Common Chronic Disease Patterns in Arabian Gulf, Saudi Arabia & YemenDr. O. P. Kapoor
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Diabetes Mellitus

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The incidence of Diabetes Mellitus ("Boal Sakar" or"Sukar") amongst Arabs varies depending on where they come from. It occurs in increasing order of frequency from Yemen, Dubai, Ras al Khymah, Sharjah, Abu Dhabi, Oman, Bahrain, Saudi to Qatar, so much so that from Qatar every second or third middle aged or elderly person is likely to be a diabetic. In Yemen it is a rare disease and when seen, it is more in "Saudi" type of Yemenis. In U.A.E., it is most common in Abu Dhabi.

Most of the times the disease is detected incidentally. Since no sophisticated equipment is required for diagnosis of diabetes, it is easy to pick up this disease on a routine health check-up. Also many practitioners ask for blood sugar examination, when they associate many symptoms like weakness, giddiness, malaise, impotency etc. to diabetes as they do in case of hypertension. Unfortunately, such symptoms are abundant in Arabs. On most of the occasions these are not due to "mild" diabetes (in fact glucose intolerance) only detected incidentally as above. Often this fact can be confirmed on a follow-up.

The following are some observations made on this diabetic population—

  1. Even with moderately severe diabetes, often the symptoms of day time ("Finnhaar") or night time ("Fillail") polyuria are absent.
  2. Although Arabs normally complain of dry mouth ("Iyaabus"), but diabetics do not complain of polydypsia or increased thirst.
  3. Polyphagia is rarely complained of, because even normally Arabs eat heartily.
  4. Many Arabs complain of marked weakness, which turns out to be psychogenic or of sexual origin. But patients having moderately severe or even severe diabetes often do not complain of muscular weakness ("Daeef") or fatigue ("Tahbaan").
  5. Loss of weight is not a common complaint of Arab diabetics.
  6. The incidence of Diabetes is much more in males.
  7. Pruritus ("Hakka") a very conlmon symptom in the general Arab population is hardly complained of more by diabetics.
  8. Ketonuria is very rare in Arab diabetics.
  9. As regards sexual impotency, more often the symptom appears to be of psychogenic origin with the presence of normal nocturnal tumescence ("Zib Fillail Subah" "Mazboot"). Perhaps the severity is more marked because of the dreaded fear of the disease of diabetes. Unfortunately at present in Bombay we have no facilities to investigate impotence. Clinically if a patient has evidence of peripheral neuropathy or autonomic nervous disturbances, then the impotence can be considered as organic and due to diabetes. In the rest, it is only on a 'follow-up' that one can confirm the label of 'psychogenic'. Thus it is so common to see a Saudi or a Qatari, who is neither dieting nor taking proper treatment for diabetes, and yet has responded to "sex tonics".
  10. Microvascular complications like diabetic retinopathy or nephropathy are also very rare. It is difficult to believe that "Allah" (God) protects them from these complications, inspite of suffering from severe diabetes and not taking regular treatment. It reminds me of the old days when I used to read that Insulin therapy lowers the sugar but "increases" the process of atheroma.
  11. Even amongst the macrovascular complications, the incidence of cerebral arteriosclerosis resulting in stroke is not so common. Stroke when seen is more common in Saudis. (It is worth noting that in Arab population, often, in patients suffering from stroke, there is no evidence of diabetes or hypertension). Also coronary atheroma with resultant symptoms of ischaemic heart disease is less common than one should expect. Arteriosclerosis of peripheral vessels of limbs is not uncommon. But the symptoms of claudication and gangrene, are extremely rare compared to the severity of diabetes and often, associated heavy smoking. Minor foot problems are observed especially in the poor class with poor habits of hygiene.
  12. Balanitis is unknown because of the practice of circumcision.
  13. Although Pulmonary Kochs is seen, off and on, in Yemenis or U.A.E. patients, yet in most of the diabetics, who mainly come from other Arab countries, Kochs is a rare complication.
  14. Complication of carbuncle is rare.
  15. Premature cataract due to diabetes is very uncommon.
  16. Kidney infections due to underlying diabetes seem to be rare. Even if blood urea is found to be elevated, often associated prostatic enlargement turns out to be the cause.
  17. The only common complication seen is that of peripheral neuropathy. Here again sometimes it is difficult to diagnose this complication clinically, because even normal Arabs do complain of symptoms of tingling and numbness ("Naum"), burning ("Haar") and pains ("Vajaa") in the legs ("Rijley"). Unless the sense of vibration or the deep tendon jerks are affected, electromyography and nerve conduction studies may have to be done to confirm the diagnosis. Severe lancinating burning pains of advanced diabetic neuropathy are rare in Arabs. Similarly rare are the other complications affecting the central nervous system .
  18. An Arab would always like to know the details of his disease of diabetes like—
    1. Is sugar present only in urine or only in blood or in both?
    2. What are the readings of fasting and post-prandial blood sugar?

In practice, we find that though some of the pathologists still estimate venous blood "sugar" by the Folin-Wu method, others do

  1. Blood "glucose" or
  2. "Serum glucose" or
  3. "Capillary" blood sugar or
  4. Glycosylated Haemoglobin estimation.

    Similarly some pathologists do "post-glucose" blood sugar, while some others do the post-prandial blood sugar estimation.

Amongst those using "post-glucose" load test, some use 75 G of glucose, others use 100 G. yet others use 1 G/kg of body weight. Amongst food, no specifications are mentioned. Some Arabs go after eating bread and butter only. Others go after a full breakfast or a "heavy" lunch. Yet others go after consuming a tot of "sweet meats" ("Haluwas"), because they want to "try" and see if blood sugar does get elevated with these.

After the post-glucose load test or post-prandial test, some pathologists call them after one and half hours, others, after two hours and yet others, after two and half hours. An average Arab who goes to eat in a restaurant or a hotel can hardly keep up the "accurate" timing. And even when he does reach the hospital in time, to this should be added the average long "waiting" time for a lift or an elevator to reach the laboratory and finally to find a technician to be ready to receive him at any odd time.

Arabs are known to try more than one laboratory ("Ayyadaa"), lest there may be new machines ("Makinaa") in other clinic. All these reports from the various laboratories thoroughly confuse our Arab visitor.

Naturally the permutations and combinations of the above circumstances would lead to variable results.

  1. When it comes to advise on diet, for an average Arab, it is difficult to change his main diet of rice ("Roz"), plenty of bread ("Roti" or "Ayesh"), fat Chapatis ("Khubuz") and meat ("Laaham"). They do not include high fibre diet of vegetables, ("Khodraa") and pulses ("Hadas"), though a few of them do consume the latter. The universal habit of eating dates ("Khajoor" or "Tamar") even in severe diabetics cannot be discouraged.
  2. (20) Although, initially, they do not mind insulin injections twice or even thrice a day, within a few days or weeks, they gradually begin to omit some doses, finally omitting the in jections altogether. Often "Ramadaan" (when they observe a fast during the day and avoid all food, cigarettes and drugs—lasting over a month) is responsible for discontinuation of injections. At other, times, they stop because they do not believe in "long-term" therapy.

    The same applies to compliance with tablets. More often they are happy to continue tablets and prefer them to injections. But even when at their best, the tablets are consumed regularly, only for a few months. They do not mind "re-starting" when advised to do so.

  3. Many Arabs consume Diabinese (chlorpropamide) tablets. I have never heard of the history of an "Alcohol Chlorpropamide" reaction in an Arab. Now since we know that this reaction is determined by the underlying HLA antigen-pattern, in future it may be possible to explain the rarity of this "syndrome" in Arabs.
  4. Finally I would like to stress that when these patients come back for a follow up, I find that though they are living happily with the uncontrolled disease, without developing much of the complications, many of them have constant underlying tension and anxiety of the disease and are looking forward to come back to have a check up for the "state" or the "stage" or the "control" of the disease.

And of course this does not mean that all of them show this behaviour. Those few, who were "symptomatic" show a better compl iance.

Those patients whose doctors have co-related their "sex weakness" with diabetes are the ones who come back again and again and go for repeated check-ups of their blood sugar levels till the specialist positively disconnects the two diseases in their minds.

 

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