FEATURES
FEATURES
Section Editor: Prof. Talaat I. Farag
During the ICTX Tampere Conference, I met Dr. Hani El Nezami, University of Kuopio and we discussed how to strengthen the cooperation between scientists in Finland and their counterparts in Egypt. I was involved with Dr. Hani El Nezami together with Dr. Jussi Kauhanen and Dr. Hannu Mykkanen in writing a project called North to South Higher Education Programme (NS) to be funded by the Finnish Ministry of Foreign Affairs and administered by Centre for International Mobility.
I visited Kuopio in 2006. The visit came as one of the activities of North to South Higher Education Programme (NS). The aim of the visit was to meet different authorities of the university and discuss how to promote the activities of the North to South Programme.
The programme included the following visits and meetings:
· National Institute of Public Health, University of Kuopio
· Department of Clinical Nutrition /ETTK, University of Kuopio
· School of Public Health, University of Kuopio
· University of Kuopio Hospital, University of Kuopio
· University of Turku
· Institute of Occupational Health, Helsinki
During the visit, I gave 2 presentations, the first one at the National Institute of Public Health hosted by Matti Viluksela. The title was "Gene-Environment Interactions." The second presentation was at the School of Public Health, hosted by Professor Jussi Kauhanen, Head of the School of Public Health and Clinical Nutrition. The title was "Challenges and Possibilities for Modern Health and Biotechnology Research in Egypt and Africa." The visit was highly successful both from the Egyptian and the Finnish points of view. It gave the opportunity of exposure to educational system in Finland regarding public health, nutrition and toxicology.
It was recommended that we start to apply for funding from different sources including FP7 projects from EC. One of the cooperative research topics was Prevention of Diabetes. We agreed to organize a series of scientific activities entitled "Healthy Food for Healthy People."
1- to be acquainted with the experience gained in how to prevent type 2 Diabetes using the changes in life style and also through genetic prediction.
2- to plan for a long intervention program to be implemented in Egypt
3- to coordinate between the collaborating institutions from Finland and Egypt
4- to prepare the curriculum of training the staff on different methodology from different specialties.
5- to prepare Health Education material for Diabetic patients to change their life style.
Prevention of Type 2 Diabetes in Egypt
Type 2 diabetes (T2D) increases tremendously all over the world. It imposes significant economic consequences on individuals, families, health systems. Some risk factors of T2D (elevated plasma glucose, overweight and sedentary lifestyle) are shown to be beneficially affected by changing the lifestyle. Modifying these factors with a lifestyle-intervention program would prevent the development of T2D. University of Kuopio (UKU), together with several collaborating institutions in Finland has prominent experience in prevention of T2D using lifestyle changes.
Diabetes is an emerging public health problem in Egypt. The prevalence of diabetes in Egypt was 9.3% in 1996, rising to 20% in higher socioeconomic classes in urban areas by 2003 (WHO, 2003). Two surveys have attempted to document the prevalence of diabetes mellitus among the Egyptian adults. The first was a population-based survey of adults in Cairo and surrounding rural villages (Herman et al, 1995). The prevalence of diabetes, defined by the WHO criteria was 4%, 13.5% and 20% in rural, low-SES urban and high-SES urban areas, respectively. Extrapolating these estimates and the risk factors of obesity and sedentary lifestyle to the Egyptian population generally, the authors estimated that 63% of the adult Egyptians are sedentary and 27% is obese, 5.4% have diagnosed diabetes and 4.0% with undiagnosed diabetes. A direct relationship between diabetes and obesity was evident, with rates of obesity and diabetes being 16% and 4.9% in the rural subjects, 37% and 13.5% among low-SES urban subjects and 49% and 20% among higher-SES urban subjects, respectively. The second survey (Arab, 1997) studied almost 5000 individuals over 10 years of age (2920 over 30 years) in 11 governorates selected to represent urban area (Alexandria, Damanhour and El-Mahala), rural agricultural Nile Delta areas and rural desert groups. Rural prevalence rates were duplicate compared to the estimate in the Cairo study, and urban prevalence estimates were somewhat lower. The lower estimate for urban adults may be attributable to the life style of Cairo vs. other cities. The overall population estimate of diabetes for individuals over 10 years of age in the wider study was 4.58%.
Therefore, any measures to prevent or delay the development of diabetes are urgently needed. As a result of all the communications and revision of the existing situation, it was noticed that the collaborating institutes in Egypt, who can carry the preventive programs, are facing several challenges and have at the same time promising opportunities which can be summarized as follows:
· Type 2 diabetes is considered a significant health problem in Egypt.
· It is well known that the experience in Finland shows clearly that modifying risk factors of type 2 diabetes by a lifestyle-intervention program prevents or delays the development of diabetes. Unfortunately, there is a big gap for dissemination of the information and transfer of technology due to social and economic barriers.
· In Egypt, there are potential resources either at the institutional level or at the individual level in the collaborating countries. On the other hand, there is a need for:
o new approaches for prevention which may start early in life (childhood, adolescent and in pre-diabetic stages)
o assessment of the current situation at the community level in terms of disease prevalence and/or nutritional pattern.
o dissemination the information and transfer the experience gained from the success stories in Finland.
o revised and well developed training curricula for personnel involved in such programs.
o simplified health education materials to be ready for educators to the public and to patients and their families.
o more interaction between national and international institutions to be able to apply to competitive international funding.
Marie Curie Fellowship and the Prevention of Type 2 Diabetes
The Marie Curie fellowship gave me the opportunity to be oriented about the Finnish experience gained in how to prevent type 2 diabetes (T2D) by using the life style changes (especially reduced weight gain, increased physical activity, less dietary fat, increased fibre intake) and also through genetic prediction. Several meetings with experts and visits to different departments at University of Kuopio (UKU) and also to other institutes in Finland were arranged. Also, I attended many scientific events. There was opportunity to be aware of the training curriculum of health care workers on different methodology of related subjects either by meeting the coordinators of the training courses, attending some courses or even involved in teaching of related courses. Also an effort was made to screen the available health education materials for diabetic patients to change their life style and the forms usually used to investigate for the risk to develop diabetes. Knowledge of the research activities for genetic prediction was also considered to identify individuals at risk of developing T2D.
The outcome of fellowship was a plan to implement Diabetes Prevention Program in Egypt with simplified curriculum and health education materials. The intended preventive program involves exchanging of know-how and experience in disseminating the knowledge gained in Finland on prevention of type 2 diabetes by changing life style.
After my return to Egypt I will start the implementation with workshops and training courses for the staff contributing in such activities. The outcome will be a network of trained scientists capable of designing and implementing the plan of prevention in different collaborating institutes.
Achieving the objectives of the fellowship:
The activities were facilitated by regular meetings with the collaborators at the University of Kuopio which helped for the follow up of the implementation of the different activities. For more interaction with the experts in UKU, 2 seminars were carried out to introduce the Egyptian expertise and needs for intervention (the available resources, the existing health problems and needs and the international activities trying to improve the public health of the people in Egypt). The first seminar was in September 2008: entitled "International Cooperation in Health: Diabetes Prevention Program as a Model" and also giving idea about background and activities. The second was in April 2009-about the Egyptian Experience.
In order to be acquainted with the experience gained on how to prevent T2D, it was necessary to review the available literature about the situation of diabetes in Egypt in comparison to other countries of the world and other studies dealing with prevention of diabetes. Also, several visits and meetings with the research team of the Finnish Diabetes Prevention Study were organized by the host organization School of Public Health and Clinical Nutrition and Food and Health Research Center in Kuopio. The visits included a visit to the National Public Health Institute, Department of Health Promotion and Chronic Disease Prevention, Diabetes Unit, Helsinki, Meeting with Dr. Jaakko Tuomilehto, Dr. Markku Peltonen and Dr. Jaana Lindström in October 2008 and January 2009.
A visit to VTT in Helsinki was organized to be aware of the role of food technology in prevention of Diabetes. Discussion was about finding the local Egyptian products promoting health, and which would be available and affordable for everyone. Heavy use of Egyptian bread, beans, vegetables and fruits create a good basis for compilation of a healthy Egyptian diet, where as the excessive use of sunflower oil and fatty meat weakens the quality of the diet.
A basic Egyptian food stuff is bread, which is subsidized by the state and sold cheaper for every one. If we can modify the fibre content or the vitamin contents of the bread, it will add to its nutritional value. This will require policy makers’ support and approval.
A very informative visit to the Diabetes Association in Tampere was arranged in May 2009.
During the visit, there was orientation about the structure and activities of the association. A tour around the facilities demonstrated how effective the program and the availability of training and educational materials.
Attending, training courses in different disciplines of public health, nutrition and molecular medicine such as: Food and Nutrition Toxicology Lecture Series about Food Safety, Grant Writing Course, Course Genetic and Molecular Aspects of Alzheimers Disease organized, Regulatory Toxicology Course, Principles of Nutrition, Introduction to Public Health, Health Policy course, Applications of Public Health, Nutrition in the Life Cycle, Molecular Medicine I (Cancer), Molecular Medicine II (Ageing), Molecular Medicine III (Diabetes), Nutritional Epidemiology Course, and Research Methodology Course.
Attending and participating in the Health Policy Course helped in the program planning.
Several seminars and conferences were also attended such as Seminar Physical Activity and Nutrition in Children, Surgical treatment of Obesity, Finish Society of Toxicology Conference, International Placental Perfusion Workshop, Alzheimer and lipid conference, The International Puijo Symposium “Physical Exercise in Health Promotion and Medical Care: Current Evidence for Metabolic Syndrome”.
Field trips to communities implementing the program and visits to health care centers were carried out to be aware of the Finnish health system and its involvement in the Prevention program. These visits included the Primary Health Care Center, Kuopio, the primary health care and emergency in University Hospital of Kuopio, the Clinical Nutrition in University Hospital, the health care center at Lapinlahti, May 2009
Hands-on experience on settings of the clinical trials in nutrition was also organized within the schedules of the on-going interventions in the Department. Attending the follow up sessions of patients (DPS project) who used to come to the department of clinical nutrition, UKU were very useful practical experience.
Study designs, ethical applications, patient recruitment, sample collections and handling, major clinical laboratory assays, and data analysis were demonstrated in practice.
In the meantime preparation for future activities and cooperation was taken in consideration. I met Dr. Kirsi Vähäkangas to arrange for the training course in Egypt in November 2009 which will be about research ethics. Also, I met Dr. Laura Kauhanen, Public Health Assistant to discuss the curricula of the e Ethics in Health Research courses that are provided for MPH students. This will help prepare for similar courses in Egypt.
In order to plan for the future intervention program to be suitable to the Egyptian culture to start the implementation in Egypt. It was necessary to adapt tools and guidelines for training of the staff who will implement the program in Egypt, and translate and adapt questionnaire and health education materials. During the visit, training curricula were collected on different methodology from different specialties (Health Education, nutrition, Molecular Medicine and Ethics of Research). This include training on designing the questionnaire, collecting information, computerizing the data, analysis of data, sample collection, analysis of samples and protocols for the genetic study. Training curricula were revised. Selected materials (for training or health education) were prepared and translated to English in case they are in Finnish language. These materials were selected from different sources provided from the Clinical Nutrition department, Public health department, Public health institute and Diabetes association or dedicated websites.
In order to coordinate between the collaborating institutions from Finland and Egypt, initiation of communication with the Egyptian scientists was done by e-mail and sometime telephone (Ain Shams University Departments - Endocrinology, Internal Medicine, Clinical Pathology, Public Health, Medical Research Center; Ministry of Health – National Diabetes Institute and National Nutrition Institutes).
Two scientific events were organized in Egypt to discuss the future cooperation which helped to develop the plan for prevention. The first seminar in Cairo, Egypt, entitled "Diabetes and Nutritional Status in Egypt" was held on 21 November 2008 during which presentations were given about the importance of prevention of type 2 diabetes and to interact with scientists and different responsible persons in the field. The seminar was organized at the department of Community Medicine in presence of Dr. Hannu Makynen and representatives from concerned institutions and WHO. The Second Workshop was organized in Cairo, Egypt in 15 March 2009 in cooperation with the Regional office of the WHO (Dr. Haifa Madi, Director, Health Protection and Promotion, EMRO, WHO and Dr. Ibtihal Fadhil, Regional Adviser, Non-Communicable Diseases, EMRO, WHO).
The March Workshop entitled “Nutrition and Prevention of Non Communicable Diseases: Finnish Experience in Prevention of Type 2 Diabetes” was considered the starting activity for the dissemination of information and establish networking with Egyptian specialists.
The workshop was successfully organized at Regional Office, Eastern Mediterranean Region (EMRO), World Health Organization (WHO), Cairo, Egypt. It was officially opened by Dr. Hussein A. Gezairy, Regional Director, EMRO, WHO, Dr. Maged El Sherbini, Assistant Minister of Higher Education and Scientific Research, Dr. Amr Kandil on behalf of Dr. Nasr E Sayed, Assistant Minister Health and Dr. Mohsen Gadallah on behalf of the Dean of Faculty of Medicine, Ain Shams University. All the speeches gave political support to the initiative and the subject of the workshop.
During the opening session, I expressed my hope that this gathering will establish channels for a successful partnership and indicated that partnership is a necessity for preventive programs. I gave an idea of the size of the problem in Egypt and the need to establish mechanisms for cooperation nationally and internationally to prevent Type 2 Diabetes through life style changes and nutritional pattern. In order to achieve these actions, there is a need for responsible and creative partnerships with both traditional and non-traditional partners.
The main objectives of the workshop were as follows:
• Dissemination of the Finish experience on how to prevent type 2 Diabetes using the changes in life style and on how to increase the fibre content in the Egyptian diet by promoting the positive healthy Egyptian Dietary habits.
• Advocating for implementation of a long intervention program (community based project) for prevention of T2D with coordination between the collaborating institutions in Egypt.
• Enhancement of public- private partnership dealing with health and nutrition programs in supporting this initiative as a realistic form of activity. Improvement of dietary pattern will need intensive actions from the community represented by the NGOs.
The workshop was attended by approximately 180 participants, representing different institutions in Egypt including Departments of Community Medicine, Endocrinology, Internal Medicine, Pediatric, Environmental and Occupational Medicine and Nutritional Therapy Department, from different universities such as Ain Shams University, Cairo University, Azhar University, Menia University, National Research Centre and National Nutrition Institute. The participants also included representations from NGOs and Media. The participation from different institutions is a clear indication of the attractive value of the workshop.
The workshop provided an opportunity to draw on the latest scientific information available taking the Finnish experience as evidence. The outstanding scientific program was owed to the valuable presentations from the guest speakers from Finland who presented their experience (which demonstrated a remarkable and internationally recognized success) on how life style changes and improving the diet, specially bread, can improve the health of the people. The program on prevention of Type 2 Diabetes in Finland responded significantly to changes in diet. A healthy diet included reducing the intake of total fat (saturated fatty acids in particular) and increasing intake of dietary fibres by consuming more vegetables and fruits and whole grain cereal products. The focus has mainly been on whole grain's contribution of dietary fibres, magnesium and potassium, and antioxidants, which have documented effects on insulin sensitivity. Several studies showed a convincing association between intake of wholegrain products and prevention of type-2 diabetes. Also studies proved low glycemic response after intake of rye bread.
Dr. Jaakko Tuomilehto, from National Public Health Institute, Helsinki who spoke about “Finnish Diabetes Prevention Study: Success Story Leading to the National Strategy for Prevention of Diabetes, (DEHKO)”.
Dr. Hannu Mykkanen, Department of Clinical Nutrition, School of Public Health, University of Kuopio who gave presentation about “Glycaemic response: normal metabolism and T2D and Role of High-fiber rye bread“ .
Dr. Kaisa Poutanen, Head of the Department of Food and Health Research (ETTK), University of Kuopio delivered presentation about “New food and nutrition concepts for promotion of consumer well-being“ .
During the discussion session, which was moderated by Dr. Ibrahim El Kerdany, EMRO, WHO, the attendants interacted actively with the speakers, which helped to enrich their learning experience during the workshop. Sufficient time was given to talk about the situation in Egypt regarding nutritional pattern of the Egyptian food and Diabetes, clarify the obstacles, challenges and possibilities for implementation and to allow the participants to reflect on how to implement realistic preventive program.
A panel recommendation was moderated by Dr Ibtihal Fadhil, regional adviser/NCD/EMRO/ WHO. The recommendations were developed taking in consideration the lectures and the discussions. This is important to have common agreement for future actions from concerned partners in the public and private sectors to deal with increasing public health awareness related to diet and health. The recommendations are directed to decision makers and scientific researchers. They were developed after considering the following facts and beliefs:
* that prevention of non communicable diseases in its various multidisciplinary aspects will have a profound impact on human in the years to come
* that Diabetes is a public health problem and increasing in Egypt
* that Egyptian scientists, researchers and people have an important contribution to make to prevention and control of Diabetes.
* that research should be directed by a willingness to collaborate in the interests of improving ordinary people's lives.
The workshop participants call on scientific researchers, institutions, decision makers and civil societies to take actions to execute the following recommendations:
Establishing a mechanism of interaction between scientists and institutions.
· Establish a national committee formed from representations from different institutions and ministries for the purpose of putting national strategy and action plan, setting priorities and identify the role of different institution (governmental or nongovernmental). (The involved institutions can be National: Egyptian Ministry of Health, Ministry of Scientific Research and Technology, Faculty of Medicine, Ain Shams University, National Nutrition Institute, National Diabetes Institute, Concerned NGOs and Media. International: Regional Office WHO and different concerned institutions in Finland including University of Kuopio and Public Health Institute.)
· Maintain a network of communication between scientists. Mechanisms need to be developed to communicate effectively through the national committee. This can help in exchanging of ideas and thoughts for implementation.
· Design a dedicated website, for the purposes of collaboration. The website should be linked to other existing websites available in different institutions.
· Regular publication of the results of cooperative projects and research activities.
· Sharing information about different activities and resources needs to be disseminated more effectively to enhance public awareness.
Organizing conferences, workshops and training courses
· Specialists are encouraged to convene on regular basis (e.g. every year), to share ideas and experiences, enter into debates and consider the developments and implications of a National Program for Prevention of Type 2 Diabetes.
· The multidisciplinary nature of these meetings is recommended to continue for broad and intersectoral dialogue in order to tackle effectively the many important issues emanating out of the application of the program.
· Plan a conference/workshop/training course dedicated to education and training in tools for scientific research and practical prevention programs with the aim of getting consensus on relevant curricula and the sharing of knowledge on methodologies and tools.
Encouraging international cooperation and fundraising
· Investigate the existing bilateral agreements in the field of research between Finland and Egypt to be updated and revitalized. These agreements could include exchange programs for graduate students, postdoctoral research and sabbatical programs.
· Establish partnerships and research cooperation between the 2 countries and institutions on specific research topics.
· Work on finding financial support for established cooperative projects while at the same time seeking to establish a strategy for the optimal usage of research funds. The private sector should be encouraged to contribute more to R&D.
· Seeking the continuation of the support from EMRO, WHO to similar initiatives and implementation of the recommendations.
· Encourage international agencies that have research stations or regional offices in Egypt to be engaged and contribute to the efforts in to prevent Type 2 Diabetes.
Capacity building, training and education: A program can be developed for the training of young scientists, educators and media specialists to promote the related subjects.
· Promotion and enhancement of the quality of education at several levels including school programs and researchers to become more responsible and aware of ethical issues of research when dealing with collaborators from developed countries; and for decision-makers.
· Establishing a system of encouraging and rewarding scientists and of enhancing leadership within this field needs to be developed.
· Capacity building of young scientists in different institutions with the assistance of other well established institutions elsewhere in the world such as Finland.
· Scientists need to interact with teachers, textbook writers and curriculum developers to ensure that up to date science and related ethical issues are transmitted to school students in an exciting way.
· Encourage Ministry of Health to organize a training program for primary Health Care health workers for early detection of Diabetics and pre-diabetics, follow up of Diabetic patients to avoid complications and nutrition education.
Research: A concerted effort must be made by all research institutions to carry out research studies in different research topics that help to prevent Type 2 diabetes.
· Encourage researchers to popularize their work, for example through the media or by direct feedback to participants, so that results, debates and conclusions are entered into the public discourse. Ensure benefits from the research to contribute to the prevention and management of diseases.
· Support multidisciplinary research projects.
· Encourage a community based intervention survey to map the level of preparedness to face the challenges of increasing NCD and Type 2 Diabetes in particular.
· Develop a mechanism needs to help, partner and sponsor scientists to plan and execute research and report their results.
· Encourage specialized centers with good infrastructure for research and well-trained personnel.
· Establish a database of existing research institutions and centers in Egypt should be established in order to promote cooperation.
· A great emphasis should be focused on the genetic resources in terms of molecular characterization for genetic susceptibility studies. Diabetes need to be handled on the molecular level as to promote new diagnostic tests or via molecular therapy approaches.
The role of University of Kuopio and Finnish Institutes to enhance cooperation with Egyptian Institutions to provide technical support:
• Exchanges of Visits
• Collaborative projects which will help in fund raising to support such studies and preventive programs
• Organizing training courses to raise the capacity of researchers and
• Joint workshops with concerned decision makers to implement the program.
To summarize, we should all work towards prevention of Diabetes and not only its treatment. Finland’s know-how can inspire the Egyptians in change of attitude.
Why Finland? Why the University of Kuopio?
I had several good reasons for choosing it to collaborate and to come to spend one year. When I visited University of Kuopio in 2006, I realized that Finland is a Nordic country with specialities that you can't find anywhere else. In Kuopio you can familiarise yourself with all the Finnish traditions. The nature is everywhere, you are surrounded by lakes, forests, nature trails, skiing tracks…etc. You can do all kinds of free time activities in the pure nature. Even the university campus is located by a lake.
University of Kuopio has an international reputation in the fields of health, environment and well-being, with particular strengths in biotechnology, biosciences and molecular medicine. It is the first university in Finland that has been awarded a quality assurance audit certificate by the Finnish Higher Education Evaluation Council (FINHEEC). The university is really well organised, efficient and everybody live in Kuopio in a beautiful environment. It is easily to realize honesty, no bias, encouragement to good work, good supervision, networking and cooperation between people.
The University offers a wide range of degree and non-degree programmes in English. Internship and research opportunities are also available for international students. Also a modern learning environment and flexible support services are offered to students. The University provides an excellent, conclusive learning atmosphere. The teaching methods are excellent in the sense that it promotes learning and understanding of concepts not only for passing exams but using in the field of study. The university is well equipped with Learning and information material for everybody. There are lots of computers, libraries and laboratories for the students to use. Lecturers and professors really care a lot about the students.
I was curious about getting to know new cultures and the way of life in a country which was not a usual destination. Finland is different! Finland: snow, skiing, very interesting culture and something completely different.
It's very safe to live in Kuopio; you can walk on the streets and forests without any fear. However, this doesn't mean that Kuopio is a boring place. You can enjoy lively life, culture and sports as well as experience the nature at its best. Picking berries and mushrooms in the pure nature are new experience. I chose Kuopio because it is not such a big city. It is easy to find your way around in the city and get to know people. Kuopio is a very comfortable city to live in. People can walk or cycle almost everywhere. Everything you need is within easy reach. You don't have to spend hours on travelling.
Generally the Finns speak very good English and they are always happy to help you. The people in Kuopio are especially known to be very easy-going and friendly.
In Finland you can realize and appreciate the beauty the 4 seasons of the year (summer, autumn, winter and spring). You do not hear any noise, there is no environmental pollution. You can drink safely from the tape water and you can breathe fresh air all the time. The proper planning of the city, away from any industrial areas, protects the residents from industrial pollution. What is very impressive is the system for collection of the waste and the separation of every type of waste from home to the end point where recycling is done easily. Also, recycling of the bottles and containers and the system of refunding is very encouraging to the people to do it voluntary. Sorting at the restaurants is very impressive. All nationalities (Pakistan, India, Ethiopia, Egypt, Sudan, ….) respect the system and follow it easily. I hope they will do the same when they come back home. The system of transportation is very accurate. It may be expensive but you will not need to take a taxi and you can save your cars and its expenses.
Healthy food from different brand names which are available in the supermarkets encourages people to use it frequently.
I believe that there is a need to share experiences, so as to identify existing knowledge and best practices in our country. Also to identify knowledge gaps between developing and developed countries. This can enhance collaboration on ongoing research and put plans for future research activities in areas of greatest priority.
References:
Arab M. Epidemiology of diabetes mellitus in Egypt. Egyptian J Diabet 1997; 2:1–14.
Herman WA, Ali MA, Aubert RE, Engelgau MM, Kenny SJ, Gunter EW, et al. Diabetes mellitus in Egypt: risk factors and prevalence. Diab Med 1995; 12:1126–31.
WHO global strategy on diet, physical activity and health: Eastern Mediterranean regional consultation meeting report, Cairo, 30 April − 2 May 2003.
