Exploring the Growing Challenge of Diabetes across the GCC and within the United Arab Emirates

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Table of Contents

Executive Summary .........................................................................................3

Sounding the Alarm: The Burden of Diabetes on Lives and Livelihoods ...............6

Regional Rates and Trends ........................................................................7

Diabetes in the UAE: Portrait of a Nation at Risk .............................................10

Economic Costs ......................................................................................10

Risk Factors ............................................................................................12

Diabetes Awareness and Attitudes in the UAE ................................................12

Diabetes is a Public Health Priority ...........................................................13

Personal Concern about Diabetes is Widespread ......................................13

Comprehensive Prevention is Not Well Understood ....................................14

Information Comes Primarily via Media while Physicians are Highly Trusted Sources ......................................................................14

Taking Prevention to the Next Level ................................................................15

Exploring Solutions: The Dynamic Tensions Between Diabetes and Long-Term Economic Competitiveness of the GCC .....................................17

Past Experiences...........................................................................................18

Alzheimer’s Disease ................................................................................18

Pandemic Influenza .................................................................................18

HIV/AIDS ................................................................................................19

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Executive SummaryThe World Health Organization (WHO) and the International Diabetes Federation (IDF) call diabetes the 21st century’s leading health care challenge.1 Diabetes complications and mortality create social and economic challenges that affect individuals, families, businesses, and society as a whole. The growing diabetes burden is particularly challenging for the Middle East and North Africa (MENA) region and within the Gulf Cooperation Council (GCC) countries2 specifically where the disease has reached pandemic proportions. Six MENA region countries are among the world’s 10 highest for prevalence of diabetes and impaired glucose tolerance. The United Arab Emirates (UAE) has the highest diabetes prevalence rate in the region, while GCC countries including Qatar and Kuwait have high rates as compared to other high-income countries. Left unchecked, the spread of diabetes portends devastating social and fiscal consequences, including threats to economic progress and investment stability in the region.3

In order to inform diabetes prevention efforts in the MENA region, Booz Allen Hamilton commissioned two studies in 2012. The first assessed UAE diabetes prevalence and incidence, risk factors, prevention programs and economic costs; reiterated the scope of the problem; and examined contributing lifestyle and genetic factors. This study also categorized existing prevention programs and highlighted collaborative efforts and outcomes.4 Booz Allen Hamilton then commissioned a survey to understand the attitudes and behaviors that put Emiratis at risk of developing diabetes and to identify possible ways to mitigate risk factors and encourage healthy behaviors. This survey found that while high levels of awareness exist among Emiratis, there are widespread obstacles to preventative behaviors. The survey found that awareness levels about diabetes and the behavioral changes needed to reduce risk varied according to educational level.5

Based on the data collected, all Emirati citizens should be concerned about diabetes, both for the risk that it poses to them and to their country’s economy. Thirty-one percent of all deaths in the UAE are caused by diabetes and correlated cardiovascular disease. This startling statistic belies the enormous associated costs borne by the government, civil society, and private sectors. Treatment of diabetes constitutes approximately 40 percent of the UAE’s overall health care expenditures. In 2011, the cost was nearly $6.6 billion or 1.8 percent of GDP, higher than in any other GCC country.6 As diabetes is predicted to escalate in the region, associated costs will skyrocket. The growth of diabetes is so serious that healthcare systems are already struggling to cope with treatment costs. Medical expenditures for those with diabetes are on average 2.3 times higher than for those without the disease.7 These costs have contributed to a 20-percent rise in health insurance premiums in the private sector, a cost primarily borne by Emirati businesses.

These findings, along with the epidemiologic and financial data, point to an imperative need to broaden the reach of diabetes prevention and management efforts within the UAE. Booz Allen Hamilton’s studies provide crucial insight into how to successfully slow the spread of the disease in the GCC region. The first

1 Epinex Diagnostics Inc. Diabetes in the Middle East. 2008. Accessed at: <http://epinex.com/pdf/Epinex_Diabetes_MidEast.pdf.> [Accessed on September 18, 2012.]

2 The GCC countries comprise Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates.3 Epinex Diagnostics Inc. Diabetes in the Middle East. 2008. Accessed at:

<http://epinex.com/pdf/Epinex_Diabetes_MidEast.pdf.> Accessed September 18, 2012.4 Booz Allen Hamilton. Discussion Document: Diabetes in the Middle East. February 2012.5 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012.6 Booz Allen Hamilton analysis of data from: Boston Analytics; International Monetary Fund World Outlook Database; International

Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009; World Bank Atlas; World Bank Databank, 2009.

7 American Diabetes Association. The Cost of Diabetes. 2012. Accessed at: <http://www.diabetes.org/advocate/resources/cost-of-diabetes.html>

The Staggering Costs of Diabetes• 31 percent of all deaths in the UAE are caused

by diabetes and correlated cardiovascular disease.

• Diabetes treatment constitutes 40 percent of the UAE’s overall health care expenditures, at $6.6 billion or 1.8 percent of GDP.

• Medical expenditures for diabetics are on average 2.3 times higher, which has contributed to health insurance premiums in the private sector rising up to 20 percent.

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in a series of events focused on exploring the impact of public health issues on the GCC region’s economic competitiveness, Booz Allen Hamilton will be convening key decision makers and thought leaders in the UAE to discuss solutions that will address the diabetes pandemic and its projected role in decreasing economic competitiveness. The dynamic discussion will facilitate open dialogue around best practices and empower participants to take concrete next steps. This supports the UAE’s 2011–2013 national strategy to create a competitive knowledge economy by enhancing the capabilities, efficiency, and productivity of the Emirati workforce.8 There is tremendous opportunity to turn the story around and raise awareness of diabetes prevention and control strategies by developing a range of public-private partnerships and using trusted sources of information to deliver prevention messages.

8 Highlights of the UAE Government Strategy 2011–2013: Putting Citizens First.

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ملخص تنفيذي

التبعات الجسيمة لمرض السكري• نسبة 31 في المائة من إجمالي الوفيات في

اإلمارات العربية المتحدة يتسبب بها مرض السكري وأمراض القلب والشرايين المترتبة عليه.

• يشكل عالج مرض السكري نسبة 40 في المائة من إجمالي نفقات الرعاية الصحية باإلمارات العربية

المتحدة، بما يساوي 6,6 مليار دوالر أمريكي أو 1,8 في المائة من إجمالي الناتج المحلي.

• ترتفع معدالت النفقات الطبية لمرض السكري بمتوسط 2,3 مرة، مما ساهم في ارتفاع أقساط

التأمين الصحي في القطاع الخاص بحوالي نسبة 20 في المائة.

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Sounding the Alarm: The Burden of Diabetes on Lives and LivelihoodsDiabetes9 is a chronic disease that arises when the body does not produce enough or cannot effectively use insulin. Both the World Health Organization (WHO) and the International Diabetes Federation (IDF) consider diabetes the 21st century’s leading health care challenge.10 Complications from diabetes are common and often occur if the disease is not diagnosed or treated soon enough. These complications include heart disease and stroke, eye disease, and kidney disease, as well as nerve damage that may eventually lead to limb amputation. The overall risk of dying among diabetics is at least double the risk of their peers without diabetes, with the risk for stroke two to four times higher and a 50-percent increased risk of dying of cardiovascular disease (CVD). In addition, other conditions are strongly linked to diabetes risk. Impaired glucose tolerance, which also involves the inability of the body to use its insulin, carries an increased risk of diabetes.11 In addition, women who suffer from gestational diabetes (a form of the disease that can develop only during pregnancy and that poses labor and fetal health complications) have an increased risk of developing diabetes later in life. Thus, within communities, among employees and across society as a whole, diabetes and related illnesses have a tremendous impact on the quality of life and well-being of the millions affected. This in turn creates economic challenges that include excessive absenteeism, reduced productivity, and increased medical expenditures.12

As the following epidemiologic and trend data illustrate, diabetes has reached pandemic proportions within the Middle East and North Africa (MENA) and Gulf Cooperation Council (GCC) countries specifically (see Figure 1). In the MENA region, 32.8 million people have been diagnosed with the disease. Six MENA region countries—Bahrain, Egypt, Kuwait, Oman, Saudi Arabia, and the United Arab Emirates (UAE)—are among the world’s 10 highest for prevalence of diabetes and impaired glucose tolerance. By 2030, it is estimated that nearly 4 percent of all deaths in the MENA region will be caused by diabetes, representing a rise of 85 percent from 2008. And the increase in mortality for women will be even more pronounced: by 2030, deaths from diabetes among women will be 63 percent higher than among men, despite similar prevalence rates.13

The reason why this pandemic continues to grow includes demographic changes and increasing rates of overweight/obesity. Rapid economic development has led to lifestyle changes that resulted in low levels of physical activity, unhealthy nutrition, and increased obesity, all key risk factors for the disease. Left unchecked, the spread of diabetes portends devastating social and fiscal consequences, including threats to the stability of financial investments in the MENA region.14

9 For the purposes of this report, “diabetes” refers to type 2 diabetes, the most common form of the disease and the form which commonly arises in adulthood.

10 Epinex Diagnostics Inc. Diabetes in the Middle East. 2008. Accessed at: <http://epinex.com/pdf/Epinex_Diabetes_MidEast.pdf.> [Accessed September 18, 2012]

11 International Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009.

12 World Health Organization. The global burden of disease: 2004 update. Geneva, World Health Organization: 2008. World Health Organization WHO Global Infobase, (WHO web services). [online] Available at: <http://www.who.int/evidence/bod> [Accessed September 12, 2012]

13 Ibid.14 Ibid.

Figure 1 | Number of People with Diabetes in the MENA region—up 94 percent from 2010–203012

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Figure 3 | Diabetes-Related Deaths in the Age Group of 20–79 years in 2011 ('000)18

In fact, the growthofdiabetesissoseriousthathealthcaresystemswillsoonbestrugglingtocopewiththecostsoftreatingthepredictedlevelofcomplications. Though more than half of cases of type 2 diabetes can be prevented or delayed in people with known risks through eating a healthy diet and increasing physical activity, the IDF projects that the number of people with diabetes in the MENA region will almost double, reaching 51.7 million by 2030.15 Diabetes is predicted to affect more than 16 percent of the adult population in Qatar and Kuwait, more than 17 percent in Bahrain and Saudi Arabia, and more than 19 percent in the UAE.16

RegionalRatesandTrendsAn analysis of prevalence and mortality data conducted by Booz Allen Hamilton found that in 2011, Saudi Arabia had the highest number of diabetes-related deaths and undiagnosed cases amongst GCC nations followed by the UAE, as illustrated in Figures 2 and 3. Thus, it may be useful to focus prevention efforts in these countries as well as others on the higher end of prevalence, such as Qatar and Kuwait.17

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15 International Diabetes Federation. IDF Diabetes Atlas, 4th Ed. Brussels, Belgium: International Diabetes Federation. 2009.16 Ajlouni K, Jaddou H, Batieha A. Diabetes and impaired glucose tolerance in Jordan: prevalence and associated risk factors. J Intern

Med, 1998;244(4):317-23.; Sadeghi M et al. Diabetes and associated cardiovascular risk factors in Iran: the Isfahan Healthy Heart Programme. Ann Acad Med Singapore, 2007;36(3):175-80; Hadaegh F et al. High prevalence of undiagnosed diabetes and abnormal glucose tolerance in the Iranian urban population: Tehran Lipid and Glucose Study. BMC Public Health, 2008;8:176.; and Amini M et al. Prevalence and risk factors of diabetes mellitus in the Isfahan city population (aged 40 or over) in 1993. Diabetes Res Clin Pract.1997;38(3):185-90.

17 Health Authority Abu Dhabi. Health Statistics 2010. International Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009.

18 Ibid.

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Figure 4 | Cooperative Diabetes Prevalence Among High-Income Group Countries19

Among high-income countries, those in the GCC rank the highest in terms of comparative diabetes prevalence, which reinforces the importance of preventive efforts in these countries, including the UAE and Qatar (see Figure 4).19

19 International Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009.

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Obesity, hypertension, and cardiovascular diseases are often comorbid to diabetes in that they are disorders that appear in addition to a primary disease—in this case with a causal relationship. Diabetics in the UAE, along with Qatar, have the highest prevalence of cardiovascular disease among the GCC nations, as illustrated in Figure 5.20

This is significant because comorbidities complicate treatment and contribute to mortality rates. Within the20 UAE, 31 percent of all deaths in 2005 were due to diabetes and cardiovascular disease.21 The risk of a heart attack is three times greater22 and the risk of a stroke is two to four times greater23 for all individuals with diabetes, leading to the sobering statistic that approximately 50 percent of diabetics eventually die from cardiovascular disease.24 However, studies have demonstrated that effective treatment can lead to over a 50-percent reduction in heart failure.2526

20 World Health Organization Statistical Information System. 2009.21 Fikri M. The Magnitude of Diabetes in UAE: National Diabetes Strategy and Achievements. MENA Diabetes Leadership Forum.

2010: 7. [online] Accessed at: <http://www.menadiabetesleadershipforum.com/presentations/MENA%20DLF%20-%20Day%201%20-%20Session%201%20-%20Understanding%20and%20confronting%20diabetes%20-%20Dr%20Mohmood%20Fikri.pdf>

22 NovoNordisk. MENA Diabetes Briefing Book. Pg. 16 Accessed at: <http://www.novonordisk.com/images/about_us/changing-diabetes/PDF/Leadership%20forum%20pdfs/MENA%20Forum/MENA_Diabetes_briefing_book_EN.pdf>

23 National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Accessed at: <http://diabetes.niddk.nih.gov/dm/pubs/statistics/>

24 Ibid.25 NovoNordisk. MENA Diabetes Briefing Book. Pg. 16 Accessed at: <http://www.novonordisk.com/images/about_us/changing-diabetes/

PDF/Leadership%20forum%20pdfs/MENA%20Forum/MENA_Diabetes_briefing_book_EN.pdf>26 World Health Organization Statistical Information System. 2009.

Notes: (A) Comorbidities are ranked in the order of impact on diabetes incidence.(B) Among 20+ age group population.(C) Among 25+ age group population.(D) Data is for high cholesterol level (one of the major risk factors leading to heart disease) among +25 age group population. (E) Reliable estimates, especially for the GCC countries, about some of the other key co-morbidities (CKD/ESRD, Neuropathy, Amputation, Retinopathy, etc.) are not available

Figure 5 | Prevalence of Comorbidities20, 26

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Diabetes in the UAE: Portrait of a Nation at RiskTo illustrate the scope of the problem, it is useful to look at the case of the UAE. Of MENA countries, the UAE has the highest diabetes prevalence rate—estimated by the IDF at 18.7 percent of the adult population.27 And by 2020, 32 percent of the adult UAE population (age 20–79) may have diabetes or pre-diabetes at a possible cost of $8.52 billion (AED 31.27 billion) if current trends continue.28 Nearly three-quarters of diabetes patients in the UAE do not have their diabetes under control,29 a challenge particularly pronounced among children and young adults.30 And, by 2030, the rate of diabetes-related deaths in the UAE will be 17.3 percent among men and a startling 31.6 percent among women.31

economiccostsAs illustrated in Figure 6 on the following page, the burden of diabetes is straining the UAE’s financial resources and incurring societal costs:

• Our analysis found that in 2011, the total cost of diabetes in the UAE (including health care costs and both mortality- and disability-related opportunity costs) was nearly $6.6 billion or 1.8 percent of GDP, higher than in any other GCC country.32

• Direct diabetes treatment constitutes approximately 40 percent of the nation’s overall health care expenditures.33

• The estimated annual costs attributed to diabetes in the UAE are forecast to increase to as much as $1.04 billion (AED 3.82 billion) by 2020, representing a 58-percent increase from an estimated $657 million (AED 2.41 billion) in 2010.34

The UAE’s per capita health care spending, ranked as second highest compared to the GCC region, is expected to grow at a compound annual growth rate of 5 percent by 2014.35 An increase in diabetes will potentially increase demand for highly specialized medical services. Today, the UAE government accounts for almost 70 percent of expenditures on health care services.36 Increased cost of diabetes in the UAE associated with demand for specialized services will increasingly and disproportionately impact the government’s healthcare expenditures.

27 International Diabetes Federation. IDF Diabetes Atlas, 4th Ed. Brussels, Belgium: International Diabetes Federation. 2009.28 UnitedHealth Group. Diabetes in the United Arab Emirates: Crisis or Opportunity? 2010.29 Health Statistics 2010, Health Authority Abu Dhabi.30 Health Authority Abu Dhabi. Health Statistics 2010.31 Epinex Diagnostics Inc. Diabetes in the Middle East. 2008. Accessed at: <http://epinex.com/pdf/Epinex_Diabetes_MidEast.pdf>.

[Accessed on September 18, 2012]32 Booz Allen Hamilton analysis of data from: Boston Analytics; International Monetary Fund World Outlook Database; International

Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009; World Bank Atlas; World Bank Databank, 2009.

33 Ibid.34 UnitedHealth Group. Diabetes in the United Arab Emirates: Crisis or Opportunity? 2010.35 World Health Organization Statistical Information System. 2009.36 The Economist Intelligence Unit. August 2011.

Unless we act now, one in three

adults in the UAE may have

diabetes or pre-diabetes by 2020.

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Figure 6 | Medical Cost of Diabetes in the UAE

Source: UnitedHealth Group Modeling, 2010

The majority of pre-diabetes cases and about37 35 percent of diabetes cases in the UAE remain undiagnosed, representing lost opportunities to minimize the costs and complications of a largely preventable disease.38 In addition, three-fourths of diagnosed diabetes patients do not have their diabetes under control, presumably due in part to a lack of regular diabetes tests (see Figure 7). The high level of undiagnosed and poorly controlled diabetes threatens to lead to an increase in related complications and to increased health care costs in the future.39

37 Health Statistics 2010, Health Authority Abu Dhabi.38 UnitedHealth Group. Diabetes in the United Arab

Emirates: Crisis or Opportunity? 2010.39 El-kebbi IM, Engelgau MM. The Burden of Diabetes

and its Complications in the Middle East and Eastern Mediterranean Region. Diabetes. 2008:121-131.

baselinediabeTesPRojecTion(adUlTPoPUlaTion20To79)YEAr 2010 2020 2011–2020

Type2Total Population (000) 3,563 4,320

Disease Cases (000) 288 440 3,665Disease Prevalence (%) 8.1% 10.2% 9.3%Medical Costs (US $ Millions) $353 (AED 1.30 billion) $563 (AED 2.07 billion) $4,607 (AED 16.92 billion)Medical Cost per Case (US $) $1,227 (AED 4507) $1,281 (AED 4705) $1,257 (AED 4617)Type1Total Population (000) 3,563 4,32Disease Cases (000) 29 44 366Disease Prevalence (%) 0.81% 1.02% 0.9%Medical Costs (US $ Millions) $54 (AED 198.3 million) $89 (AED 326.9 million) $714 (AED 2.62 billion)Medical Cost per Case (US $) $1,861 (AED 6835) $2,021 (AED 7423) $1,947 (AED 7151)UndiagnosedType2diabetesTotal Population (000) 3,563 4,320Disease Cases (000) 155 237 1,973Disease Prevalence (%) 4% 5% 5%Medical Costs (US $ Millions) $190 (AED 697.8

million)$303 (AED 1.11 billion) $2,481 (AED 9.11 billion)

Medical Cost per Case (US $) $1,227 (AED 4507) $1,281 (AED 4705) $1,257 (AED 4617)PrediabetesTotal Population (000) 3,563 4,320Disease Cases (000) 508 671 5,915Disease Prevalence (%) 14.3% 15.5% 14.9%Medical Costs (US $ Millions) $60 (AED 220.4 million) $84 (AED 308.5 million) $721 (AED 2.65 billion)Medical Cost per Case (US $) $118 (AED 433) $125 (AED 459) $122 (AED 448)Total Medical Cost (US $ Millions) $657 (AED 2.41 billion) $1,039 (AED 3.82 billion) $8,522 (UAE 31.30 billion)Cost per UAE Case (US $) $184 (AED 676) $241 (AED 8859) $215 (AED 790)

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Figure 7 | Diagnosed Patients with Diabetes in Abu Dhabi37

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RiskfactorsThe UAE ranks high on significant diabetes risk factors, including a shift to higher calorie diets and reduced physical activity, though it should be noted that these risks are moderate relative to other GCC countries.40 Approximately 36 percent of UAE nationals are obese, which is a major contributing factor to diabetes as well as to cardiovascular diseases. In addition, while globally 2 to 5 percent of women have gestational diabetes, the rates are much higher in the MENA region (e.g., 9.2 percent in UAE and 12.5 percent in Saudi Arabia). Ten percent of those women go on to develop type 2 diabetes within an average of six years.41 Further, hot temperatures, a sedentary lifestyle, and lack of exercise lead to reduced physical activity, which in turn leads to a higher risk of diabetes.

Additionally, there is some clinical evidence that peninsular Arabs and South Asians share a genetic tendency towards insulin resistance.42 A genetic impact on increased rates of insulin resistance has been theorized for populations around the world, including African-Americans,43 Native Australians,44 Pacific Islanders,45 and South Asians.46 This combination of insulin resistance with lifestyle factors may contribute to the significant number of individuals suffering from diabetes.

Diabetes Awareness and Attitudes in the UAE47 To better understand the attitudes and behaviors that contribute to this growing problem and to identify possible ways to mitigate risk factors and encourage healthy behaviors, Booz Allen Hamilton commissioned a study48 during the spring of 2012. The study involved a survey of 1,000 UAE nationals; 200 guest workers and expatriates; and 150 UAE professionals representing fields such as medicine, government, corporate human resources, and media (see Figure 8).

The findings indicate that large majorities of Emiratis recognize the potential impact diabetes would have on their lives, and understand that they and their peers are at substantial risk of developing the condition and its associated health problems. In fact, there is more concern among many Emiratis about diabetes than other conditions. However, awareness of diabetes risks appears to differ amongst social groups according to their relative levels of education

40 Booz Allen Hamilton analysis of data from: Boston Analytics; International Monetary Fund World Outlook Database; International Diabetes Federation. IDF Diabetes Atlas, 5th Ed. Brussels, Belgium: International Diabetes Federation. 2009; World Bank Atlas; World Bank Databank, 2009.

41 Epinex Diagnostics Inc. Diabetes in the Middle East. 2008. Accessed at: <http://epinex.com/pdf/Epinex_Diabetes_MidEast.pdf>. [Accessed on September 18, 2012]

42 UnitedHealth Group. Diabetes in the United Arab Emirates: Crisis or Opportunity? 2010.43 Reimann M, Schutte AE, Schwarz PE. Insulin resistance—the role of ethnicity: evidence from Caucasian and African cohorts. Horm

Metab Res. 2007: 39(12):853-7.44 Reaven GM. Insulin Resistance: The Metabolic Syndrome X. Humana Press. 1999: 25.45 Reaven GM. Insulin Resistance: The Metabolic Syndrome X. Humana Press. 1999: 19.46 Ibid.47 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 8.48 On behalf of Booz Allen Hamilton, Ipsos administered a general population survey to measure attitudes and awareness regarding

diabetes, behaviors, and attitudes regarding the risk factors for diabetes, and general medical behaviors. Because of restrictions on door-to-door interviewing, respondents were recruited through intercepts in public locations. In order to include those who rarely or never venture into public locations, some intercepted individuals were asked to refer someone to complete the survey, rather than to complete the survey themselves. The number of sampling locations in a district was proportionate to the district population. The target population for the main survey was Emiratis age 18 through age 39. Sample targets were set based upon the age and gender demographics of each of the seven Emirates.

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Figure 8 | Perception of the Relative Health Priority of Diabetes47

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and income. In addition, although information on diabetes is available via the media and trusted physicians, there appears to be a lack of understanding about adequate prevention measures. These findings point to key opportunities to launch efforts that use a mix of effective messengers to address misperceptions about effective diabetes prevention and control, and to enhance awareness of diabetes risks—particularly among lower income populations. Further studies may be required to better understand how to effectively reach these populations.

diabetesisaPublicHealthPriority49

Booz Allen Hamilton’s study reveals that health professionals, government officials, and media employees consider diabetes the single most important public health issue facing the UAE (see Figure 9).50 Other health concerns given high priority, including obesity, heart disease and hypertension, are part of the same constellation of health issues for which diet and exercise are strong behavioral contributors. We also found that large majorities of these social groups are favorable toward public health policy interventions that have been tested to prevent diabetes, such as requiring employers to provide exercise facilities to workers, a ban on trans fats in food served in restaurants, and higher taxes on sugary drinks and junk food.51 Taken together, these data imply potential support among these social groups for the implementation of education and policy efforts designed to prevent diabetes and its complications.

PersonalconcernaboutdiabetesisWidespreadAlmost 9 in 10 (89 percent) Emiratis who participated in our study say that they were very (56 percent) or somewhat (33 percent) familiar with diabetes. But, those with less education (less than secondary education) may not be as aware about diabetes and effective preventative methods to avoid the disease.52 Emiratis are more likely to mention diabetes as the medical condition that con-cerns them more than any other condition, followed by obesity (16 percent) and hypertension (13 percent). Concern is higher among men than among women and among the obese than among those of normal weight. More Emiratis are concerned about the potential impact of diabetes on maintaining their lifestyle than about any other condition.53 These data suggest that an area of opportu-nity to raise awareness and target interventions might include a special focus on raising awareness among less educated, lower income, or female Emiratis—especially in light of the increased risk following gestational diabetes.

49 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 9.50 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 8.51 Ibid.52 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 10.53 Ibid.

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Figure 9 | Diabetes as Personal Concern49

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comprehensivePreventionisnotWellUnderstoodA comprehensive strategy to prevent diabetes requires both exercise and a healthy diet, but many Emiratis may think that one or the other may be sufficient. Although 48 percent of Emiratis have exercised to lose weight and 36 percent have changed their eating habits to do so, only 26 percent have done both (see Figure 10). More than half (52 percent) of all Emiratis age 18–39 want to exercise more or begin exercising, and 51 percent say they want to eat more nutritious meals, but only 31 percent identify both of these activities as health goals.54 Thus, interventions must raise awareness of the necessity to prevent/control diabetes through both healthy eating and physical activity, while policies must make healthy foods and opportunities to exercise both accessible and convenient.55

informationcomesPrimarilyviamediawhilePhysiciansareHighlyTrustedsourcesAmong those who have heard information or news about diabetes, the media is a primary source; 64 percent did so via television and 48 percent via newspapers, as illustrated in Figure 11. Physicians, however, are the most trusted source of information about diabetes. In fact, most Emiratis think regular check-ups are important and have visited the doctor recently, and slightly more than 4 in 10 (42 percent) Emiratis have heard information or news about diabetes from their doctors. Only 5 percent have heard about diabetes from government websites and 3 percent from government officials.56 Thesefindingspointtotremendousopportunitytoraiseawarenessofdiabetespreventionandcontrolstrategiesby:developingpublic-privatepartnershipsthatleveragemediainterest;employingamixoftraditionalandnontraditionalmessagechannels;andengagingphysiciansto

deliverimportantinformation.

54 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 1455 Ibid.56 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 29.

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Figure 11 | Sources of Information of News about Diabetes57

Taking Prevention to the Next Level57

These findings, along with the epidemiologic data, point to an imperative to broaden the reach of diabetes prevention efforts within the UAE. We found that in 2011, there were numerous diabetes-related initiatives underway, most with a focus on disease prevention and management, as described below. Yet while a 5-percent decline in the diabetes prevalence rate in the UAE from 2003–201158 may indicate the initial success of programs like these, we see awareness lagging among some subgroups, such as less educated Emiratis, and the potential for prevalence rates to skyrocket. It is time to redouble our efforts by examining the most promising practices and engaging across sectors to expand the impact of diabetes prevention, detection, treatment, and care in the UAE.

57 Booz Allen Hamilton and Ipsos. Diabetes-Related Behaviors and Attitudes in the United Arab Emirates. June 2012: 29.58 International Diabetes Federation. IDF Diabetes Atlas, 2nd Ed. Brussels, Belgium: International Diabetes Federation. 2003.

Based on the data, GCC countries should consider focusing on a range of preventive and mediating actions:

• Education about diabetes and its risk factors, particularly among less educated Emiratis.

• Early detection through screening as part of routine physician checkups.

• Lifestyle modifications that encompass both improved nutrition and increased physical activity.

• Disease management to avoid future complications from the disease.

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UaediabeTesRelaTediniTiaTives,2011(illUsTRaTive)

The Ministry of Health’s nationalstrategyforcontrolofdiabetesfocuses on primary and secondary prevention of type 2 diabetes, improving and promoting the quality of care, monitoring and evaluating diabetes, promoting research and empowering patients. It comprises multiple initiatives to reach health care professionals, the general public, and children.59

diabetesKnowledgeaction, from the Imperial College London Diabetes Centre and The Emirates Foundation for Philanthropy, is focused on imparting knowledge on diabetes prevention to the general public and school children, parents, and teachers.60

decidediabetes, from Servier, Nestlé Health Science, MPC, Merck Serono, Medtronic, LifeScan, Bristol-Myers Squibb, and AstraZeneca, educates and provides support and the relevant products to help patients and health care professionals diagnose, treat, and manage the symptoms of diabetes.61

i–actProgram, sponsored by Metlife Alico and Lifescan (a Johnson & Johnson company), is designed to help thousands of MetLife Alico medical cardholders and their dependents with diabetes in the UAE control their condition.62

The Roche Diagnostics accu-chekdiabeteseducationProgram is designed to improve the management of diabetes via four therapy modules, lifestyle guides, nurse training, and support groups.63

Medcare Hospital in Dubai’s diabetesawarenessWorkshop aimed to increase diabetes prevention awareness among mothers and young women through a partnership with Shape Xpress, a fitness center designed exclusively for women.64

jointhemovement, a campaign of the UAE Ministry of Health and the Emirates Diabetes Society, aims to raise awareness of the causes of obesity through a series of outdoor exercise events, free body mass index testing, blood sugar testing, blood pressure testing, and lectures.65

Many of these programs have the potential to scale up their work and impact more beneficiaries. This is important in order to continue reducing the prevalence rate in the UAE. For example, one methodology created community-based programs that enlisted local pharmacists to help patients take medication on time, make routine visits to patients for preventive care, and guide healthy eating and activity goals through private, face-to-face coaching. In the more than 10 communities utilizing this approach, it was found that the intervention resulted in 50 percent of patients showing signs of decreased glucose levels on each follow-up visit.66 Now is the time to explore strategies to leverage the UAE’s initial success in raising awareness and to scale-up impact to prevent the potential enormous impact and cost of diabetes.

59 Fikri M. The Magnitude of Diabetes in UAE: National Diabetes Strategy and Achievements. MENA Diabetes Leadership Forum. 2010: 40. Accessed at: <http://www.menadiabetesleadershipforum.com/presentations/MENA%20DLF%20-%20Day%201%20-%20Session%201%20-%20Understanding%20and%20confronting%20diabetes%20-%20Dr%20Mohmood%20Fikri.pdf>

60 Imperial College London Diabetes Centre and Mubadala Healthcare. About ‘Diabetes-Knowledge-Action’. Diabetes-Knowledge Action. 2011. Accessed at: <http://www.diabetesuae.ae/about-%E2%80%98diabetes-knowledge-action%E2%80%99>

61 Decide™ Diabetes Initiative brings together healthcare companies for the first concrete and collective effort to alleviate diabetes explosion in the UAE. MENA Business News Network. September 27, 2011. Accessed at: <http://www.menann.com/article/decide%E2%84%A2-diabetes-initiative-brings-together-healthcare-companies-first-concrete-and>

62 MetLife Alico UAE. What is i-Act? i-Act, Managing Diabetes One Step at a Time. 2010. Accessed at: <http://www.metlifealico.ae/en/Business/Support-Centre/i-Act.html>

63 Roche LTD. The Arabic Accu-Chek Diabetes Education Program. Accu-Chek Patient Education. 2009. Accessed at: <https://www.accu-chekarabia.com/arabic/en_SA/professionals/diabeteseducation.html>

64 AME Info. MedCare, Shape Xpress join fight against diabetes. 2007. Accessed at: <http://www.ameinfo.com/140324.html>65 Arabian Business. New campaign to tackle obesity. 2008. Accessed at:

<http://www.arabianbusiness.com/new-campaign-tackle-obesity-192837.html>66 Sources include the International Diabetes Foundation; World Health Organization; Agency for Healthcare and Research quality;

and Colaquiri S. Walker AE. Using an economic model of diabetes to evaluate prevention and care strategies in Australia. Inst of Obesity, Nutn, and Ex. 2008 Jan-Feb;27(1):256-68.

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Exploring Solutions: The Dynamic Tensions Between Diabetes and the Long-Term Economic Competitiveness of the GCCThroughout the GCC region and the UAE in particular, the government, civil society, and private sectors are struggling with diabetes’ enormous economic costs, which amount to $6.6 billion each year, or 1.8 percent of the country’s GDP—more than any other country in the GCC.67 This number is anticipated to grow as the disease’s prevalence rate continues to rise throughout the region. Such staggering costs can stymie the progress of economic gains, preventing the country from attaining all it otherwise would have been capable of. To maintain the country’s economic competitiveness, thought leaders serving at the forefront of the diabetes challenge must come together to explore effective solutions to the ongoing crisis.

Booz Allen Hamilton is hosting a series of dynamic events for key decision makers in the government, civil society, and private sectors in the GCC to explore solutions to the critical issues surrounding the intersection of public health challenges and economic competitiveness. Booz Allen Hamilton’s work in addressing the growing epidemic of Alzheimer’s disease in the United States and reducing the prevalence of HIV/AIDS in India, China, and Nigeria has demonstrated the necessity of dialogue between different stakeholders to identify solutions for multifaceted public health issues. These forums will be held throughout the GCC to foster open dialogue around regionally appropriate, innovative best practices for addressing public health issues and their economic impacts.

The first in the series, “Diabetes and Workplace Well-Being Solutions,” will convene UAE’s top business leaders to discuss and develop a common viewpoint on their mutual challenges. They will then develop and test action plans for solving the diabetes crisis through a uniquely designed simulation exercise. Simulation exercises can help participants explore creative ideas and identify effective, viable solutions to realistic scenarios. They are a powerful tool for thinking about the future in ways that challenges conventional wisdom, allowing participants to break with “known truths” and personal assumptions. The simulation is designed to help participants identify the best plans for maintaining economic competitiveness via reducing the growing impact of diabetes on their industry.

The end result of this event will be empowerment of industry leaders to actualize the plans they developed during the sessions. Through Booz Allen Hamilton’s facilitation and the ingenuity and efforts of Emirati citizens, countries will guarantee their future progress by building resiliency against diabetes. Such work aligns with national and Emirate strategic priorities, including the UAE’s 2011–2013 national strategy to create a competitive knowledge economy by enhancing the capabilities, efficiency, and productivity of the Emirati workforce68 and the Abu Dhabi Emirate’s “Vision 2030” priority to support the distribution of economic development’s benefits to the entire population of the Emirate.69

“Stakeholders are brought together based

on their overlapping vital interests, and

they can pursue those interests, to their

benefit, without worrying about giving

up their identities or betraying their core

constituencies.”

— Reggie Van Lee, Executive Vice President, Booz Allen Hamilton; Co-Author of "Megacommunities: How Leaders of Government, Business and Non-Profits Can Tackle Today's Global Challenges Together", www.megacommunities.com

67 Signature Healthcare. Changing Diabetes Day Addresses Community Health Need. 2012. Accessed at: <http://www.signature-healthcare.org/Main/News/Changing_Diabetes_Day_Addresses_Community_Health_N_74.aspx>

68 Highlights of the UAE Government Strategy 2011-2013: Putting Citizens First.69 The Abu Dhabi Economic Vision 2030. “Section One: Abu Dhabi’s Economic Policy Priorities.”

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Past ExperiencesLeaders of many organizations must work together toward common goals, without any one of them being in control of the whole system. The key is a shift in focus from maximizing to optimizing. Booz Allen Hamilton has used strategic simulation to help find solutions to several other complex health problems such as Alzheimer’s disease, the HIV/AIDS challenge, and pandemic influenza.

alzheimer’sdiseaseBooz Allen Hamilton engaged nearly 80 leaders from the public, private, and civil sectors in a simulation to explore how to address the challenges associated with Alzheimer’s disease. The firm developed and conducted this strategic event with the following objective: to explore how collaboration across sectors can enhance prevention, detection, treatment, and care to mitigate the impact of Alzheimer’s disease on patients, caregivers, and society. Outcomes focused on understanding priorities and concerns of the stakeholders, identifying integrated priorities across all sectors, and defining a process for how the network of stakeholders should move forward. As a result, a core set of participants established Leaders Engaged on Alzheimer’s Disease (LEAD), a coalition of more than 40 organizations dedicated to working together to leverage resources to fight Alzheimer’s disease. Through the culmination of diverse stakeholder perspectives and ideas, four common themes quickly emerged that touched on all aspects of Alzheimer’s disease: (1) Recognizing the Epidemic; (2) Empowering the Patient and the Caregiver; (3) Transforming the Care Model; and (4) Accelerating Discovery. These shared issues led to the development of a national strategic plan that was adopted by the US Congress in 2009. Today, more than 30 members continue to collaborate on efforts to coordinate research, identify obstacles, and raise awareness about the disease. LEAD’s successes include the 2009 Rock Stars of Science briefing in collaboration with cancer and HIV/AIDS advocacy groups that was attended by more than 300 Capitol Hill staffers, members of Congress, policy makers, and advocates.

PandemicinfluenzaIn January 2006, Booz Allen Hamilton successfully conducted a pandemic influenza simulation at the World Economic Forum introducing senior public and private sector leaders to the devastating human health, societal, and economic potential of an influenza pandemic. Following this major event, and continued engagement with the United Nations System Coordinator for Pandemic Influenza, Booz Allen Hamilton developed a customizable Pandemic Influenza Simulation for use with individual organizations and associations to assist their personnel or members in better understanding the complexities and impacts of a pandemic across a broad spectrum of issues, from workplace absenteeism to hospital overcrowding and supply chain disruptions.

Hiv/aidsIn March 2005, Chinese and international business leaders, government officials, and representatives from non-governmental organizations and international donor groups gathered in Beijing, China for the People’s Republic of China Ministry of Health—Global Business Coalition on HIV/AIDS Joint Summit on Business

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and AIDS in China. At the summit, Booz Allen Hamilton introduced and led the Business and AIDS in China: A Strategic Planning Exercise to launch an Action Plan for Business on HIV/AIDS in China. Booz Allen Hamilton developed the draft action plan in advance of the summit to serve as a framework for participants in creating HIV/AIDS programs for the private sector. The exercise encouraged participants to think creatively, collaborate with other sectors, and commit to launching HIV/AIDS policies and programs. Using a carefully crafted discussion agenda, facilitators led teams to identify insights into how businesses using their core competencies could help the Chinese government achieve its objectives for fighting HIV/AIDS. Following the joint summit, Booz Allen Hamilton analyzed team discussion input to update the action plan, which was officially presented to the Ministry of Health in spring 2005. In addition, 26 companies committed to launching HIV/AIDS programs in their Chinese operations as a result of the summit. The Global Business Coalition continues to use the action plan to motivate and guide multi-sectoral collaboration in the development and implementation of private sector HIV/AIDS policies and programs in China.

“The strategic convening on HIV/

AIDS exceeded all our expectations…

[and] resulted in some very innovative

partnerships. I was deeply impressed by the

energy and commitment of the participants,

who came from four continents and

included people from China. The outcome

was the commitment to try to collaborate in

innovative ways, building on the expertise

of each sector. This sort of creative thinking

could pave the way for genuine progress in

reversing this terrible epidemic”

— Richard C. Holbrooke, 2005, former US ambassador to the United Nations

www.boozallen.com/international ©2012 Booz Allen Hamilton Inc.

10.138.12

To learn more about the firm and to download digital versions of this article and other Booz Allen Hamilton publications, visit www.boozallen.com.

Booz Allen Hamilton has been at the forefront of strategy and technology consulting for nearly a century. Today, the firm provides services to US and international governments in defense, intelligence, and civil sectors, and to major corporations, institutions, and not-for-profit organizations. Booz Allen Hamilton offers clients deep functional knowledge spanning strategy and organization, engineering and operations, technology, and analytics—which it combines with specialized expertise in clients’ mission and domain areas to help solve their toughest problems.

Booz Allen Hamilton is headquartered in McLean, Virginia, employs approximately 25,000 people, and had revenue of $5.86 billion for the 12 months ended March 31, 2012. To learn more, visit www.boozallen.com. (NYSE: BAH)

Grant McLaughlin Vice President mclaughlin_grant@bah.com +1-703-917-2055

Jason Kemp Senior Associate kemp_jason@bah.com +1-703-377-7128

Katherine Stoltz Lead Associate stoltz_katherine@bah.com +971-2-691-3600

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