World diabetes day: celebrating two decades of Progress in combating diabetes and its complications in Iran

Every year World Diabetes Day (WDD) is celebrated on 14 November all across the globe to raise awareness about the diabetes and its prevention, complications, and treatment. November 14th is chosen as the WWD because it is the birthday of Frederick Banting who discovered insulin in collaboration with his colleague Charles Best in 1922. It should be noted that since discovery of insulin, management of diabetes and its complications has been revolutionized. World Diabetes Day was first launched in 1991 by the IDF (International Diabetes Federation) and the World Health Organization (WHO) in response to the rapid rise of diabetes around the world.

For 2019 World Diabetes Day, the theme of “DIABETES: PROTECT YOUR FAMILY” has been chosen for a second consecutive year to highlight the supportive role family can play in the management of patients with diabetes.

Diabetes which is a major non-communicable disease (NCD) consists the seventh cause of mortality in the world; and, in high and middle income countries and constitutes the sixth leading cause of NCD-related death [1]. NCDs are responsible for 71% of all global mortality, and more than 85% of them occur in low- and middle-income countries [1]. In 2017, the number of patients with diabetes was estimated to be 425 million, and this number is predicted to rise to 629 million in 2045 [2].

The recent sharp increase in the prevalence of NCDs can be attributed to different factors such as accelerated urbanization, unhealthy lifestyle (poor diet and low physical activity), and ageing populations [3]. Moreover, a number of metabolic risk factors such as increased blood pressure, hyperglycemia, increased blood lipids levels, and obesity lead to metabolic changes that increase the risk of NCDs and diabetes [3]. Unhealthy behaviors like physical inactivity, unhealthy diet and tobacco and alcohol use which increase the risk of NCDs are modifiable [1].

In Iran, NCDs are responsible for 79.2% of general mortality and 74% of burden of diseases [4]. In 2017, the prevalence of type 2 diabetes in Iran was 9.6%, and there existed approximately five million adults with diabetes living in the country [2]. Iran is one of the countries with high number of adults with diabetes in the region and current number of petients is predicted to double by 2045 [2].

Considering the increased rate of NCDs in the world and the high health and economic burden they impose, the WHO to control NCDs, proposed 9 global targets for NCDs to be achieve by all nations by 2025 against the figures in baseline in 2010 [5]. According WHO plan, and considering the fact that the prevalence of NCDs is considerably high in the country, Iran committed to achieve NCDs goals by 2025. To facilitate this, a national NCD committee was established at the Ministry of Health in Iran, and the “National Action Plan for Prevention and Control of NCDs and the Related Risk Factors” was officially launched in 2014 [6].

With the view of fulfilment of WHO global mandate, Iranian NCDs committee established 13 targets to be achieved in Iran by 2025. Amongst these targets, 7 are the same as WHO targets, 2 are modified WHO targets, and 4 are Iran-specific targets [6]. In regards with diabetes, the WHO and Iranian targets are identical and aim to halt increasing rate of obesity and diabetes by 2025 to the same figures recorded in 2010 [6].

To fulfil national NCDs goals which are designed and developed based on the WHO global mandates, Endocrinology and Metabolism Research Institute (EMRI) developed several national NCD projects in collaboration with the Ministry of Health and Medical Education. One of these projects includes the national STEPs project which has recruited a huge sample size of 30,541 adults above 18 years. This national project is designed for the purpose of monitoring and management of NCD risk factors in the country [7]. In fact, STEPS is an ongoing project which aimed to identify and monitor NCD risk factors and investigate their adverse health outcomes in both urban and rural areas as well as in provincial levels [7].

In order to form a synchronized approach to management of diabetes as a major NCD, a diabetes working group was formed under supervision of NCDs committee and Iranian National Service Framework for Diabetes was provided with the main objective of efficient implementation of diabetes control policies in the country. This document is consisted of 6 main goals for prevention and control of diabetes.

These goals include control of the rising rate of diabetes and its risk factors, increasing coverage of health insurance, improving the quality of care offered to patients with diabetes, encouraging diabetic patients for regular periodic clinical examinations, maximizing the number of diabetic patients registered in National Diabetes Register System, and full insurance coverage of drugs, devices and instruments required by patients with diabetes [8].

In 2017, a Diabetes Registry program was launched by the EMR according the goal of National Service Framework for Diabetes. This registry was formed with the primary objective of facilitation of the monitoring and management of diabetes and its complications rate in the country and also to facilitate achievement of WHO global targets.

Moreover, following lunching and extending diabetes registry program, specialty Diabetes Clinics were founded and expanded in local medical universities all across the country. These nationwide clinics were founded to facilitate the access to diabetic patients, to improve coverage of cutting-edge diabetes services and to improve the quality of diabetes care in the country (as a requirement of the National Service Framework for Diabetes). Furthermore, these clinics will assist us to expand our diabetes registry in different remote and regional parts of the country. These measures are forecast to revolutionize diabetes care in Iran to an unprecedented scale and lead to huge health outcomes in the country.

In addition to the endeavors of the Ministry of Health and Medical Education, reducing the burden of NCDs and diabetes requires a multidisciplinary approach and proactive involvement of several governmental bodies and NGOs. One example of such multidisciplinary approach is newly-launched Bidood project launched by the municipality of Tehran. This recently-launched project aims at promotion of bicycle use by the citizens (mainly in young and middle-aged male citizens), thereby increasing the level of physical activity and controlling obesity and hypertension which are considered major risk factors of development of NCDs. Such multisectoral and comprehensive strategies and approaches can lead to remarkable achievements and greatly facilitate achievement of WHO goals in the country.

According to the findings of our recent study in Iran, it is predicted that the number of death due to NCDs (including cancers, cardiovascular diseases, asthma and COPD) will reduce in both sexes by 2030, while the diabetes mortality rate will remain unchanged in both genders (from 16.6 in 2015 to 16.5 in 2030)) during the same time [9]. Such predictions imply that achievement of the NCD commitments of the Iranian government and WHO goals about diabetes is not far away.

In 2002, with the primary objective of establishment of a comprehensive network for prevention and management of diabetes and its complications (and data collection for research purposes) all across the country, EMRI established National Diabetes Research Network to facilitate collaboration amongst members from different regions of the country.

Through collaborative work of the National Diabetes Research Network, EMRI has published several diabetes guidelines for professionals and developed a great number of educational materials for the public and patients with diabetes [10]. The educational and awareness raising publication of EMRI aim at educating patients with diabetes and enhancing public awareness about different aspects of diabetes, its complications, and treatment. It should be noted that these diabetes guidelines and educational material are updated on a regular basis every few years.

With the main objective of coordination of diabetes research and avoiding potential duplications, the first Diabetes roadmap was developed by the EMRI in 2016. This comprehensive illustration of research activities in the field of diabetes in Iran can be of great assistance to scientists for identification of research gaps and addressing them in a nationally-synchronized manner. This roadmap which will define future research directions in the field will be regularly updated, the first update being currently undertaken [11–14].

In conclusion, diabetes is a complicated disease which imposes great health and financial burdens on societies. Considering its multifactorial etiology and the dimension and variety of its consequence, it is imperative that a synchronized and multifaceted approach should be adopted against diabetes and its contributing factors. Currently, in addition to conventional and new drugs and medications, promising new horizons have been opened in diabetology [15], including personalized/precision medicine and stem cell transplantation/cell therapy technology which needs further research to be completely applicable in management of diabetes. We sincerely hope that our endeavors will lead to improvement of diabetes care in both national and global dimensions.