Retrospective #254: Saudi Approach to Diabetes

At a 2014 European Association for the Study of Diabetes (EASD) meeting, Anne Peters, MD, for Medscape Medical News, interviewed Saudi MD and diabetologist Aus Alzaid. Dr. Peters asked, “…knowing the epidemic of diabetes that you are having in Saudi Arabia, can you tell us what diabetes care is like there?” Dr. Alzaid replied, citing International Diabetes Federation figures, “Saudi Arabia has the highest rate of diabetes in the world after the small island nations in the Pacific.” Citing previous studies, he said, 1 in 4 people after the age of 30 has diabetes.”

Dr. Alzaid explained: “That part of the Middle East is steeped in history and tradition and culture, which means a lot to people. Then we have diabetes as a condition, which has to do with a person’s perception of lifestyle modifications that must be made.” “I don’t know of any Saudi family that doesn’t have a member or two with diabetes.”

Dr. Peters replied by relating how she “work(s) with the Latino population in East Los Angeles where everybody just shrugs and says, ‘Everyone in my family has diabetes, so of course I have it too.’” They make a good point. Resistance to change is strong, and fatalism commonly prevails. But would that be so if there were a “treatment” that worked?

Dr. Peters: “Most healthy 30-year-olds don’t go to the doctor. Are you making a push to convince young, healthy people to be checked earlier?”

Dr. Alzaid: “Absolutely, and there are messages going out about lifestyle modification. In our institution, we have Diabetes Awareness Day in November. [Whoopee!] It is still an overwhelming issue, and we are doing research to find out why we have such a high rate of diabetes.” [They don’t know?! That’s money well spent…if it’s good research.]

Dr. Peters: “Have diet and rates of physical activity changed? What have you seen over the course of your career?”

Dr. Alzaid: “Decades ago, people were more mobile. Very little food was available in years gone by, but over recent decades, with the dividends of good fortune [oil revenue], there has been a ‘constant feast.’”

Okay, the well-meaning Dr. Peters has turned the conversation to “diet and exercise,” the Western meme that we are eating too much and exercising too little. Well, at least the conversation has begun to turn. Let’s see where it goes.

Dr. Alzaid continued: “There are cultural things that we adhere to as part of our social etiquette. Food items such as rice and dates are very popular in our part of the world, and they are obviously very heavy in terms of calories. Fizzy drinks are commonly consumed.” That’s it, folks. That’s the good Saudi doctor’s understanding of nutrition, as captured in this interview. It’s all about calories-in/calories-out. True, there was no mention of “eating fat making you fat,” or anything about dietary cholesterol. But neither was there so much as a word about CARBS, just calories.

Newsflash, Dr. Alzaid: Dates and rice and fizzy [sugary] drinks are ALL CARBOHYDRATES! Sugar and starch! 4 Medjool dates, about 100 grams of pitted dates, are 277 calories, of which 266 (96%) are sugar. 100 grams of medium grain white rice, about 3.5 ounces, is 130 calories, of which 116 are carbohydrates. I don’t know what kind of “fizzy drinks” Saudis use to quaff their thirst, but I’ll assume (generously) it’s Coca Cola. A 12-ounce (370g) cola is 152 calories.

So, I think that Dr. Alzaid has identified the problem with the Saudi diet; he just hasn’t named it. The “constant feast” he refers to is a carbohydrate feast, not a calorie feast. The fact that Dr. Alzaid describes “rice and dates” (part of the Saudi social etiquette) as “obviously very heavy in terms of calories” implies to me that it is his understanding it is the calorie content of these foods, not the carbohydrate content, that is the cause of the Saudi diabetes epidemic. But what is there to do about it? It’s a cultural thing, and “that part of the Middle East is steeped in history and tradition and culture, which means a lot to people.” To which Dr. Peters replies, empathetically, ‘Everyone…has diabetes, so of course I have it too.’ Fatalism. And, for both doctors, treatment means prescribing drugs to control high blood sugars.

And the Saudi Ministry of Health has launched a public-awareness campaign “to tackle the problem with the right lifestyle.” The right lifestyle? To both doctors, that means, “diet and exercise.” Eat less of the same carbohydrate-dominated diet and move more? THAT IS A LIFESTYLE CHANGE THAT IS GUARANTEED TO FAIL. Type 2 diabetics are CARBOHYDRATE INTOLERANT, by definition. The best treatment for Type 2 diabetes is a very low carbohydrate diet.