
      • Al-Anqoodi Z.
      Prevalence and risk factors of diabetic nephropathy in omani type 2 diabetics in Al-dakhiliyah region.
      699NRUrine ACR and medical records42.5
      Micro-albuminuriaIran, 2009
      • Esteghamati A.
      • Ashraf H.
      • Nakhjavani M.
      • Najafian B.
      • Hamidi S.
      • Abbasi M.
      Insulin resistance is an independent correlate of increased urine albumin excretion: a cross-sectional study in Iranian Type 2 diabetic patients.
      833NRUrine albumin excretion29.1
      UAE, 2008
      • Al-Maskari F.
      • El-Sadig M.
      • Obineche E.
      Prevalence and determinants of microalbuminuria among diabetic patients in the United Arab Emirates.
      45179% ≥10 yearsUrine albumin excretion or creatinine61
      53.3% men; 46.7% women.
      Egypet, 1998
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      364NRACR21 (in diagnosed diabetes) 21.9 (in undiagnosed diabetes)
      NeuropathyBahrain, 2007
      • Al-Mahroos F.
      • Al-Roomi K.
      Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study.
      1477Mean (9.5 (SD 8.4))NSS, NDS, and VPT36.6
      UAE, 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      245NRDNS and/or DNE questioner34.7
      UAE, 2007
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      51379% ≥10 yearsDNS and/or DNE questioner39
      Egypt, 1998
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      364NRVPT21.9
      (Egypt, Lebanon, Jordan and Gulf States of Kuwait and the united), 2010
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      4097NRDN4 questioner (painful neuropathy)53.7
      Peripheral Vascular DiseaseUAE, 2007
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      51379% ≥10 yearsFoot examination12
      Bahrain, 2007
      • Al-Mahroos F.
      • Al-Roomi K.
      Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study.
      1477Mean (9.5 (SD 8.4))Foot examination12.1
      UAE, 2007
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      245Median 3 yearsFoot examination11.1
      Yemen
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      311Mean (6.3 (SD 6.5))Foot examination and/or patients report9.1
      a Mean (SD) were 15.96 (7.41) in diabetes retinopathy (DR) and7.39 (6.6) in non DR.
      b 19.7% mild non-proliferative diabetes retinopathy (NPDR); 7.8% moderate NPDR; 1% sever NPDR; 3.3% proliferative diabetes retinopathy (PDR).
      c 6.7% NPDR; 2.3% PDR.
      d 54.2% had background DR, none had PDR.
      e Reported in diagnosed diabetes (6.8% in undiagnosed diabetes).
      f 53.3% men; 46.7% women.
      Diabetic retinopathy (DR) was assessed using retinal photography or fundoscopy (Table 3). Across nine MENA countries, retinopathy affected 17–54% of people with diabetes aged 49–60 years [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      ,
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      ,
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ,
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ,
      • Malekmakan L.
      • Haghpanah S.
      • Pakfetrat M.
      • Malekmakan A.
      • Khajehdehi P.
      Causes of chronic renal failure among Iranian hemodialysis patients.
      ,
      • Elshafei M.
      • Gamra H.
      • Khandekar R.
      • Al Hashimi M.
      • Pai A.
      • Ahmed M.F.
      Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey.
      ,
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ,
      • Khan A.R.
      • Al Abdul Lateef Z.N.
      • Khamseen M.B.
      • Al Aithan M.A.
      • Khan S.A.
      • Al Ibrahim I.
      Knowledge, attitude and practice of ministry of health primary health care physicians in the management of type 2 diabetes mellitus: a cross-sectional study in the Al Hasa District of Saudi Arabia, 2010.
      ,
      • Macky T.A.
      • Khater N.
      • Al-Zamil M.A.
      • El Fishawy H.
      • Soliman M.M.
      Epidemiology of diabetic retinopathy in Egypt: a hospital-based study.
      ]. Men were generally more commonly affected by DR [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of risk factors for diabetic foot complications.
      ,
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ,
      • Malekmakan L.
      • Haghpanah S.
      • Pakfetrat M.
      • Malekmakan A.
      • Khajehdehi P.
      Causes of chronic renal failure among Iranian hemodialysis patients.
      ,
      • Elshafei M.
      • Gamra H.
      • Khandekar R.
      • Al Hashimi M.
      • Pai A.
      • Ahmed M.F.
      Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey.
      ,
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ,
      • Khandekar R.
      • Al Lawatii J.
      • Mohammed A.J.
      • Al Raisi A.
      Diabetic retinopathy in Oman: a hospital based study.
      ] except in Saudi Arabia where no sex difference was found [
      • Khan A.R.
      • Wiseberg J.A.
      • Lateef Z.A.
      • Khan S.A.
      Prevalence and determinants of diabetic retinopathy in Al hasa region of saudi arabia: primary health care centre based cross-sectional survey, 2007–2009.
      ] and in Egypt where DR prevalence was higher in women [
      • Macky T.A.
      • Khater N.
      • Al-Zamil M.A.
      • El Fishawy H.
      • Soliman M.M.
      Epidemiology of diabetic retinopathy in Egypt: a hospital-based study.
      ].
      In terms of different stages of DR progression, mild non-proliferative diabetic retinopathy (NPDR) was the most prevalent stage of DR observed among 9–65% of people with diabetes in Iran, Qatar, and Saudi Arabia [
      • Malekmakan L.
      • Haghpanah S.
      • Pakfetrat M.
      • Malekmakan A.
      • Khajehdehi P.
      Causes of chronic renal failure among Iranian hemodialysis patients.
      ,
      • Elshafei M.
      • Gamra H.
      • Khandekar R.
      • Al Hashimi M.
      • Pai A.
      • Ahmed M.F.
      Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey.
      ,
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ,
      • Khan A.R.
      • Wiseberg J.A.
      • Lateef Z.A.
      • Khan S.A.
      Prevalence and determinants of diabetic retinopathy in Al hasa region of saudi arabia: primary health care centre based cross-sectional survey, 2007–2009.
      ]. Severe NPDR was least prevalent, reported in 0.3–3% of these populations [
      • Malekmakan L.
      • Haghpanah S.
      • Pakfetrat M.
      • Malekmakan A.
      • Khajehdehi P.
      Causes of chronic renal failure among Iranian hemodialysis patients.
      ,
      • Elshafei M.
      • Gamra H.
      • Khandekar R.
      • Al Hashimi M.
      • Pai A.
      • Ahmed M.F.
      Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey.
      ,
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ,
      • Khan A.R.
      • Wiseberg J.A.
      • Lateef Z.A.
      • Khan S.A.
      Prevalence and determinants of diabetic retinopathy in Al hasa region of saudi arabia: primary health care centre based cross-sectional survey, 2007–2009.
      ]. The prevalence of proliferative diabetic retinopathy (PDR) varied between 2.3 and 10% among people with diabetes in Iran, Saudi Arabia, and UAE [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      ,
      • Latif Z.A.
      • Jain A.
      • Rahman M.M.
      Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008.
      ,
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ,
      • Khan A.R.
      • Wiseberg J.A.
      • Lateef Z.A.
      • Khan S.A.
      Prevalence and determinants of diabetic retinopathy in Al hasa region of saudi arabia: primary health care centre based cross-sectional survey, 2007–2009.
      ]. In its advanced stages, DR leads to visual impairment, legal blindness, and/or low vision (defined as best corrected visual acuity less than 20/60, but equal to or better than 20/400 in the better eye). Legal blindness was noted among 5% of those with diabetes and elevated HbA1C levels (∼9%) in Egypt [
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ], and 1.6% of people with diabetes in Iran [
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ]. Also the prevalence of low vision was 6.5% (95% CI: 4.7–8.7) among people with diabetes in Iran [
      • Javadi M.A.
      • Katibeh M.
      • Rafati N.
      • Dehghan M.H.
      • Zayeri F.
      • Yaseri M.
      • et al.
      Prevalence of diabetic retinopathy in Tehran province: a population-based study.
      ].

      3.3.4 Limb complications

      Prevalence of neuropathy associated with diabetes was very high in the MENA region. Across available studies, peripheral neuropathy was defined based on composite scores from questionnaires (e.g., Diabetic Neuropathy Symptom score >0; abnormal Neuropathy Disability Score) and/or examinations (e.g., Diabetic Neuropathy Examination score >3) [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey.
      ,
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ] and/or vibration perception threshold testing [
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ,
      • Al-Mahroos F.
      • Al-Roomi K.
      Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study.
      ]. No studies used monofilament testing. The prevalence of diabetic neuropathy among people in communities with diabetes for ten years was 35% in the UAE and 37% in Bahrain [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ,
      • Al-Mahroos F.
      • Al-Roomi K.
      Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study.
      ]. Diabetic neuropathy was even more common among the clinic-attending population, affecting 54% of outpatients at clinics across Egypt, Lebanon, Jordan, Kuwait, and the UAE [
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      ]. Neuropathy contributes greatly to risk of amputation as 38–94% of cases of diabetic foot problems in Saudi Arabia had neuropathy [
      • Al-Wahbi A.M.
      The diabetic foot. In the Arab world.
      ].
      Neurovascular compromise and associated foot ulceration affected 5.9% of diabetic patients in Bahrain [
      • Al-Mahroos F.
      • Al-Roomi K.
      Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study.
      ] and 1% of patients in Egypt [
      • Herman W.H.
      • Aubert R.E.
      • Engelgau M.M.
      • Thompson T.J.
      • Ali M.A.
      • Sous E.S.
      • et al.
      Diabetes mellitus in Egypt: glycaemic control and microvascular and neuropathic complications.
      ] and UAE [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of risk factors for diabetic foot complications.
      ]. Further, foot amputation was rare in Iran (0.7%) and the UAE (0%) [
      • Al-Maskari F.
      • El-Sadig M.
      Prevalence of risk factors for diabetic foot complications.
      ,
      • Latif Z.A.
      • Jain A.
      • Rahman M.M.
      Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008.
      ]. PVD was highly prevalent among people with diabetes in Saudi Arabia (50–79%) [
      • Al-Wahbi A.M.
      The diabetic foot. In the Arab world.
      ] compared with other countries of the region (9.1–34.7%) [
      • Al-Khawlani A.
      • Atef Z.A.
      • Al-Ansi A.
      Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yeman.
      ,
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ]. Several factors that are unique to the region increase the risk of neurovascular limb diseases including: harsh weather, habits like walking barefoot, phobia of surgery, and differences in access to the health care [
      • Al-Wahbi A.M.
      The diabetic foot. In the Arab world.
      ].

      3.3.5 Other complications

      The relative risk of cancers among people with type 2 diabetes mellitus in Israel over 20 years of follow-up was 1.32 (95% CI 0.96–1.81, P = 0.09) compared with people without diabetes [
      • Dankner R.
      • Chetrit A.
      • Segal P.
      Glucose tolerance status and 20 year cancer incidence.
      ]. Another study over 4.5-years of follow-up noted that 6% of Israelis with diabetes had some form of cancer [
      • Buchs A.E.
      • Silverman B.G.
      Incidence of malignancies in patients with diabetes mellitus and correlation with treatment modalities in a large Israeli health maintenance organization: a historical cohort study.
      ], most commonly, breast cancer among women, prostate cancer among men, and gastrointestinal cancers in both sexes [
      • Dankner R.
      • Chetrit A.
      • Segal P.
      Glucose tolerance status and 20 year cancer incidence.
      ,
      • Buchs A.E.
      • Silverman B.G.
      Incidence of malignancies in patients with diabetes mellitus and correlation with treatment modalities in a large Israeli health maintenance organization: a historical cohort study.
      ]. Studies with longer follow-up have challenged these results, stating that diabetes is not an independent predictor for cancers among men [
      • Chodick G.
      • Heymann A.D.
      • Rosenmann L.
      • Green M.S.
      • Flash S.
      • Porath A.
      • et al.
      Diabetes and risk of incident cancer: a large population-based cohort study in Israel.
      ].
      Erectile dysfunction was noted among men with diabetes in Morocco, Egypt, Lebanon, Jordan, Kuwait, and the UAE [
      • Jambart S.
      • Ammache Z.
      • Haddad F.
      • Younes A.
      • Hassoun A.
      • Abdalla K.
      • et al.
      Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region.
      ,
      • El A.Y.
      • Berraho M.
      • Benslimane A.
      • Chrit M.
      • El Hassani H.
      • Lyoussi B.
      • et al.
      Diabetes and erectile dysfunction in Morocco: epidemiological study among outpatients.
      ]. Periodontal disease and sensori-neural hearing loss have also been reported in people with type 2 diabetes in Jordan [
      • Khader Y.S.
      • Albashaireh Z.S.
      • Hammad M.M.
      Periodontal status of type 2 diabetics compared with nondiabetics in north Jordan.
      ] and Iran [
      • Mozaffari M.
      • Tajik A.
      • Ariaei N.
      • Ali-Ehyaii F.
      • Behnam H.
      Diabetes mellitus and sensorineural hearing loss among non-elderly people.
      ].

      3.4 Mortality

      A study from Libya showed that diabetes alone contributes to 5.1% of mortality and contributes significantly to other fatal conditions, particularly coronary artery disease (32.7%) and strokes (20.1%) [
      • Roaeid R.B.
      • Kablan A.A.
      Diabetes mortality and causes of death in Benghazi: a 5-year retrospective analysis of death certificates.
      ].

      3.5 Care and management

      3.5.1 Quality of care

      Studies in the MENA region tended to use different clinical care guidelines to define optimal glycemic, blood pressure, and lipid control levels. As a result, we used a set of minimal care guidelines from the IDF as common low thresholds for risk factor control and preventative care goals for people with diabetes [

      International Diabetes Federation Clinical Guidelines Task Force; 2011–2012.

      ].
      Defining optimal glycemic control as HbA1C < 7% (53 mmol/mol), reports from 2004 to 2008 showed that 66–68% of people with diabetes in UAE [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ,
      • Khattab M.S.
      • Swidan A.M.
      • Farghaly M.N.
      • Swidan H.M.
      • Ashtar M.S.
      • Darwish E.A.
      • et al.
      Quality improvement programme for diabetes care in family practice settings in Dubai.
      ], 73–76% in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ], and 43–59% in Israel [
      • Drach-Zahavy A.
      • Shadmi E.
      • Freund A.
      • Goldfracht M.
      High quality diabetes care: testing the effectiveness of strategies of regional implementation teams.
      ,
      • Shani M.
      • Nakar S.
      • Lustman A.
      • Baievsky T.
      • Rosenberg R.
      • Vinker S.
      Patient characteristics correlated with quality indicator outcomes in diabetes care.
      ] were not achieving target control. Even with an HbA1C goal of ≤9% (75 mmol/mol), 49% of primary care clinic patients in Palestine and 22% of patients in Israel were unable to meet care targets [
      • Ghosh H.A.
      • Shaar A.
      • Mashal J.
      • Dheidil K.
      • Barghuti N.
      • Shalaldeh N.
      • et al.
      Diabetes control in 3 villages in Palestine: a community-based quality improvement intervention.
      ,
      • Goldfracht M.
      • Porath A.
      Nationwide program for improving the care of diabetic patients in Israeli primary care centers.
      ]. Using fasting blood glucose ≤7.8 mmol/l (140 mg/dl) as a treatment target, data from two randomly-selected health centers in Tunisia showed that 75% of people with diabetes were not achieving control [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ]. Similarly, 66% of people with diabetes in Saudi Arabia were not achieving glycemic goals (FPG < 7.2 mmol/l [130 mg/dl]) [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ].
      For lipid control defined as LDL < 2.6 mmol/l (100 mg/dl), data from primary care clinics in UAE show that 69–79% of people with diabetes were not meeting goals [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ,
      • Khattab M.S.
      • Swidan A.M.
      • Farghaly M.N.
      • Swidan H.M.
      • Ashtar M.S.
      • Darwish E.A.
      • et al.
      Quality improvement programme for diabetes care in family practice settings in Dubai.
      ]. Poor lipid control was also noted among 50–65% of diabetes patients in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ,
      • Eledrisi M.
      • Alhaj B.
      • Rehmani R.
      • Alotaibi M.
      • Mustafa M.
      • Akbar D.
      • et al.
      Quality of diabetes care in Saudi Arabia.
      ] and 50–54% in Israel [
      • Drach-Zahavy A.
      • Shadmi E.
      • Freund A.
      • Goldfracht M.
      High quality diabetes care: testing the effectiveness of strategies of regional implementation teams.
      ,
      • Shani M.
      • Nakar S.
      • Lustman A.
      • Baievsky T.
      • Rosenberg R.
      • Vinker S.
      Patient characteristics correlated with quality indicator outcomes in diabetes care.
      ]. Defining blood pressure control as <130/80 mmHg, 77–84% of diabetes patients in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ,
      • Al-Baghli N.A.
      • Al-Turki K.A.
      • Al-Ghamdi A.J.
      • El-Zubaier A.G.
      • Al-Ameer M.M.
      • Al-Baghli F.A.
      Control of diabetes mellitus in the Eastern Province of Saudi Arabia: results of screening campaign.
      ], 56–72% in Israel [
      • Drach-Zahavy A.
      • Shadmi E.
      • Freund A.
      • Goldfracht M.
      High quality diabetes care: testing the effectiveness of strategies of regional implementation teams.
      ,
      • Shani M.
      • Nakar S.
      • Lustman A.
      • Baievsky T.
      • Rosenberg R.
      • Vinker S.
      Patient characteristics correlated with quality indicator outcomes in diabetes care.
      ] and 57.9% in UAE [
      • Saadi H.
      • Carruthers S.G.
      • Nagelkerke N.
      • Al-Maskari F.
      • Afandi B.
      • Reed R.
      • et al.
      Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates.
      ] were not meeting targets. Using less stringent targets of <140/90 mmHg, 33% of diabetes patients in Tunisia and Saudi Arabia were still uncontrolled [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ,
      • Eledrisi M.
      • Alhaj B.
      • Rehmani R.
      • Alotaibi M.
      • Mustafa M.
      • Akbar D.
      • et al.
      Quality of diabetes care in Saudi Arabia.
      ].
      Awareness of diabetes status and attitudes regarding diabetes influence patients’ behaviors. In Oman, a study in a semi-urban locality showed that ≥50% of people responded appropriately to questions regarding diabetes complications [
      • Al Shafaee M.A.
      • Al-Shukaili S.
      • Rizvi S.G.
      • Al Farsi Y.
      • Khan M.A.
      • Ganguly S.S.
      • et al.
      Knowledge and perceptions of diabetes in a semi-urban Omani population.
      ]. In Iran, a community-based survey showed that 54.6% of people with diabetes were aware of their disease and 46.2% of them were under treatment [
      • Shirani S.
      • Kelishadi R.
      • Sarrafzadegan N.
      • Khosravi A.
      • Sadri G.
      • Amani A.
      • et al.
      Awareness, treatment and control of hypertension, dyslipidaemia and diabetes mellitus in an Iranian population: the IHHP study.
      ]. However, processes do not always correlate with better outcomes – audits of three diabetes centers in Egypt showed 80% compliance with appointments, but 69.2% of patients with diabetes were still not achieving care targets [
      • Abou El-Enein N.Y.
      • Abolfotouh M.A.
      An audit of diabetes care at 3 centres in Alexandria.
      ]. Furthermore, 60.2% of people with diabetes who had advanced diabetic retinopathy were unaware until eye complications had developed [
      • Abueleinen K.G.
      • El-Mekawey H.
      • Saif Y.S.
      • Khafagy A.
      • Rizk H.I.
      • Eltahlawy E.M.
      Sociodemographic factors responsible for blindness in diabetic Egyptian patients.
      ].
      In terms of screening for earlier detection and treatment of complications, the proportion of diabetes patients receiving annual foot examinations varied across countries (32% in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ], 40% in Egypt, Kuwait, and Israel [
      • Goldfracht M.
      • Porath A.
      Nationwide program for improving the care of diabetic patients in Israeli primary care centers.
      ,
      • Abou El-Enein N.Y.
      • Abolfotouh M.A.
      An audit of diabetes care at 3 centres in Alexandria.
      ,
      • Al-Adsani A.
      • Al-Faraj J.
      • Al-Sultan F.
      • El-Feky M.
      • Al-Mezel N.
      • Saba W.
      • et al.
      Evaluation of the impact of the Kuwait Diabetes Care Program on the quality of diabetes care.
      ], 44.5% in Tunisia [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ] and 76% in a multi-country study [
      • El-Shazly M.
      • Abdel-Fattah M.
      • Zaki A.
      • Bedwani R.
      • Assad S.
      • Tognoni G.
      • et al.
      Health care for diabetic patients in developing countries: a case from Egypt.
      ]). Annual eye checks were received by 62% of people with diabetes attending clinics in Egypt [
      • El-Shazly M.
      • Abdel-Fattah M.
      • Zaki A.
      • Bedwani R.
      • Assad S.
      • Tognoni G.
      • et al.
      Health care for diabetic patients in developing countries: a case from Egypt.
      ], 38–59% in Israel [
      • Shani M.
      • Nakar S.
      • Lustman A.
      • Baievsky T.
      • Rosenberg R.
      • Vinker S.
      Patient characteristics correlated with quality indicator outcomes in diabetes care.
      ,
      • Goldfracht M.
      • Porath A.
      Nationwide program for improving the care of diabetic patients in Israeli primary care centers.
      ], 31% in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ], and 10.8% in Tunisia [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ]. The frequency of annual urine examinations among people with diabetes was reported to be 33% in Tunisia [
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ] and 72.6% in Israel [
      • Shani M.
      • Nakar S.
      • Lustman A.
      • Baievsky T.
      • Rosenberg R.
      • Vinker S.
      Patient characteristics correlated with quality indicator outcomes in diabetes care.
      ]. Annual screening for CVD risk factors in patients with diabetes was reported to be 55.5% in Tunisia and 20% in Saudi Arabia [
      • Al-Elq A.H.
      Current practice in the management of patients with type 2 diabetes mellitus in Saudi Arabia.
      ,
      • Alberti H.
      • Boudriga N.
      • Nabli M.
      “Damm sokkor”: factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia.
      ].

      3.5.2 Quality of life

      The overall mean score (0–100) of health-related quality of life (by the translated version of the WHO questionnaire) was 63.1 among Emirati population with diabetes and was mostly affected by diabetes duration, presence of its complications, and marital status [
      • Bani-Issa W.
      Evaluation of the health-related quality of life of Emirati people with diabetes: integration of sociodemographic and disease-related variables.
      ].

      3.5.3 Cost

      Data regarding costs associated with diabetes are scarce in the region. Studies from four countries reported costs, of which only one study from Iran reported both direct and indirect costs of diabetes [
      • Esteghamati A.
      • Khalilzadeh O.
      • Anvari M.
      • Meysamie A.
      • Abbasi M.
      • Forouzanfar M.
      • et al.
      The economic costs of diabetes: a population-based study in Tehran, Iran.
      ]. Costs varied considerably across countries, based on income and purchasing power. In Abu Dhabi (UAE) in 2004, average annual direct costs for people with diabetes were US$1,605 which were 9.4 times higher for those with complications [
      • Al-Maskari F.
      • El-Sadig M.
      • Nagelkerke N.
      Assessment of the direct medical costs of diabetes mellitus and its complications in the United Arab Emirates.
      ]. Meanwhile, in Sudan, estimated direct costs for adults with type 2 diabetes were $175/year [
      • Elrayah-Eliadarous H.
      • Yassin K.
      • Eltom M.
      • Abdelrahman S.
      • Wahlstrom R.
      • Ostenson C.G.
      Direct costs for care and glycaemic control in patients with type 2 diabetes in Sudan.
      ].
      From a national perspective, a study in Israel reported that diabetes accounts for 3.5% of all medical costs [
      • Chodick G.
      • Porath A.
      • Alapi H.
      • Sella T.
      • Flash S.
      • Wood F.
      • et al.
      The direct medical cost of cardiovascular diseases, hypertension, diabetes, cancer, pregnancy and female infertility in a large HMO in Israel.
      ]. In Iran, annual direct and indirect costs associated with diabetes reported from Tehran in 2004 were $590.7million and $153.5million, respectively, with the largest amounts used for medications, devices, and hospitalizations [
      • Esteghamati A.
      • Khalilzadeh O.
      • Anvari M.
      • Meysamie A.
      • Abbasi M.
      • Forouzanfar M.
      • et al.
      The economic costs of diabetes: a population-based study in Tehran, Iran.
      ]. National estimates from 2009 suggest that diabetes leads to $2billion in direct costs and $1.7billion in indirect costs in Iran, annually [
      • Javanbakht M.
      • Baradaran H.R.
      • Mashayekhi A.
      • Haghdoost A.A.
      • Khamseh M.E.
      • Kharazmi E.
      • et al.
      Cost-of-illness analysis of type 2 diabetes mellitus in Iran.
      ].

      4. Discussion

      In this comprehensive review of diabetes in the MENA region, we noted a paucity of nationally representative survey data across the region. Most data are derived from small studies that use non-standardized measures and variable diagnostic criteria. Notably, the countries from which data were most commonly cited in this review were Iran, Israel, and Saudi Arabia [
      • Levin A.
      • Morad Y.
      • Grotto I.
      • Ravid M.
      • Bar-Dayan Y.
      Weight disorders and associated morbidity among young adults in Israel 1990–2003.
      ,
      • Esteghamati A.
      • Ashraf H.
      • Khalilzadeh O.
      • Rashidi A.
      • Mohammad K.
      • Asgari F.
      • et al.
      Trends of diabetes according to body mass index levels in Iran: results of the national surveys of risk factors of non-communicable diseases (1999–2007).
      ,
      • Almajwal A.M.
      • Al-Baghli N.A.
      • Batterham M.J.
      • Williams P.G.
      • Al-Turki K.A.
      • Al-Ghamdi A.J.
      Performance of body mass index in predicting diabetes and hypertension in the Eastern Province of Saudi Arabia.
      ]. There were very few data from North African countries and rural areas. There were also very few cohort studies, with those from Iran and Israel cited multiple times [
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      The prospective association of general and central obesity variables with incident type 2 diabetes in adults, Tehran lipid and glucose study.
      ,
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      Waist/height ratio as a better predictor of type 2 diabetes compared to body mass index in Tehranian adult men – a 3.6-year prospective study.
      ,
      • Tirosh A.
      • Shai I.
      • Afek A.
      • Dubnov-Raz G.
      • Ayalon N.
      • Gordon B.
      • et al.
      Adolescent BMI trajectory and risk of diabetes versus coronary disease.
      ].
      Our review highlighted the high region and country-specific prevalence of diabetes. Variation in diabetes prevalence estimates across the region is largely due to dependence on small ad hoc surveys, and use of non-comparable measures and diagnostic criteria. This variation reinforces the need for representative surveillance efforts in order to characterize burdens, and at the same time, to evaluate responsive policies and programs.
      Obesity and central obesity were clearly leading risk factors for diabetes in the MENA region. However, the emphasis on obesity has meant that very few studies have investigated the temporal relationships in terms of how behavioral (e.g., nutrition, physical activity) factors and genes interact in influencing the natural history of diabetes. A few studies have shown that physical inactivity and dietary patterns were associated with elevated BMI and waist circumference [
      • Levin A.
      • Morad Y.
      • Grotto I.
      • Ravid M.
      • Bar-Dayan Y.
      Weight disorders and associated morbidity among young adults in Israel 1990–2003.
      ,
      • Abdul-Ghani M.A.
      • Kher J.
      • Abbas N.
      • Najami T.
      Association of high body mass index with low age of disease onset among Arab women with type 2 diabetes in a primary care clinic.
      ,
      • Zindah M.
      • Belbeisi A.
      • Walke H.
      • Mokdad A.H.
      Obesity and diabetes in Jordan: findings from the behavioral risk factor surveillance system, 2004.
      ] and female gender, low education, and low SES appear to play a role in diabetes risk in the MENA region [
      • Harati H.
      • Hadaegh F.
      • Saadat N.
      • Azizi F.
      Population-based incidence of Type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran.
      ,
      • Musaiger A.O.
      • Al-Mannai M.A.
      Social and lifestyle factors associated with diabetes in the adult Bahraini population.
      ]. Also, the focus on obesity disregards how distribution of adiposity affects risk. Only a few studies localized in Iran and Egypt used measures of central obesity such as WC, WHR, and waist-to-height ratio [
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      The prospective association of general and central obesity variables with incident type 2 diabetes in adults, Tehran lipid and glucose study.
      ,
      • Hadaegh F.
      • Zabetian A.
      • Harati H.
      • Azizi F.
      Waist/height ratio as a better predictor of type 2 diabetes compared to body mass index in Tehranian adult men – a 3.6-year prospective study.
      ,
      • Abolfotouh M.A.
      • Soliman L.A.
      • Mansour E.
      • Farghaly M.
      • El-Dawaiaty A.A.
      Central obesity among adults in Egypt: prevalence and associated morbidity.
      ]. Altogether though, our review suggests that lifestyle factors are associated with diabetes risk in MENA countries, implying that culturally-acceptable lifestyle interventions may have sizeable benefits in reducing diabetes incidence.
      Diabetes complications were common in the region. Macrovascular complications were found in 9–12% of people with diabetes in the region while microvascular complications were observed in 15–54% of those with diabetes. Neurovascular limb diseases associated with diabetes were notably prevalent across MENA countries and may be related to specific lifestyle and culture norms. Representative data are scarce, however, and the studies available were heterogeneous in terms of designs, methods of assessing and defining presence of complications, and population characteristics.
      Control of other risk factors for vascular complications among people with diabetes was generally suboptimal in the region. More than 50% of those with diabetes did not meet glucose, lipid, and/or blood pressure treatment targets. Regular and affordable access to health services and medications may be an important underlying concern as health insurance is relatively uncommon in MENA countries. Stimulating a culture of auditing health services and outcomes will not only help in identifying treatment gaps, but may also stimulate interest in quality ratings, quality improvement strategies, and competition between providers to achieve better health outcomes.
      Reviews of this nature are limited by the quantity and quality of the studies available. Studies related to diabetes in the MENA region were not easily comparable due to variation in quality of studies, measures used, and diagnostic criteria chosen. These limitations notwithstanding, our narrative overview contributes to the literature by aggregating all of the relevant data related to diabetes in the region, provides an appraisal of the available epidemiological data, draws attention to important gaps in the literature, and provides insights into issues like quality of care and management that have been long overlooked. We recommend future approaches to measurement, notwithstanding the challenges to fund such efforts. We also recommend representative and regular surveillances as well as more data regarding costs and effectiveness of diabetes prevention and control interventions.
      In summary, more representative data and greater use of standardized data collection tools are needed. At the same time, we recommend adaptation of tested lifestyle interventions for diabetes prevention and implementation of effective quality improvement interventions in the region. There are some local models, for example from Kuwait [
      • Al-Adsani A.
      • Al-Faraj J.
      • Al-Sultan F.
      • El-Feky M.
      • Al-Mezel N.
      • Saba W.
      • et al.
      Evaluation of the impact of the Kuwait Diabetes Care Program on the quality of diabetes care.
      ], that may be beneficial in terms of contextual relevance. To fulfill all these considerations, other non-health sectors may need to become involved. Coordinated multidisciplinary approaches involving government and non-government actors are required to identify and scale avenues for successful prevention and control of diabetes.

      Conflicts of interest

      The authors declare that they have no conflicts of interest.

      Acknowledgements

      We would like to thank Ms. Barbara Abu-Zeid for her assistance with developing and implementing search strategies using Medline. There was no funding source for the current study.

      Appendix A. Search term used for systematically reviewing the articles published from 1990 to 2012 on diabetes in the Middle East and North Africa region

      Tabled 1
      Medline via Pubmed (from January 1990 to January 2011)
      #1 “diabetes”
      #2 Algeria OR Bahrain OR Djibouti OR Egypt OR Iran OR Iraq OR Jordan OR Kuwait OR Lebanon OR Libya OR Israel OR Morocco OR Oman OR Qatar OR Saudi Arabia OR Sudan OR Syria OR Tunisia OR United Arab Emirates OR Yemen OR (West Bank and Gaza) OR Palestine
      #3 1 AND 2

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