Type 2 diabetes: diagnosis, treatment and living well in the Middle East

Why is type 2 diabetes a particular problem in this region?

The Middle East and North Africa carries one of the heaviest burdens of type 2 diabetes in the world. A study published in the Saudi Medical Journal in 2021 found that Gulf Cooperation Council countries have prevalence rates exceeding 17 percent of adults in some countries, and that the trend continues upward. The International Diabetes Federation's data consistently rank this region among the highest globally.

The reasons are a combination of rapid dietary transition from traditional foods to processed ones high in sugar and refined carbohydrates, rising rates of overweight and obesity, reduced physical activity driven by urban lifestyles and heat, and genetic factors that increase susceptibility in certain populations. These pressures converged quickly in a region that urbanised and oil-wealth-industrialised faster than its health systems could adapt.

A substantial proportion of people with type 2 diabetes in the region remain undiagnosed. The IDF Atlas estimates that roughly half of those affected in the Middle East are unaware of their condition, a higher undiagnosed fraction than the global average. This is partly because the disease can run silently for years, damaging blood vessels without producing symptoms obvious enough to prompt a clinic visit.

How is type 2 diabetes diagnosed?

Diagnosis requires confirmation, not a single high reading. The accepted criteria include a fasting blood glucose of 126 mg/dL or above on two separate occasions, a random blood glucose of 200 mg/dL or above when classic symptoms such as excessive thirst, frequent urination, and unexplained fatigue are present, or an HbA1c of 6.5 percent or above confirmed on repeat testing.

Prediabetes is the stage before full diabetes, when blood glucose is above normal but has not yet reached the diagnostic threshold. A fasting glucose between 100 and 125 mg/dL, or an HbA1c between 5.7 and 6.4 percent, points to this stage. Prediabetes is not inevitable as a path to diabetes. Lifestyle change at this stage, particularly weight loss of 5 to 7 percent and regular physical activity, can prevent or significantly delay progression, as multiple trials have confirmed.

Risk factors that justify regular screening even in the absence of symptoms include overweight or obesity, age above 45, a family history of type 2 diabetes, a history of gestational diabetes, hypertension, raised cholesterol, and physical inactivity. If several of these apply to you, ask your doctor how often you should be tested. In the Middle East context, a first-degree family history of type 2 diabetes is extremely common and is itself a significant risk factor.

What is HbA1c and why does it matter more than a fasting glucose?

HbA1c, or glycated haemoglobin, measures the average blood glucose level over the preceding three months. It reflects the proportion of haemoglobin that has had glucose attached to it, and because red blood cells survive for about three months, the result is a rolling average rather than a snapshot of one moment. This makes it much more useful for judging whether someone's diabetes is well managed than a single fasting glucose.

The target for most people with type 2 diabetes without major complicating illnesses is below 7 percent. This target is adjusted for the individual. An older patient with established heart disease or significant kidney disease may have a less strict target, such as below 8 percent, to reduce the risk of hypoglycaemia. A younger patient planning pregnancy or with few complications may aim for below 6.5 percent. Your doctor sets this target for your situation.

A review published in Diabetes Therapy in 2022 on diabetes and hypertension management in Gulf countries found that a substantial proportion of patients in the region do not reach their HbA1c targets, and identified gaps between guideline recommendations and real-world practice. Understanding why your HbA1c is the number it is, and what changes in diet, activity, or medicines could move it, is the conversation to have at every follow-up appointment.

Medicines for type 2 diabetes

Metformin is the first medicine usually prescribed for type 2 diabetes, because it is effective, safe, weight-neutral, and has decades of evidence behind it. It reduces the liver's overproduction of glucose and improves insulin sensitivity. The most common side effects are digestive, particularly nausea and diarrhoea in the early weeks, and these improve greatly if it is taken with food. Metformin is inexpensive and widely available across the region.

When metformin alone does not reach the target HbA1c, or as initial treatment when blood glucose is very high, a second medicine is added. Options include sulfonylureas, SGLT-2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and others. Each class has different advantages and side effect profiles, different effects on weight and on heart and kidney protection. The choice is personalised to the patient's other health conditions, weight, cost considerations, and how the medication is available locally.

Insulin is not a last resort or a punishment. It is the appropriate treatment in certain situations, including very high initial blood glucose, pregnancy, and progressive beta cell failure as diabetes advances over years. Many people with long-standing type 2 diabetes eventually need insulin. Learning to inject insulin, monitor blood glucose, and adjust doses under guidance is manageable with proper training, and is safer than staying on an inadequate oral regimen when the disease requires more.

Food and activity: the most powerful tools

Medicines manage diabetes but food and physical activity are the foundation. A paper published in Frontiers in Nutrition in 2022 developed a transcultural dietary algorithm specifically adapted for Middle Eastern eating patterns, recognising that standard Western dietary recommendations do not translate directly to the regional context of rice-based meals, communal eating, heavy starch portions, and the social role of food at gatherings.

The guiding principle is not deprivation but portion management and better choices. Reducing added sugar and sugary drinks, cutting large portions of white rice and white bread, eating more vegetables and legumes, and spreading meals across three regular portions rather than one large evening meal all improve blood glucose control. Stewed dishes, vegetable soups, and olive oil based preparations align well with both regional food culture and diabetes management. Dates eaten in moderation with balanced meals are manageable for most patients, but portion size matters because they are concentrated in sugar.

Physical activity improves insulin sensitivity directly and helps lower blood glucose. Thirty minutes of brisk walking most days of the week is a realistic and evidence-supported target. In the extreme heat of regional summers, morning or evening walks, indoor walking in shopping centres or air-conditioned spaces, and swimming where accessible are all practical options. Consistency matters more than intensity, and any movement is better than none.

Complications: early detection protects you

Diabetes complications accumulate silently over years of inadequate blood glucose control. Recognising them early and attending routine screening appointments is the most effective protection. Complications are divided into microvascular, affecting the kidneys, eyes, and nerves, and macrovascular, affecting the heart and large blood vessels.

Diabetic retinopathy affects the small blood vessels of the retina. A systematic review published in Ophthalmology in 2021 projected that the global burden of retinopathy will continue to rise alongside diabetes prevalence, with the Middle East among the regions of concern. An annual eye examination by a trained professional is needed to detect changes before they affect vision. Diabetic kidney disease develops gradually and can progress to kidney failure if it is not caught. Annual urine testing for microalbumin and measurement of eGFR are essential for every person with diabetes.

Diabetic neuropathy, particularly in the feet, causes numbness, tingling, or loss of sensation. This is what makes the diabetic foot one of the most serious regional complications, with amputation rates that are high across the Middle East. Annual foot examination in a diabetes clinic, daily self-inspection at home, and appropriate footwear are all part of prevention. Cardiovascular disease is the leading cause of death in people with diabetes, and managing blood pressure and cholesterol alongside blood glucose is not optional.

Diabetes and Ramadan: plan ahead with your doctor

Ramadan presents a unique challenge for people with type 2 diabetes in this region. The shift from three meals spread across the day to two meals at iftar and suhoor, the nature and timing of those meals, and the long fasting hours all require specific medicine adjustments. A systematic review published in Frontiers in Nutrition in 2022 found that patients on insulin require careful dose and timing adjustment to prevent both hypoglycaemia during fasting hours and post-iftar glucose spikes.

The most important step is seeing your doctor several weeks before Ramadan begins, not the day before. The doctor needs to assess whether fasting is medically safe for you given your current control and medications, and then adjust the treatment plan accordingly. People on sulfonylureas or insulin carry a real risk of hypoglycaemia during long fasting hours and usually need dose reductions or timing changes.

Home blood glucose monitoring becomes even more important during Ramadan. Signs of hypoglycaemia, including dizziness, shakiness, sweating, and confusion, mean breaking the fast immediately. Islamic jurisprudence is clear that breaking a fast for a genuine medical necessity is permitted, and continuing to fast through dangerous hypoglycaemia is not required. Pre-planning with your doctor is what makes safe fasting possible for most people with well-controlled type 2 diabetes.

Regional realities and living well with diabetes

People with diabetes in parts of the region face challenges that go beyond what standard diabetes guidelines address. Intermittent insulin supply or complete medicine shortages in conflict-affected areas of Syria, Yemen, and Sudan are a reality for many patients. Keeping insulin at the right temperature in a hot climate during power cuts requires practical solutions such as clay pots filled with water, insulated bags, or community refrigerator arrangements. Lack of specialist diabetes clinics in rural or conflict-affected areas makes quarterly follow-up difficult.

In these circumstances, patient and family knowledge becomes the critical safety net. Knowing when to break a fast, how to treat hypoglycaemia with whatever sugar source is available, how to store insulin as best as possible, and how to recognise early signs of kidney or foot trouble, can prevent catastrophic outcomes when medical care is not promptly accessible. Community health workers and pharmacists often fill the gap.

Living well with type 2 diabetes is genuinely achievable. Many people maintain excellent blood glucose control for decades and live full, active lives with no major complications. The pillars are medicine adherence, blood glucose monitoring at the frequency your doctor recommends, attention to diet and activity, and regular screening for complications. Diabetes is manageable, and the tools to manage it, even in a resource-constrained setting, are real.

The monitoring schedule you should not skip

A structured monitoring routine for type 2 diabetes covers several tests at different intervals. HbA1c every three months until the target is reached, then every six months. Kidney function tests and a urine microalbumin test once a year. An eye examination for retinopathy once a year. A foot examination at every clinic visit. Blood pressure measurement at every visit. A cholesterol panel at least annually.

Home blood glucose monitoring gives a daily picture that complements the HbA1c. A pre-breakfast fasting reading reflects overnight control, while a reading two hours after a meal shows how the body handles food. Keeping a log and sharing it with your doctor at each visit enables precise medication adjustments based on real patterns rather than guesswork.

Vaccinations matter more than many patients realise. Diabetes impairs immune defence against certain infections. Annual influenza vaccination, pneumococcal vaccination as recommended by your doctor, and staying up to date with general immunisation schedules all carry extra benefit for people living with diabetes.

Sources

• Aljulifi MZ: Prevalence and reasons of increased type 2 diabetes in Gulf Cooperation Council Countries, Saudi medical journal, 2021
• Hassanein M, Akbar MAJ, Al-Shamiri M et al: Management of Diabetes and Hypertension within the Gulf Region: Updates on Treatment Practices and Therapies, Diabetes therapy, 2022
• Hamdy O, Al Sifri S, Hassanein M et al: The Transcultural Diabetes Nutrition Algorithm: A Middle Eastern Version, Frontiers in nutrition, 2022
• Sonmez A, Sabbour H, Echtay A et al: Current gaps in management and timely referral of cardiorenal complications among people with type 2 diabetes mellitus in the Middle East and African countries, Journal of diabetes, 2022
• Kieu A, Iles A, Khan MA et al: A Systematic Review of Insulin Management Recommendations to Improve Glycemic Control and Reduce Hypoglycemic Events During Ramadan Fasting in Patients With Insulin-Requiring Type 2 Diabetes, Frontiers in nutrition, 2022
• Teo ZL, Tham YC, Yu M et al: Global Prevalence of Diabetic Retinopathy and Projection of Burden through 2045: Systematic Review and Meta-analysis, Ophthalmology, 2021
• Ogurtsova K, Guariguata L, Barengo NC et al: IDF diabetes Atlas: Global estimates of undiagnosed diabetes in adults for 2021, Diabetes research and clinical practice, 2022