Glycemic control in patients with diabetes across primary and tertiary government health sectors in the Emirate of Dubai, United Arab Emirates: a five-year pattern

Objectives: In the UAE, the comparative prevalence of diabetes is reported as 18.98%, but there are very few studies evaluating glycemic control. Attaining the optimum glycemic control has been a global challenge over the years. However, there is a trend of global improvement with the availability of newer options of antidiabetic medications, increasing numbers of physicians, and patient awareness. Our primary aim was to assess the level of glycemic control across Dubai Health Authority points of care over the past five years. Additionally, we aimed to compare the differences in glycemic control between primary and tertiary centers, between nationalities, and type I and II diabetes

Methods: We conducted a retrospective analysis of the electronic medical records of all patients who attended primary and tertiary care centers within the Dubai Health Authority between 2012 and 2016. All patients with any type of diabetes were included in this assessment

Results: A total of 26 447 patients were included in the study; of these, 73.8% [n = 19 508] were UAE nationals while the other nationalities accounted for 26.2% [n = 6939] of patients. The overall mean glycated hemoglobin [HbA1c] levels from 2012 to 2016 was 7.76%. Patients attending primary care clinics had a mean HbA1c of 7.64% compared to 7.68% for the tertiary care cohort. Out of the total population, 37.7% achieved HbA1c < 7%. Over 40% of the patients attending primary care centers achieved HbA1c < 7% compared to 34.9% of those who attended tertiary care centers

Conclusions: Optimum glycemic target was achieved by less than 40% of patients. Glycemic control is still below the desired levels. However, there has been a trend of improvement in the last few years and we are achieving the international average targets. Further collaborative actions from clinical, educational, and strategic sectors are needed to improve our goals further

Relation between plasma leptin level and left ventricular function in obese females with insulin resistance

An association between obesity and cardiac mass has been recognized for almost two decades, whereas the precise nature of the association remains elusive Theoretical consideration have long suggested that it may be mediated at least in part by insulin resistance [Mc, Nutly ,2003].Several studies have found an association between insulin resistance and left ventricular hypertrophy. [Lacobellis et al, 2003]. In human, production of leptin[ an adipocyte - derived peptide], has been linked to obesity, insulin and insulin sensitivity [Leyva et al, 1998]. It was considered that alteration in plasma concentration could constitute an additional component of metabolic syndrome of cardio-vascular risk[Leyva et al, 1998]. The aim of this work was to evaluate the relationship between obesity, insulin resistance, leptin and left ventricular mass and function in young obese females with insulin resistance. Sixty five premenopausal females aged 25-45 years with no history of diabetes or hypertension was participated in this study. Twenty were non obese and forty five were obese .Fasting serum glucose, insulin and leptin were assessed and homeostatic model assessment HOMA-IR score was calculated. According to HOMA-IR obese premenopausal females were divided into 2 subgroups: - Subgroups 1: [Insulin sensitive group or IS group] included 20 obese females with HOMA-IR <3.8.And Subgroup 2: [insulin resistance group or IR group] included 25 obese females with HOMA-IR>/=3.8.Echocardiography was done for all females participated in the study to evaluate L.V mass and function. Waist circumference [WC], serum insulin, serum leptin and HOMA-IR were significantly higher in obese group compared to non obese group [p<0.05, <0.05, <0.001 and <0.00l respectively] and between IR and IS subgroups [p<0.05, <0.05, <0.001 and <0.00l respectively].As regard Echocardiographic studies left ventricular mass[LVM] and left ventricular mass corrected t height 2.7 [LVM/h2.7 ]were significantly higher in obese group compared to non obese group [p<0.05] and between IR and IS subgroups [p<0.05 for both],while the ratio between peak transmitral E and A wave velocity[E/A ratio] was lower in obese group compared to non obese group [<0.05], it was also lower in IR subgroup compared to IS subgroup [p<0.05].There was positive significant correlation between LVM and LVM/H2.7 and serum insulin [p<0.05]and serum leptin [p<0.05] in IS subgroup while the correlation was highly significant between both and fasting leptin [p<0.001] in IR subgroup. Obesity is a clinical syndrome associated with hyperinsulinemia, hyperleptinemia and insulin resistance Abnormalities of LV diastolic function and mass occur frequently in obese patients. Hyperleptinemia can be an early sign for left ventricular dysfunction in obese females

Recommendations for management of hyperglycemia in type 2 diabetes in the Arab Countries based on the consensus statement from the American Diabetes Association [ADA] and the European Association for the Study of Diabetes [EASD]

We would like to emphasize that stepwise interventions will help to achieve glycemic goals. Unfortunately there are barriers to effective management of hyperglycemia in type 2 diabetes, particularly in much of the Arab world [38]. We would like to emphasize that antihyperglycemic therapies with the possible exception of TZD should be titrated frequently [at intervals of days to at most weeks] based on glucose levels achieved and tolerability. Most patients can achieve A1C levels less than 7% in a matter of a few months. Suboptimal healthcare systems impede achievement of glycemic goals. Other barriers to effective management include insufficient communication with patients due to limited physician consultation time. This often contributes to inappropriate prescription of medications which patients cannot afford or will not tolerate and contributes to poor adherence. A multidisciplinary team approach to diabetes care - involving diabetologists, primary care providers, diabetes specialist nurses, pharmacists, dieticians and health educators, among others, with the patient at the centre of the team - has been demonstrated to improve both glycemic control and patient quality of life [39]. Equally or arguably more critical to optimizing patient outcomes is adequate treatment of comorbid conditions [e.g. dyslipidemia, hypertension, hypercoagulability] and early complications [e.g. retinopathy, microalbuminuria and the insensate foot]. A team approach with appropriate attention to patient education, motivation and adherence is critical to success, even if the team is just a patient and a primary care provider working together in a context of mutual respect with shared goals, understanding of their individual roles and open communication [40]. We strongly feel that these basic principles should guide every practitioner working with every patient with type 2 diabetes to ensure optimal care in their individual circumstance with an overall aim of reducing the proportion of patients who do not achieve control of diabetes with its asso-ciated omorbidities and complications from current levels of more than 60% [41,42]. Putting into consideration the local concerns mentioned above, our group supports the ADA/EASD consensus algorithm. Our aim is to highlight specific barriers in the Arab world and to adapt these recommendations to be more consistent with local circumstances in our countries