El proceso de integración MERCOSUR Introducción

Diabetes mellitus is a chronic disease which affects many people around the globe. People of different ages, genders and in developing and even developed countries have been diagnosed with diabetes and the prevalence of diabetes mellitus is expected to increase internationally to 592 million in 2035 (Ministry of Health, 2016b).

Diabetes mellitus is a group of metabolic disorders known as hyperglycaemia which is caused by deficient insulin secretion and/or insulin actions (American Diabetes Association, 2013). Diabetes mellitus is developed in a human body for a number of reasons. One reason is the destruction of pancreas cells, which is responsible for insulin production. This results in a deficiency in insulin production. Another reason for diabetes development is the deficient insulin action, which includes insufficient insulin secretion and/or reduced insulin responses from different tissues of the human body. There are different symptoms of diabetes mellitus. Some of which are polydipsia, polyuria and weight loss. In addition, signs such as blurred vision and polyphagia can also be symptoms of hyperglycaemia.

There are two main types of diabetes mellitus: type 1 diabetes and type 2 diabetes. In addition, the WHO organisation have mentioned another type of diabetes mellitus and this is gestational diabetes (WHO, 2016a). The differences between the three types are summarised as follows:

1. Type 1 diabetes: caused by the destruction of B-Cells in the pancreas. This leads to absolute deficiency in insulin production. Type 1 diabetes appear in between 5% and 10% only of diabetic people in the world (American Diabetes Association, 2013). 2. Type 2 diabetes: caused by the resistance of insulin in the human body. This

resistance usually is combined with insulin deficiency or defects in insulin secretion. This type of diabetes mellitus accounts for 90% to 95% of diabetic individuals in the world (American Diabetes Association, 2013).

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hyperglycaemia. However, the hyperglycaemia level is still below those who are diagnosed with type 1 or type 2 diabetes. Women with this diabetes type may encounter complications during pregnancy and/or delivery. Despite most cases being resolved after delivery, diagnosed women and their children are at a higher risk of type 2 diabetes in the future (American Diabetes Association, 2013; WHO, 1999).

Diabetes mellitus has a high prevalence all over the world, affecting a tremendous number of people from different ages, genders and nationalities. Currently, there are over 350 million people diagnosed with diabetes mellitus and one billion people are pre-diabetics who are at risk of getting diabetes (Lotfy et al., 2017). In 2014, the number of diabetic individuals has reached 244 million and increased from only 108 million in 1980 (WHO, 2016b). In 2012, it was estimated that diabetes mellitus has caused 1.5 million deaths whereas another 2.2 million deaths were attributed to high blood glucose levels. According to the International Diabetes Federation (2015), the prevalence of diabetes mellitus is increasing quickly and the number of diabetic people will reach 642 million in 2040.

Saudi Arabia, like other developing countries, has a considerable number of patients who are suffering from different kinds of chronic diseases. One of those diseases is diabetes mellitus, which has a high percentage of appearance among citizens in almost every part of the Kingdom. According to Shaw et al.(2010), Saudi Arabia is in third place among the top ten countries for diabetes prevalence. In 2010, the prevalence percentage for diabetes mellitus in Saudi Arabia was 16.8% among adults in the ages of 20 to 79 years old. This percentage is expected to rise in 2030 to reach 18.9% (Shaw et al., 2010). The number of outpatient visits made by diabetic individuals to PHCs is 1.8 million out of 29.3 million overall outpatient visits to HCCs in Saudi Arabia. This number of diabetic people’s visits represents 6.44% of the overall number of visits to all PHCs in Saudi Arabia, and puts diabetic people in third place in the scale of all outpatient visits in the Kingdom (Ministry of Health, 2011).

Official reports from the MOH in Saudi Arabia show an increasing numbers of visits to public hospitals over the years. The number of visits to MOH hospitals due to diabetes mellitus was over 434 thousand in 2011 (Ministry of Health, 2011). The number has increased over four years to exceed 477 thousand visits to MOH hospitals in 2014 (Ministry of Health, 2014) (see Figure 2.12).

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Figure 2.12. Visits to MOH hospitals due to diabetes mellitus from 2011 to 2014 Source: (Ministry of Health, 2011, 2012, 2013, 2014)

In recent statistics, the International Diabetes Federation revealed that Saudi Arabia had more than 3.8 million cases of diabetes mellitus in 2014 and the prevalence of this disease among individuals represents 20.5% (International Diabetes Federation, 2014). Those diabetic people are not limited to a particular age. In 2015, Saudi Arabia is in the list of top countries in terms of the prevalence of type 1 diabetes among children under 14 years old, with 16,100 cases (International Diabetes Federation, 2015b). In the same year, the prevalence of diabetes mellitus among people from 20 to 79 years old is 20%. Diabetic people in Saudi Arabia suffer from various complications of diabetes. However, the most serious complication encountered by diabetics in Saudi Arabia is mortality. According to the Centers for Disease Control and Prevention (2016), diabetes mellitus is considered the first cause of death in Saudi Arabia among all other diseases in 2013.

People suffering from diabetes mellitus could find themselves with consequential health conditions. Bouillon et al. (2013) found that diabetes risk scores, in particular the Finnish

434,300 453,002 466,006 477,211 410,000 420,000 430,000 440,000 450,000 460,000 470,000 480,000 490,000

Number of Visits to MOH Hospitals Due to Diabetes Mellitus

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score, were associated with future frailty. Another study found that type 2 diabetes mellitus results in a small relative risk increase for depression (Hasan et al., 2013). Sánchez-Quesada and Pérez (2013) mentioned that cardiovascular disease derived from atherosclerotic conditions is the leading cause of death in patients with diabetes mellitus. People with diabetes are in 15 times greater danger of having leg amputations than people without diabetes (Holt et al., 2010). In addition, diabetes mellitus can cause heart failure (Hunt et al., 2009), in addition, and can cause blindness (Frank, 2013). Moreover, diabetic individuals are at higher risk of having kidney failure and strokes (Appuhamy et al., 2013).

Many lifestyle activities can help in terms of the prevention of diabetes mellitus and its consequences. These lifestyle activities include diet and physical activities (Fareed et al., 2017). Diet plans help diabetic individuals to meet the blood glucose level required. Different diet plans are recommended for those who have lower risk of diabetes mellitus. In particular, diet plans that include fibre and wholegrain are found in different studies to be associated with lower risk of developing diabetes or any of its risk factors (Aune et al., 2013 ; Hodge et al., 2004). Physical activities, on the other hand, benefit diabetic individuals by increasing insulin uptake in different muscles of the body and enhances the overall glycaemic control. Moreover, physical activities are very beneficial in postponing different cases of diabetes mellitus and its associated complications including neuropathy, retinopathy and nephropathy.

Beside many complications which could result from this disease, diabetic individuals also face other difficulties and issues related to controlling the disease and its consequences through different lifestyle activities. These issues are known by the non-health-related complications of diabetes mellitus (see Figure 2.13). Péres et al. (2007) reported some of those challenges people with diabetes mellitus can have in their daily life, including difficulties controlling impulses related to eating habits, doubts in the correct way of using medications, refusal to take insulin because of concerns regarding dose preciseness and doubts regarding time schedules for antidiabetics. Blonde (2005), in addition, indicated patient deficiency in adherence to lifestyle measures and pharmacologic therapies as one of the most common reasons cited for failure to achieve glycaemic goals. Patients who have diabetes face problems in identifying medications and understanding prescriptions, especially when patients asked to change medication. Most patients could not remember their

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blood glucose and blood pressure target. According to Onwudiwe et al., (2014), the lack of knowledge of a desired blood glucose level is the major barrier of diabetes self-management. Another study suggested that appropriate knowledge about diabetes mellitus is essential to ensure patients’ adherence to medication (Sweileh et al., 2014). The study found that diabetic individuals expressed their concerns regarding the adverse effects of multiple anti-diabetes medications. In addition, participants in the study believe that diabetes medications can be harmful, which suggests that assessment of patients’ knowledge and education about diabetes mellitus prior medication intake to ensure adherence of patients prior to medications.

In addition to the above complications, diabetic patients in Muslim countries face difficulties related to controlling diabetes during the holy month of Ramadan. Since people in Muslim countries fast every day of the month of Ramadan from sunrise until sunset, Muslims who have diabetes mellitus might be at risk of considerable fluctuations in the blood glucose level (Zargar, 2017). Muslims in Ramadan change their eating routines, which includes changing the types and timing of almost all meals during this month. This can affect fasting people with diabetes mellitus in terms of identifying the appropriate diet, medication time and amount (Hassanein et al., 2017).

Figure 2.13. Non-health related complications of diabetes mellitus

Diabetes non- health-related complications Identifying appropriate diet Identifying physical activites Identifying the right medication Identifying the right dosage Remebering medication Measuring blood glocuse level Identifying the right glocuse level Coexisting with diabetes mellitus Managing diabetes in Ramadan

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The lack of education and management of diabetes mellitus has consequences with serious health complications. Deficient adherence to diet and physical activities are the most common cause of developing diabetes mellitus and its complications, along with other complications, such as hypertension and coronary artery diseases (Sharaf et al., 2013). In addition, poor execution of diabetes medication can result in serious health complications, including morbidity and mortality. Moreover, non-adherence to diabetes medication may result in increased loss to healthcare services (Sharaf et al., 2013).

Scholars have suggested solutions to overcome diabetic individuals’ difficulties and problems. According to Onwudiwe et al. (2011) inadequate health literacy can lead to an inefficient use of health services. The WHO described health literacy as allowing access of people to resources and information in order to make appropriate decisions related to their health (Protheroe et al., 2017). Therefore, diabetes education and self-management are the two terms that have been highly cited in terms of overcoming diabetics’ difficulties. The term self-management is known as the role patients managing their diseases. The term has been widely used in the healthcare domain to empower individuals to control their chronic illnesses, and its resulted complications, by increasing their knowledge, skills and confidence (Lorig et al., 2000). Furthermore, self-management enables people who suffer from particular diseases to manage their negative emotions and maintain better life health conditions. It has been applied globally and has proved its usefulness to a number of diseases, including different chronic conditions. In terms of diabetes mellitus, self-management and support are seen to have a positive impact on diabetic individuals by facilitating their knowledge and skills to increase diabetic individuals’ abilities to take care of the diabetes by themselves on an ongoing basis (Powers et al., 2017).

Blonde (2005) stressed the importance of ongoing medical nutrition therapy and said that self-management education must be made available to all individuals with diabetes. Furthermore, Onwudiwe et al. (2011) defined diabetes education, knowledge and self- management as the key to successful diabetes management. Self-management education helps people with diabetes in improving knowledge, dietary habits, accurate glucose self- monitoring and weight (Deakin et al., 2005). In the United Kingdom, the National Institute of Clinical Excellence (NICE) guidelines recommend diabetes education programmes to be

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offered to diabetics and their healthcare providers, to assist patients in managing their condition. One example that is highly recommended in the UK is the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) which offers short courses through presentations and workshops, to develop patients’ skills and knowledge to empower them to manage their illnesses.

One of the widely utilised methods for increasing education and self-management awareness among patients is the utilisation of internet technologies. The internet is used increasingly by people who suffer from chronic diseases in order to self-manage their illnesses and learn from other patients’ experiences (Ziebland et al., 2014). The literature review conducted by Ziebland and Wyke (2012) revealed seven domains for accessing health experiences of others on the internet; (1) finding information, (2) feeling supported, (3) maintaining relationships with others, (4) experiencing health services, (5) learning to relate the story, (6) visualizing disease, and (7) affecting behaviour. In terms of diabetes mellitus, internet technology has been utilised to manage diabetes mellitus and its complications. Ramadas et al. (2011), for example, discussed the intervention of web-based technology for managing type 2 diabetes. They reviewed 13 web-based results on the positive impact of such intervention on the management of the disease. Another study showed how a web-based diabetes management system helped its users reduce their glycated haemoglobin (HbA1c) (Kwon et al., 2004). It offered educational programmes related to diabetes management, exercise, nutrition and recommendations for the patients with type 2 diabetes based on the information they entered, such as their medications and glucose levels.

Official reports showed promising indications in terms of utilising internet technology as an educational and self-management method. Internet penetration in Saudi Arabia rose from 13% in 2005 to 63.7% in 2014 and the number of internet users reached about 19.6 million (CITC Annual Reports, 2014). The internet is commonly used to search for health related information in Saudi Arabia (AlGhamdi and Moussa, 2012). However, the number of studies available about e-health initiatives in the Kingdom is limited to a few organisations and remains low (Alsulame et al., 2016). There is also a lack of e-systems to support diabetes patients in Saudi Arabia, and in Ramadan, in spite of the increasing number of people with diabetes mellitus in the Kingdom. In fact, studies available to support diabetes care in the

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kingdom are limited and related to specific healthcare organisations only and not tailored to support diabetic patients outside those organisations. There is a critical need to provide e- healthcare to support diabetic citizens to cope with their daily life difficulties and support healthcare professionals in providing quality and consistency of care to their patients.

The literature review has identified several studies undertaking various aspects of diabetes preventions and treatment in Saudi Arabia. In addition, studies have discussed different types of treatment of diabetes mellitus in the Kingdom. For example, Aljumah et al., (2013) compared the effects of the intervention of drug, diet, weight reduction, smoke cessation exercise and insulin on the treatment of diabetes mellitus. They concluded that diet control, weight reduction, exercise and smoking cessation are mutually essential for diabetes treatment. However, the literature review lacks in terms of identifying non-health-related complications in the Saudi Arabian context. In addition, the literature review witnessed a deficiency in relation to the self-management and education effort offered to diabetic individuals in Saudi Arabia. According to Alshammari (2016), Saudi Arabia is experiencing a deficient effort in relation to patients’ education about their diseases along with its appropriate management. Moreover, a limited number of large hospitals in the Kingdom offer educational and counselling services to their patients. For example, Al-Ghamdi et al. (2012) assessed a medication counselling programme provided for discharged patents from a territory hospital in Riyadh to avoid adverse drug events. The study showed that the knowledge and education effort provided for patients prevented them from adverse drug events. In another study conducted at King Abdulaziz Medical City, another major hospital in the Kingdom, the education and counselling programme increased the medical knowledge of patients in relation to their recognition of medication and its side effects (Alkatheri and Albekairy, 2013).

In this study, we aim to fill this gap by investigating different non-health-related complications of Saudi Arabian diabetic citizens. In addition, we contribute to the concept of self-management and education in healthcare. Diabetes mellitus is the domain of application to apply appropriate diabetes self-management and education in the Kingdom, which is one of the major countries in the prevalence of diabetes mellitus worldwide.

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