Content uploaded by Sina Noshad
Author content
All content in this area was uploaded by Sina Noshad on May 21, 2016
Content may be subject to copyright.
REVIEW
Diabetes Care in Iran: Where We Stand and
Where We Are Headed
Sina Noshad, MD, MPH, Mohsen Afarideh, MD, MPH, Behnam Heidari, MD, MPH,
Jeffrey I. Mechanick, MD, FACP, FACE, FACN, Alireza Esteghamati, MD
Tehran, Iran, and New York, NY
Abstract
BACKGROUND The prevalence of diabetes has steadily increased in Iran from the time of the first
published nationally representative survey in 1999 and despite efforts and strategies to reduce disease
burden.
OBJECTIVES The aim of the present review was to describe the current status of diabetes care in
Iran.
METHODS A selective review of the relevant literature, focusing on properly conducted studies,
describing past and present diabetes care strategies, policies, and outcomes in Iran was performed.
FINDINGS The quality of diabetes care has gradually improved as suggested by a reduction in the
proportion of undiagnosed patients and an increase in affordability of diabetes medications. The
National Program for Prevention and Control of Diabetes has proven successful at identifying high-risk
individuals, particularly in rural and remote-access areas. Unfortunately, the rising tide of diabetes is
outpacing these efforts by a considerable margin.
CONCLUSIONS Substantial opportunities and challenges in the areas of prevention, diagnosis, and
management of diabetes exist in Iran that need to be addressed to further improve the quality of care
and clinical outcomes.
KEY WORDS diabetes, diabetes epidemiology, health care policies, Iran, population surveillance,
quality of care, type 2 diabetes
©2015 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
INTRODUCTION
Over the past 4 decades, the prevalence pattern of
various diseases and their respective causes of death
have significantly changed in Iran. A developing
country, Iran is located in a predominantly flat ter-
rain with a mostly subtropical climate throughout
the year. Iran has undergone a rapid rise in
urbanization and industrialization that is in line
with drastic cultural and socioeconomic transitions
over the past few decades. This rapid transition
has been accompanied by changes in nutritional
habits and physical activity, whereby sedentary life-
styles and frequent consumption of fast foods have
grown into a major part of daily habitual behav-
iors.
1,2
At present, Iran’s population is young:
The authors have no conflicts of interest to declare.
From the Endocrinology and Metabolism Research Center, Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
(SN, MA, BH, AE); Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York (JIM).
Address correspondence to A.E. (esteghamati@tums.ac.ir).
Annals of Global Health
ª2015 The Authors. Published by Elsevier Inc.
on behalf of Icahn School of Medicine at Mount Sinai
VOL. 81, NO. 6, 2015
ISSN 2214-9996
http://dx.doi.org/10.1016/j.aogh.2015.10.003
Individuals under the age of 35 years make up about
64% of the population.
3
However, increased life
expectancy, coupled with decreased birth rates, are
transforming the population pyramid and graying
of the population.
4
As a result of these lifestyle
and demographic changes, noncommunicable dis-
eases (NCDs), such as cardiovascular disease, can-
cer, motor vehicle injuries, and diabetes are the
main causes of morbidity and mortality.
5-7
Diabetes
is a major public health concern in Iran given its
high prevalence rate, increasing incidence rate, and
overall economic burden.
8
The International Diabe-
tes Federation Atlas for Diabetes shows that the
Middle East and North Africa region of the world
has the highest prevalence of diabetes and is ranked
second worldwide in terms of projections of diabetes
increase by 2030.
9
Reports on the quality of care in diabetes from
developing countries are not widely available. For
instance, in the United States, under the Catalyst
to Better Diabetes Care Act of 2009, the Centers
for Disease Control and Prevention is required to
publish a biannual “Diabetes Report Card.”
10
But
in Iran, there are significant knowledge gaps with
respect to key indicators of diabetes control, making
the presentation of a nationwide picture of diabetes
care an unattainable goal, at least for now. With that
said, this review will briefly depict the current status
of diabetes care in Iran using the available resources
and published literature. In lieu of conducting an
exhaustive systematic review of the articles pub-
lished, more recent, properly performed, and repre-
sentative studies in the area of diabetes care in Iran
are selected. These references and the interpreta-
tions that follow may provide useful insights into
the problem at hand, namely depicting a realistic
image of the current status of diabetes care with a
focus on epidemiology and control, prevention,
and policies in place to reduce the burden of disease.
EPIDEMIOLOGY OF DIABETES AND ITS
COMPLICATIONS
Prevalence and Incidence. In a national survey con-
ducted in 2011, 11.4% (95% confidence interval,
9.86-12.89) of Iranian adults aged 25 to 70 years
had diabetes (defined here as type 1 [T1D] and
type 2 [T2D] combined; also defined as fasting
plasma glucose concentrations 126 mg/dL).
11
At
present, data describing specific prevalence rates of
T1D and T2D, or all forms of prediabetes are not
available. In about one-fourth of the population
with diabetes (specifically, 2.71% of the adult
population), individuals were not previously diag-
nosed with diabetes and were unaware of their
status. The prevalence of diabetes was higher in
women (12.86%) than in men (9.90%), and in
urban (12.69%) than in rural (7.62%) residents.
Furthermore, trend analyses showed that there
was a 35% increase in the diabetes prevalence
rate among Iranian adults from 2005 to 2011.
11
The
prevalence of one form of prediabetesdimpaired
fasting glucose (fasting plasma glucose concen-
trations 100-125 mg/dL)dwas considerably high
(14.60%).
11
Although no nationwide report on
the prevalence of another form of pre-
diabetesdimpaired glucose tolerancedis available,
a 2008 study conducted in Tehran (the capital city
of Iran) estimated the prevalence of isolated
impaired glucose tolerance among adults aged 20
years and older to be 5.4% and 7.6% in men and
women, respectively.
12
The incidence rate of dia-
betes in Iranian population is assessed in other
studies with an annual incidence rate estimated to
be about 1% of the total population.
13-22
Significant knowledge gaps with respect to the
prevalence of diabetes complications exist. Most
published studies in this venue are clinic-based sam-
ples of small sizes and often are confined to a single
region so nationally representative estimates are not
available.
23
Cardiovascular diseases are regarded as
the main cause of morbidity and mortality in
patients with diabetes.
24
Results from one study
demonstrated that the incidence rates of cardiovas-
cular and coronary heart diseases are about 25 and
23 per 1000 person-years, respectively.
25
The data
on the prevalence of diabetic foot among patients
with diabetes is also scarce.
26,27
In one study, the
prevalence of diabetic foot amputation was 0.7%
among 4150 patients with T2D.
23
Among Iranian
patients with diabetes, the prevalence of diabetic
retinopathy is about 30% to 40%
28-30
and diabetic
nephropathy about 16% to 87%.
27,31-33
Among
patients with T2D, the prevalence of microalbumi-
nuria (25.9%) is estimated to be higher than macro-
albuminuria (14.5%).
29
A retrospective cohort of
1000 patients with T2D demonstrated that over a
period of 10 years, 10.9% developed peripheral neu-
ropathy.
34
The 10-year incidence rates for diabetic
foot ulcer, diabetic nephropathy, and ophthalmo-
logic complications including retinopathy were
8%, 4.6%, and 9.1%, respectively.
34
Selected studies
on the prevalence of diabetes complications are
summarized in Table 1.
Burden and Costs. Diabetes is a leading cause of
mortality and high economic costs in Iran. The
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
840
population attributable fraction of death due to dia-
betes (ie, the proportional reduction in mortality
that would occur if, under a hypothetical scenario,
diabetes was eliminated) is estimated to be 17.3%
and 17.8% in men and women, respectively.
25
Ira-
nian patients with T2D die about 7 to 10 years
sooner than those without diabetes.
37
Several studies have evaluated health-related
quality of life (HRQoL) among Iranian patients
with diabetes.
38,39
A recent systematic review of
46 studies conducted in 20 of 31 provinces of
Iran
38
demonstrated significantly worse HRQoL
in patients with diabetes. Determinants of HRQoL
were similar to those identified in the other coun-
tries. Among Iranian patients with diabetes, the
presence of diabetes-related complications, greater
age, female gender, lower socioeconomic status,
being unmarried, higher hemoglobin A1c (A1C)
levels, higher blood pressure, higher lipid levels,
and greater diabetes duration are associated with
poorer HRQoL.
38
A study conducted with Iranian patients in 2009
found that total costs associated with T2D
amounted to approximately US$3.78 billion annu-
ally.
40
This included $2.05 billion in direct and
about $1.73 billion in indirect costs.
40
Direct costs
of T2D were estimated to be about 8.7% of the total
health expenditure in Iran.
40
Moreover, manage-
ment of diabetes complications comprises the larg-
est share of direct costs.
8
It has been concluded
that the direct and indirect annual health care costs
for an Iranian patient with diabetes is about 2.5
times higher than a healthy Iranian citizen.
8
PRESENT STATUS OF DIABETES CARE
There are 3 discrete yet interconnected and concur-
rent goals in controlling diabetes in Iran:
1. Reducing blood glucose to the recommended targets
through lifestyle and pharmacotherapy;
2. Assessment and reduction of related cardiometabolic
risk factors (eg, overweight/obesity, hypertension,
and dyslipidemia); and
3. Scheduled regular screening for micro- and macro-
vascular complications with prompt management of
incident cases.
By examining the current status of goal-directed
intervention, diabetes care in Iran can be character-
ized. Unfortunately, only a few studies to date have
adequately explored this strategy and discrete tac-
tics, and besides, the key representative surveys
with findings generalizable to the population at a
national level remain sparse. As a result, the current
understanding of the quality of care is incomplete,
although the inclusion of previously unpublished
data of the fourth round of the SuRFNCD (Surveil-
lance of Noncommunicable Diseases) can at least in
part address this shortcoming. Inaugurated in 2005,
SuRFNCD is a periodical, nationally representative
survey of risk factors of NCDs, including prediabe-
tes and diabetes. The survey adopts the framework
laid out by the World Health Organization’s
STEPS (Step-wise approach to Surveillance).
Although much more compendious, SuRFNCD
can be compared in methodology and scope to the
US NHANES (National Health and Nutrition
Examination Survey). In the latest round of the sur-
vey conducted in 2011 (SuRFNCD-2011), A1C
was measured in a randomly chosen proportion of
the sample allowing evaluation of glycemic control
status for the first time on this large scale.
11
The findings from the nationwide SuRFNCD
survey and also large community and clinic-based
cohorts are presented in Table 2. As shown, the per-
centage of patients reaching treatment targets for
hyperglycemia, hyperlipidemia, and hypertension
Table 1. Select Studies on Prevalence of Micro- and Macrovascular Complications in Iranian Patients with Diabetes
*
Year Complication Sample Size (n) Prevalence (%) Region
Macrovascular
Faghih-Imani et al.
35
2004 Myocardial infarction 500 6.3 Isfahan
Janghorbani et al.
36
2001e2004 Coronary heart disease 1566 28 Isfahan
Alavi et al.
26
2007 Diabetic foot 247 4 Kerman
Microvascular
Javadi et al.
28
2007 Retinopathy 634 37 Tehran
Sobhani et al.
33*
2014 Peripheral neuropathy 5540 53 Multicenter
Manaviat et al.
29
2000e2001 Microalbuminuria 553 25.9 Yazd
Macroalbuminuria 14.5
* Meta-analysis of 21 studies.
Annals of Global Health, VOL. 81, NO. 6, 2015 Noshad et al.
NovembereDecember 2015: 839–850 Diabetes Care in Iran
841
are comparable between SuRFNCD and the TLGS
(Tehran Lipid and Glucose Study) cohort.
42
On the
other hand, in the clinic-based sample of Mashhad
(the second most populous city in Iran and a provin-
cial capital), lower proportions of patients with dia-
betes achieved treatment targets, which could be
attributed to the longer duration of diabetes
(27.7% with durations >10 years) in this patient
group.
41
Based on the SuRFNCD-2011 results, in
nearly half of the patients with diabetes, the target
A1C is not achieved (unpublished data). For
hyperlipidemia and hypertension, rates of achieving
treatment targets are lower and around 30% to
40%. The TLGS cohort also reported the trends
in prevalence of medication use among patients
with diabetes. Over a follow-up period of more
than a decade (1999-2011), use of antihyperglycemic
medications has nearly doubled (from 33.4% to
60.5%).
42
The use of antihyperlipidemic (from
10.2% to 30.3%) and antihypertensive medications
(from 26.6% to 37.1%) also substantially increased.
42
Medication adherence is affected by numerous
factors relating to the patient, physician, and health
care system and is an essential part of reaching treat-
ment goals in patients with diabetes.
43,44
At the
patient level, medication nonadherence appears to
be a major obstacle. A systematic review of studies
investigating diabetes and cardiovascular medica-
tions reported adherence rates of 63% to 86% and
39% to 60% for oral hypoglycemic medications and
cardiovascular medications, respectively.
45
Com-
mon reasons for nonadherence, as reported by the
patients, are forgetfulness and concerns about
adverse effects.
45
These negative factors may domi-
nate the beliefs and attitudes of Iranian patients
toward diabetes medications despite high levels of
education, positive beliefs about medication efficacy,
and greater knowledge about the disease process.
45
Among Iranian patients with diabetes, poor adher-
ence with a prescribed insulin regimen is a frequent
theme. In a study of 400 patients with T2D, 77%
reported unwillingness to insulin therapy.
46
In this
study, the most common self-reported reasons for
insulin refusals or adherence issues were “fear of
injection,”“hardship from insulin injection,”and
“high cost of insulin therapy.”
46
Access to medications in Iran appears to be high;
essential medications are readily accessible and are
covered by insurance.
47,48
At present, insulin pens
manufactured by international pharmaceutical com-
panies are imported and are widely available with
the Iran Health Insurance Organization reimburs-
ing 90% of the costs. If these reimbursements
were not in place, given the plummeted value of
the Rial against US dollar over the past decade,
the out-of-pocket expenditures related to insulin
therapy would have skyrocketed, rendering this
option unaffordable for the vast majority of Iranian
patients. A 2010 randomized controlled trial in Iran
revealed that use of pen-prepared insulin analogs
even in patients switching from isophane plus regu-
lar insulin regimens is associated with improved gly-
cemic control in terms of A1C reduction, lower
rates of hypoglycemic episodes, and improved
Table 2. Percentage of Patients with Diabetes Achieving Target Levels of A1C, HDL, and LDL Cholesterol, Triglycerides, and Blood
Pressure
Target SuRFNCD-2011
*
Mashhad
TLGS
à
A1C <7.0% 56.7 25.0 n/a
HDL cholesterol >40 mg/dL in men
>50 mg/dL in women
36.9 13.1 50.45 M
37.50 F
LDL cholesterol <100 mg/dL 39.9 n/a 40.36 M
36.32 F
Triglycerides <150 mg/dL 37.2 36.9 49.40 M
41.93 F
Systolic blood pressure <130 mm Hg 46.8 n/a n/a
Diastolic blood pressure <80 mm Hg 49.6 n/a n/a
Hypertension control Systolic blood pressure <130 mm Hg
Diastolic blood pressure <80 mm Hg
33.7 21.0 37.36 M
40.43 F
SuRFNCD, Surveillance of Risk Factors of Non-Communicable Diseases; TLGS, Tehran Lipid and Glucose Study; A1C, hemoglobin A1c; HDL, high-density lipoprotein;
LDL, low-density lipoprotein; n/a, not available
* Data from SurFNCD-2011, Center for Disease Control of Iran. Targets were defined based on the latest revision of Iran’s National Diabetes Program. Data
comprised of 865 patients with diabetes across urban and rural counties of the country.
From a clinic-based sample of 752 patients with diabetes from Mashhad (the most populated city in the country, after Tehran).
41
à
From a community-based sample of 710 patients with diabetes from Tehran (the capital of Iran).
42
Figures are reported separately for males and females as
presented in the original manuscript. Herein, data from the latest follow-up round of the cohort (Phase 4, 2008-2011) are reported.
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
842
QoL.
49
Yet it wasn’t until October 2013 that state
subsidized reimbursement of insulin pens came
into effect in Iran. Nevertheless, commercially
available newer generation antihyperglycemic
medications (eg, glucagon-like peptide-1 receptor
agonists) that are incorporated into diabetes manage-
ment clinical practice guidelines are still not covered
by insurance. The high cost of these medications,
despite their accessibility, further limits the physi-
cian’s armamentarium for diabetes management.
Another issue related to the health care system is
the tremendous mismatch between supply and
demand for endocrinology care. A report by the
president of the Iran Endocrine Society indicated
that in 2008, there were 146 registered endocrinol-
ogists treating adults in Iran.
50
The report suggested
that assuming one endocrinologist is needed per
hospital unit with more than 100 beds, the country
would need at least 700 endocrinologists just to pro-
vide adequate inpatient and outpatient hospital
care.
50
However, there were only 20 endocrinolo-
gists trained annually by the 7 accredited programs
across the country.
50
This translated into a projec-
tion of 226 practicing endocrinologists by 2011,
provided no one had left practice. But, based on
the most recent published prevalence rate of diabe-
tes in 2011 (4.52 million adults with diabetes),
11
there were approximately 20,000 patients with dia-
betes per endocrinologist. This simplistic computa-
tion most likely represents an underestimation of
the current situation because a proportion of endo-
crinologists solely perform research and/or adminis-
trative work, some only practice part time, and
many clinical endocrinologists have in fact retired
or otherwise left practice. Although the endocrinol-
ogy care supplyedemand mismatch is not unique to
Iran, the extent of the problem is still quite
profound.
To provide a comparative perspective, in 2015, on
the supply side, there are 6872 board-certified endo-
crinologists in the United States.
51
Considering the
approximately 29.1 million patients with diabetes in
the United States,
52
the patient-to-endocrinologist
ratio would be 4235:1; about 5 times lower than the
20,000 estimate for Iran. The implications of this mis-
match on diabetes care are deeply rooted. Private
practices and hospital endocrinology and diabetes
clinics often are overcrowded or stretched to capacity
leading to prolonged waiting times,
53
and reduced
face-to-face patientephysician communication time.
The limited time available to each patient often trans-
lates into a simple laboratory testeprescription
exchange and leaves unaddressed many humanistic
aspects related to effective care for diabetes (eg, patient
education, individualized treatment, provision of dia-
betes self-management, and collaborative communi-
cation with other subspecialties for prevention and
management of complications). The paucity of sub-
specialty diabetes care places a substantial burden on
primary care physicians (PCPs) and general internal
medicine specialists. Diabetes care has become
increasingly complex, and nonendocrinologists often
find it difficult to keep up with the fast-paced advances
and changes in clinical care and guidelines. Although
no study to date has comparatively evaluated the qual-
ity of diabetes management by endocrinologists versus
PCPs or internists in Iran, evidence elsewhere suggests
that improved treatment outcomes result when care is
offered or provisioned by endocrinologists.
54-56
The issue of “clinical inertia,”that is, reluctance,
refrain, or delay in stepwise intensification of diabe-
tes treatment despite poor glycemic control,
57
appears to be prevalent in primary care settings.
58
Clinical inertia of the physician along with unwill-
ingness to undergo insulin therapy by the patient
leads to underutilization of insulin for patients
with diabetes. A time-series analysis of diabetes
medication utilization in Iran between 2000 and
2012 demonstrated that although overall utilization
of diabetes medications has increased by about
7-fold over the period, the share of insulin has
remained relatively constant, comprising 17% of
the total diabetes medication utilization.
48
This
rate is significantly lower than in many developed
countries where the share of insulin surpasses 30%
to 40% of total diabetes medication use.
48
A survey
of 69 Iranian PCPs, specialists, and subspecialists
other than endocrinology involved in the care of
diabetes demonstrated that knowledge, attitude,
and practice of physicians were unsatisfactory.
59
Only 36.2% of the surveyed physicians had satisfac-
tory practice scores in terms of diabetes complica-
tions prevention.
59
Surprisingly, practice skill sets
showed a declining propensity with the years of
internal medicine specialty training.
59
In another
study of Iranian PCPs, the most common educa-
tional resources used for diabetes educations were
domestic journals, reference texts, and congress pro-
ceedings, in descending order.
60
Of note, only 62%
of the physicians used any of the listed sources to
gain knowledge and even in this subset, increased
knowledge did not change clinical behavior.
60
Fur-
thermore, very few (5%) Iranian PCPs cited their
peers as a source for getting information about
state-of-the-art diabetes care.
60
These findings
expose problems with the knowledge base, attitudes,
Annals of Global Health, VOL. 81, NO. 6, 2015 Noshad et al.
NovembereDecember 2015: 839–850 Diabetes Care in Iran
843
and behaviors of PCPs, while also highlighting the
absence of sustained communication between diabe-
tes experts and PCPs for transmitting firsthand
clinical knowledge and expertise of diabetes man-
agement in Iran.
61
This is in sharp contrast to infra-
structures elsewhere in which subspecialists provide
high-quality education for generalists.
The American Diabetes Association currently
recommends that A1C measurements be conducted
at least semiannually in patients with adequate gly-
cemic control and quarterly for those not meeting
glycemic targets and for whom the therapeutic regi-
men has changed.
62
In a follow-up study conducted
alongside the first SuRFNCD in 2005
(SuRFNCD-2005), known patients with diabetes
and other family members with diabetes in the
same household were interviewed.
63
The findings
showed that only 6.3% of the sample had an A1C
measurement over the past year. The rates for
lipid measurements, eye examination, and foot
examination performed at least once in the preced-
ing year were only 24.6%, 39.80%, and 17.3%,
respectively.
63
POLICIES AND PROGRAMS FOR
DIABETES CARE MANAGEMENT AND
PREVENTION
Background. In line with earnest global efforts to
reduce the burden of diabetes, the World Health
Organization (WHO) advocates national preventa-
tive and control enterprises of NCDs by its attend-
ing members.
64
The National Committee for
Diabetes, a subdivision of Iran’s Ministry of Health,
issued the development of necessary policies and
programs for the prevention and control of diabetes,
based on a series of studies that independently
confirmed the alarming prevalence rates of diabetes
and prediabetes across the country. The historical
timeline of a consolidated diabetes preventive action
commenced with a 1992 government initiative in
selected regions of the country. However, some
major errors (including a nonstandard method of
screening, high costs of screening and surveillance
for each patient, lack of adequate equipment in the
health network system to implement the program,
and underestimated prevalence of diabetes in the
rural areas) hindered the extrapolation of the survey
results to the general population of Iran. This led to
a premature ending of the program in 1993.
65
The
official pilot phase of the National Program for
Prevention and Control of Diabetes (NPPCD)
originally ran from 1999 to 2001 under the
supervision of 17 major medical universities across
the country. The target population for the pilot
screening and program implementation primarily
included individuals >30 years of age, as well as
pregnant women.
66-68
However, concrete efforts to
establish a comprehensive national diabetes program
did not materialize until 2004, when merging the
Iranian Primary Health Care (IPHC) system into
the body of the NPCCD generated the first sys-
tematic evaluation of the target population
(NPPCD-2004).
67,69
The integrated IPHC-
NPPCD-2004 involved primary health care work-
ers known as Behvarz in rural settings. The main
objectives were to actively detect and screen the
pregnant and at-risk rural population aged >30
years.
65,66
However, collaboration difficulties
between health and treatment operational deputies
in NPPCD-2004 led to malfunctioning referral
units due to an ambiguous follow-up criteria and to
problems with timely control of complications.
65
Provisional arrangements to address shortcomings
in the rural phase culminated in the development of
the revised program: 2 urban phases of NPPCD-
2010 initially screening the inhabitants in 6 major
metropolitan areas with a population of >1 million
(phase I, incorporating 7 provincial medical uni-
versities). By the end of the phase II in 2012, a
population of just over 20 million was covered by 16
provincial faculties participating in the national
diabetes program. A major methodological differ-
ence from NPPCD-2004 (rural) to NPPCD-2010
(urban) was the passive and opportunistic screen-
ing of high-risk individuals in the latter. Addi-
tionally, introduction of the referral feedback loop
from academic specialized centers back to the lowest
levels of IPHC helped maintain the continuum of
care for patients with prediabetes and diabetes in
NPPCD-2010. The graphical representation of 3
levels of NPPCD-2010 urban specialized care
program is schematically illustrated in Figure 1.
Enrolled patients from NPPCD-2010 have since
undergone annual assessments of micro- and mac-
rovascular complication of diabetes.
70
Missions and Accomplishments. The main objec-
tives and strategies of NPPCD are depicted in
Table 3. In the NPPCD series, objectives and
strategies were largely consistent with those outlined
by the World Diabetes Program in 1989
71
and the
WHO Global Action Plan for Prevention and
Control of NCDs.
72
However, NPPCD codifica-
tion of potential private-sector health-promoting
and collaborative roles marginalized nonformal
sectors and nongovernmental organizations.
73
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
844
Specifically, the ratio of private key stakeholders
outside the health system increased in the urban
phase, but the public and health care internal
stakeholders were the only fiscal agents solicited for
their input in the formulation and decision making
of the program.
As the results from NPPCD-2004 and NPPCD-
2010 attest, treatment of diabetes in Iran has been
more effective in rural than urban areas,
74
with
IPHC-worker (Behvarz) density being associated
with lower blood glucose concentrations. As such,
integration of IPHC with the rural NPPCD-2004
suggests that IPHC, given the sufficient number of
health workers for each district and borough and a
program with well-defined guidelines and individual
follow-up of patients, can be effective in diabetes
management.
75
Better control of T2D in rural
regions is noted despite the generally lower socioeco-
nomic status in rural areas. Local health care workers
(or Behvarz) with prespecified roles in rural health
care houses actively examine rural people by perform-
ing monthly follow-up checks of their current diabe-
tes status, keep record of their adherence to
medications, and visit their respective PCPs or spe-
cialists periodically or if patients display signs of
uncontrolled hyperglycemia. Behvarz are trained to
follow their patients in designated areas and they
are available to assist rural patients.
74
As of yet, there are very few urban trained com-
munity health care professionals engaged in diabetes
prevention programs and patients’medication
adherence issues, so the supervision of diabetes con-
trol is heavily dependent on physicians. Thus, in
urban areas, the absence of such rigorous follow-
up might be the reason for lower effectiveness of
the program, despite seemingly easier access to
physicians.
75
Standardization of diabetes care pro-
grams, including offering incentives to providers
and patients who achieve superior diabetes-related
outcomes, are short-term strategies to hone diabetes
management in urban areas. Nevertheless, the suc-
cessful experience of the program in rural areas of
the country suggests that the current health care
framework should be capable of accommodating
the urban phase of NPPCD (NPPCD-2010), par-
ticularly in older individuals as part of an overall
strategy of screening high-risk individuals.
CONCLUSION
In this review, we discussed the current status of
diabetes prevalence, trends, drivers for success and
shortcomings, and established policies and pro-
grams for diabetes management and prevention in
Iran (Table 4). Evidence suggests that the quality
of care for diabetes in Iran is improving. The rate
of cases with undiagnosed diabetes has dropped
nearly 50% over the past decade, decreasing from
45.7% to 24.7% (2005-2011).
11
Accordingly, over
a period of 13 years (2000-2012) the use of diabetes
Figure 1. Three levels of diabetes care in the enhanced hierarchical model of the urban phase for the National Program on Prevention and Control of
Diabetes (NPPCD-2010). The introduction of feedback loops in cooperation with the collaborating health and management deputies was a major leap
forward from the rural phase of the program (NPPCD-2004) to the urban phase (NPPCD-2010), providing sustained and superior care to the diabetes
patients in the latter. Primary level (diabetes unit): family physician, urban health and management center, private clinic; secondary level (diabetes center):
public/private hospital, specialty polyclinic; Tertiary level (specialized care): specialty and subspecialty hospitals.
Annals of Global Health, VOL. 81, NO. 6, 2015 Noshad et al.
NovembereDecember 2015: 839–850 Diabetes Care in Iran
845
Table 3. Levels of Common Strategies, Objectives, and Endpoint Expected Outcomes in the National Program on Prevention and Control of Diabetes
(NPPCD)
Common Strategies Preventive Care Objectives
Both NPPCD-2004 and NPPCD-2010
I. Ensuring the formal support of health decision/policymakers and pro-
viding adequate monetary resources.
II. Education and notification.
III. Active patient detection and early diagnosis of diabetes.
IV. Promoting the standard of care for diabetes and prediabetes by
determining the minimum acceptable health care standards and allo-
cating required facilities.
Primary Prevention
dReducing the incidence of T2D in patients with prediabetes.
-Improving the lifestyle of individuals at high risk for diabetes and/or
prediabetes.
-Identifying individuals at high risk for diabetes according to national
guidelines.
-Active surveillance and care of high-risk individuals according to
national guidelines.
-Promotion and/or dissemination of the required level of knowledge
for health care system authorities and professionals and other sectors
of society regarding diabetes and its predisposing factors; plus how
to prevent/control detriments associated with diabetes.
Added in NPPCD-2010
V. Reinforcing the continuity of and functionality of referral system in the
care of diabetes and hypertension.
VI. Screening and early management of chronic diabetes complications in
the population under the coverage of program.
VII. Obtaining the support of society in informing and empowering
patients with diabetes and hypertension and their families.
VIII. Active and timely management of diabetes and hypertension to con-
trol/prevent the associated complications and disabilities.
IX. Reinforcing intra- and intersectorial coordination in providing desired
levels of service to referred patients with diabetes.
X. Empowering a diabetes management team at various organizational
levels.
Secondary Prevention
dPreventing, reducing, and delaying the short- and long-term complica-
tions of diabetes
-Early detection of T2D by screening high-risk individuals and preg-
nant women using national guidelines.
-Active surveillance and timely management of identified patients to
control and prevent diabetes from progression, using the national
guidelines.
-Increasing the awareness and knowledge of diabetes and its com-
plications, how to control and prevent the complications, and man-
agement and the purpose of management in patients with diabetes,
their families, their respective health care professionals, and other
involved public sectors.
-Increasing the awareness and knowledge of avoidable/modifiable
cardiovascular risk factors and their associated adverse outcomes and
how to control and/or prevent these risk factors including, tobacco
smoking, high blood pressure, adverse lipid profile, sedentary life-
style, and obesity in affected patients with diabetes, their families,
and respective health care professionals.
XI. Reinforcing the surveillance, monitoring, and evaluation systems in the
care of diabetes and hypertension.
XII. Supporting the translation of conducted research to applicable prac-
tice guidelines.
XIII. Developing reference laboratories for qualitative control of program-
related tests.
XIV. Providing medications, equipment, and materials required for the
proper control, monitoring, and self-monitoring of diabetes.
XV. Endorsing international contributions for the sustainable imple-
mentation of the program.
Tertiary Prevention
dReducing and delaying the incidence of disabilities, handicaps, and
premature deaths due to diabetes complications and reducing the years
of life lost in the population with diabetes.
-Screening of patients with T2D for early and timely detection of
macro- and microvascular (nephropathy, retinopathy, neuropathy,
and limb amputation) complications in the primary stages according
to the national guidelines.
-Timely management of macro- and microvascular diabetes
complications.
-Prevention and active surveillance of patients according to the
national guidelines.
Expected endpoint outcomes
dReducing economic burden due to diabetes and its complications.
dReducing disabilities due to diabetes and its complications.
dReducing premature mortality due to diabetes and its complications.
dImproving quality of life and increasing the life span of patients
with diabetes.
T2D, type 2 diabetes
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
846
medications has increased by 7.5-fold in Iran.
48
Community-based cohorts of patients with diabetes
have demonstrated improved rates of achieving
treatment targets.
42
Valuable policymaking efforts
have contributed to enhancements in diabetes care.
The NPPCD has made great strides toward provid-
ing care for patients with diabetes and has been par-
ticularly successful in rural areas.
Unfortunately, the status quo is far from satisfac-
tory, as it appears that the health care system infra-
structure is not wholly prepared for the rising tide of
diabetes in Iran. The weighed prevalence of prediabe-
tes, diabetes, and diabetes complications is in an
upward trend in Iran. Between 1999 and 2007, the
prevalence of diabetes among Iranian adults nearly
doubled
48
and trend analysis of later data showed
that this pattern has remained uninterrupted.
11
From 2005 to 2011, the prevalence rate of diabetes
increased by 35%, totaling to approximately 4.5 mil-
lion adults with diabetes.
11
Despite tremendous
advances in terms of medication use, low utilization
of diabetes medications in Iran remains a considerable
problem.
48
Afigure of $865 as the average per capita
indirect cost-of-illness for diabetes corresponds to
19% of the nation’s per capita income.
40
Projections
for the prevalence and burden of diabetes in the next
15 years are even more dismaying. It is estimated
that by the year 2030, 9.2 million Iranian individuals
will have diabetes.
76
Accordingly, direct and indirect
costs will nearly triple from 2009, surpassing $9 billion
in 2030.
76
Part of the shortcomings in diabetes manage-
ment and prevention in Iran are understandably
pertinent to economic and financial restrictions in
developing countries. Inadequate funding to con-
duct expensive parts of the NPCCD program,
unavailability of proper and consistent health insur-
ance coverage for advanced technology diagnostics
and therapeutics, disparities in sustained access to
therapeutic facilities, and subpar standards of labo-
ratory reporting in rural health care centers are just
a small sample of the most important barriers to
proper care. Allocation of increased budgeted funds,
for example from taxes imposed on carbohydrate-
rich products and provision of adequate medical
facilities, are among feasible solutions to overcome
these challenges.
73
Additionally, the status of diabe-
tes insurance and expenditure reimbursements
should be revisited. Limiting the out-of-pocket
costs associated with diabetes care via increasing
the share of government subsidized insurance pre-
miums especially for the lower-income strata of
society is recommended. Finally, the role of media
outlets (as the primary routes for increasing public
awareness) along with nongovernmental organiza-
tions, which disseminate knowledge and provide
education to patients with diabetes, should be
encouraged. A list of suggestions for improving dia-
betes care in Iran is presented in Table 5.
In 2010, the rate of insurance coverage in Iran
was 84%.
77
With the commencement of the
so-called “health-sector evolution”by Iran’s Minis-
try of Health in May 2014, this rate has increased
to about 95%.
78
A study of the effects of health
insurance patterns on the quality of care suggested
that health care systems with universal insurance
Table 4. Current Status of Diabetes Care in Iran at a Glance
dDiabetes prevalence rate in Iran has been continuously high (11.4% of the adult population in 2011).
dDiabetes prevalence rate in Iran is still rising (35% increase 2005-2011).
dAbout 50% of patients with diabetes have a poor glycemic control, with the rates for hypertension and dyslipidemia control being even
lower, at 30% to 40%.
dThere is an enormous mismatch between supply and demand of the endocrinology care.
dBurden of diabetes care in Iran is mainly on the shoulders of general practitioners, internists, and primary care physicians who have a
suboptimal understanding of diabetes management.
dDiabetes medication use has sharply increased, yet it remains lower than the standard expected global rate, particularly in the case of
insulin
dLack of proper and adequate packages of insurance coverage for insulin pens before 2013, patient reluctance, and physician inertia
toward insulin therapy, are the main reasons for a subpar rate of insulin utilization in Iran.
dIn Iran, programs specifically dedicated to the care of people with diabetes have been around since 1990s, however, the first con-
solidated national program for control and prevention of diabetes came into effect in the year 2004.
dNational diabetes program struggles to meet preset urban targets due to low number of urban health care professionals, lack of
rigorous follow-up, and high demand for patient-oriented “self-care”to reach the proper glycemic control.
dNational Diabetes Program is more effective in diabetes control and prevention among rural community dwellers, largely owing to
established roots of the Behvarz primary health care program.
Annals of Global Health, VOL. 81, NO. 6, 2015 Noshad et al.
NovembereDecember 2015: 839–850 Diabetes Care in Iran
847
such as that of the United Kingdom’s National
Health Service, function better in terms of diabetes
care than market-based systems like the US system
before the Affordable Care Act (ACA).
79
Further-
more, a recently published study on the effect of
the ACA revealed that the expansion of coverage
to uninsured people with diabetes is likely to
increase their access to medical care and
consequently culminate in improved management
of diabetes.
80
Similarly, although it is too early to
discern clear-cut outcomes, it is anticipated that
the universal access model introduced in 2014
in Iran would ultimately benefit patients with
diabetes by facilitating insurance reimbursements
and making their access to medical care more
affordable.
REFERENCES
1. Ghassemi H, Harrison G,
Mohammad K. An accelerated nutri-
tion transition in Iran. Public Health
Nutr 2002;5:149e55.
2. Esteghamati A, Khalilzadeh O,
Rashidi A, Kamgar M, Meysamie A,
Abbasi M. Physical activity in Iran:
results of the third national surveil-
lance of risk factors of noncommuni-
cable diseases (SuRFNCD-2007). J
Phys Activ Health 2011;8:27e35.
3. Statistical Center of Iran. Atlas of
Selected Results of the 2011 National
Population and Housing Census.
2011. Available at: http://www.amar.
org.ir/Portals/1/Iran/Atlas_Census_
2011.pdf. AccessedSeptember 12, 2015.
4. Kiani S, Bayanzadeh M, Tavallaee M,
et al. The Iranian population is gray-
ing: are we ready? Arch Iran Med
2010;13:333e9.
5. Forouzanfar MH, Sepanlou SG,
Shahraz S, et al. Evaluating causes of
death and morbidity in Iran, global
burden of diseases, injuries, and risk
factors study 2010. Arch Iran Med
2014;17:304e20.
6. Khosravi A, Taylor R, Naghavi M,
et al. Mortality in the Islamic Republic
of Iran, 1964e2004. Bull World
Health Organ 2007;85:607e14.
7. Mathers CD, Loncar D. Projections
of global mortality and burden of dis-
ease from 2002 to 2030. PLoS Med
2006;3:e442.
8. Esteghamati A, Khalilzadeh O,
Anvari M, et al. The economic costs
of diabetes: a population-based study
in Tehran, Iran. Diabetologia
2009;52:1520e7.
9. Whiting DR, Guariguata L, Weil C,
et al. IDF diabetes atlas: global
estimates of the prevalence of diabetes
for 2011 and 2030. Diabetes Res Clin
Pract 2011;94:311e21.
10. Centers for Disease Control and Pre-
vention. Diabetes Report Card 2012.
Atlanta, GA: Centers for Disease
Control and Prevention, US Depart-
ment of Health and Human Services;
2012.
11. Esteghamati A, Etemad K,
Koohpayehzadeh J, et al. Trends in
the prevalence of diabetes and
impaired fasting glucose in association
with obesity in Iran: 2005-2011. Dia-
betes Res Clin Pract 2014;103:
319e27.
12. Hadaegh F, Bozorgmanesh MR,
Ghasemi A, et al. High prevalence of
undiagnosed diabetes and abnormal
glucose tolerance in the Iranian urban
population: Tehran Lipid and Glucose
Table 5. Suggested Solutions for Improving Diabetes Care in Iran
Item Content
1 Allocate increased budgeted funds for improvement in diabetes care from taxes imposed on
carbohydrate-rich products.
2 Assign subsidies to reduce high costs associated with the efficient self-monitoring of patients (eg,
glucometer).
3 Offer incentive packages to health insurance companies for supporting the coverage of advanced
technology diagnostics and proprietary items (eg, different types of insulin, premium quality syringes).
4 Donate technical support and devices to laboratories that adhere to calibrated and standard meas-
urement and reporting of glycemic indices, particularly in rural remote-access areas.
5 Reduce the corporate tax for domestic companies that produce quality diabetes medications and
diagnostics.
6 Facilitate installment plans for companies manufacturing quality products related to care of patients
with diabetes.
7 Promote annual events to increase awareness and fiscal support for the nationwide control and pre-
ventative diabetes action plan.
8 Enhance diabetes knowledge and awareness through funding necessary materials and modalities (eg,
TV programs, pamphlets, booklets).
9 Support and fund nongovernmental organizations that offer education to patients with diabetes.
10 Take advantage of the continuing medical education platform (already in place) to provide state-of-
the-art and high-quality education by subspecialists to primary care physicians who care for patients
with diabetes, through symposiums, meetings, and workshops.
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
848
Study. BMC Public Health 2008;8:
176.
13. Ramezankhani A, Pournik O,
Shahrabi J, et al. Applying decision
tree for identification of a low risk
population for type 2 diabetes. Tehran
Lipid and Glucose Study. Diabetes
Res Clin Pract 2014;105:391e8.
14. Talaei M, Sadeghi M, Marshall T,
et al. Anthropometric indices predict-
ing incident type 2 diabetes in an Ira-
nian population: the Isfahan Cohort
Study. Diabetes Metab 2013;39:
424e31.
15. Janghorbani M, Adineh H, Amini M.
Finnish Diabetes Risk Score to predict
type 2 diabetes in the Isfahan diabetes
prevention study. Diabetes Res Clin
Pract 2013;102:202e9.
16. Janghorbani M, Amini M. Incidence
of type 2 diabetes by HbA1c and
OGTT: the Isfahan Diabetes Preven-
tion Study. Acta Diabetol
2012;49(suppl 1):S73e9.
17. Janghorbani M, Amini M. Associa-
tions of hip circumference and height
with incidence of type 2 diabetes: the
Isfahan diabetes prevention study.
Acta Diabetol 2012;49(suppl 1):
S107e14.
18. Harati H, Hadaegh F, Saadat N, et al.
Population-based incidence of Type 2
diabetes and its associated risk factors:
results from a six-year cohort study in
Iran. BMC Public Health 2009;9:186.
19. Hadaegh F, Ghasemi A, Padyab M,
et al. The metabolic syndrome and
incident diabetes: Assessment of alter-
native definitions of the metabolic
syndrome in an Iranian urban popula-
tion. Diabetes Res Clin Pract
2008;80:328e34.
20. Bozorgmanesh M, Hadaegh F,
Ghaffari S, et al. A simple risk score
effectively predicted type 2 diabetes
in Iranian adult population:
population-based cohort study. Eur J
Public Health 2011;21:554e9.
21. Hadaegh F, Hatami M, Tohidi M,
et al. Lipid ratios and appropriate cut
off values for prediction of diabetes: a
cohort of Iranian men and women.
Lipids Health Dis 2010;9:85.
22. Hosseinpanah F, Rambod M, Azizi F.
Population attributable risk for diabe-
tes associated with excess weight in
Tehranian adults: a population-based
cohort study. BMC Public Health
2007;7:328.
23. Amini M, Parvaresh E. Prevalence of
macro- and microvascular complica-
tions among patients with type 2 dia-
betes in Iran: a systematic review.
Diabetes Res Clin Pract 2009;83:
18e25.
24. American Diabetes Association. Cardi-
ovascular disease and risk management.
Diabetes Care 2015;38:S49e57.
25. Bozorgmanesh M, Hadaegh F,
Sheikholeslami F, et al. Cardiovascular
risk and allecause mortality attribut-
able to diabetes: Tehran lipid and glu-
cose study. J Endocrinol Invest
2012;35:14e20.
26. Alavi, A., Sanjari M., Haghdoost A.,
Sibbald R. G. “Diabetic foot ulcers
in Kerman, Iran: prospective, descrip-
tive review. Wound Repair Regen
2007;15:A47.
27. Khazai MH, Khazai B, Zargaran Z,
et al. Diabetic complications and risk
factors in recently diagnosed type II
diabetes: a case-control study. ARYA
Atheroscler 2006;2(2):79e83.
28. Javadi MA, Katibeh M, Rafati N,
et al. Prevalence of diabetic retinop-
athy in Tehran province: a
population-based study. BMC Oph-
thalmol 2009;9:12.
29. Manaviat MR, Afkhami M,
Shoja MR. Retinopathy and microal-
buminuria in type II diabetic patients.
BMC Ophthalmol 2004;4:9.
30. Hosseini R. Prevalence and risk fac-
tors of diabetic retinopathy in patients
referred to diabetes clinic of Kamkar
Hospital in Qom. Qom Univ Med
Sci J 2012;5(4):40e6.
31. Habibi Moeini A, Navaei L, Azizi F.
Micro-and macrovascular diabetic
complications in NIDDM: a
population-based, case-control study.
Iran Endo Metab J 1999;1:38e47.
32. Janghorbani M, Rezvanian H,
Kachooei A, et al. Peripheral neuropa-
thy in type 2 diabetes mellitus in Isfa-
han, Iran: prevalence and risk factors.
Acta Neurol Scand 2006;114:384e91.
33. Sobhani S, Asayesh H, SharifiF, et al.
Prevalence of diabetic peripheral neu-
ropathy in Iran: a systematic review
and meta-analysis. J Diabetes Metab
Disord 2014;13:97.
34. Farshchi A, Esteghamati A,
Sari AA, et al. The cost of diabetes
chronic complications among Ira-
nian people with type 2 diabetes
mellitus. J Diabetes Metab Disord
2014;13:42.
35. Faghih-Imani E, Amini M, Adibi P.
Silent ischemia in type I diabetic
patients: a study of EKG changes.
ARYA Atheroscler 2010;1.
36. Janghorbani M, Amini M,
Tavassoli A. Coronary heart disease
in type 2 diabetes mellitus in Isfahan,
Iran: prevalence and risk factors.
Acta Cardiol 2006;61:13e20.
37. Bozorgmanesh M, Hadaegh F,
Sheikholeslami F, et al. Shadow of
diabetes over cardiovascular disease:
comparative quantification of
population-attributable all-cause and
cardiovascular mortality. Cardiovasc
Diabetol 2012;11:69.
38. Kiadaliri AA, NajafiB, Mirmalek-
Sani M. Quality of life in people
with diabetes: a systematic review of
studies in Iran. J Diabetes Metab Dis-
ord 2013;12:54.
39. Javanbakht M, Abolhasani F,
Mashayekhi A, et al. Health related
quality of life in patients with type 2
diabetes mellitus in Iran: a national
survey. PLoS One 2012;7:e44526.
40. Javanbakht M, Baradaran HR,
Mashayekhi A, et al. Cost-of-illness
analysis of type 2 diabetes mellitus in
Iran. PLoS One 2011;6:e26864.
41. Bonakdaran S, Ebrahimzadeh S,
Noghabi SH. Cardiovascular disease
and risk factors in patients with type
2 diabetes mellitus in Mashhad,
Islamic Republic of Iran. East Medi-
terr Health J 2011;17:640e6.
42. Jahangiri-Noudeh Y, Akbarpour S,
Lotfaliany M, et al. Trends in cardio-
vascular disease risk factors in people
with and without diabetes mellitus: a
Middle Eastern cohort study. PLoS
One 2014;9:e112639.
43. Balkrishnan R, Rajagopalan R,
Camacho FT, et al. Predictors of
medication adherence and associated
health care costs in an older popula-
tion with type 2 diabetes mellitus: a
longitudinal cohort study. Clin Ther
2003;25:2958e71.
44. Farsaei S, Sabzghabaee AM,
Zargarzadeh AH, et al. Adherence to
glyburide and metformin and associated
factors in type 2 diabetes in Isfahan,
Iran. Iran J Pharm Res 2011;10:933e9.
45. Sarayani A, Jahangard-Rafsanjani Z,
Hadjibabaie M, et al. A comprehensive
review of adherence to diabetes and
cardiovascular medications in Iran;
implications for practice and research.
J Diabetes Metab Disord 2013;12:57.
46. Ghadiri-Anari A, Fazaelipoor Z,
Mohammadi SM. Insulin refusal in
Iranian patients with poorly controlled
type 2 diabetes mellitus. Acta Med
Iran 2013;51:567e71.
47. Cheraghali AM, Nikfar S,
Behmanesh Y, et al. Evaluation of
availability, accessibility and prescrib-
ing pattern of medicines in the Islamic
Republic of Iran. East Mediterr
Health J 2004;10:406e15.
48. Sarayani A, Rashidian A, Gholami K.
Low utilisation of diabetes medicines
in Iran, despite their affordability
(2000e2012): a time-series and
benchmarking study. BMJ Open
2014;4:e005859.
49. Esteghamati A, Rajabian R,
Amini M, et al. The safety and effi-
cacy of biphasic insulin aspart 30
(BIAsp 30) in Iranians with type 2
diabetes: an open-label, non-rando-
mised, multi-centre observational
study-the Iran subgroup of the
IMPROVEstudy. Endokrynol Pol
2010;61:364e70.
50. Azizi F. Sub-specialty training of
endocrinologyin the Islamic Republic
of Iran: estimating the need for endo-
crinologist training. J Med Educ
2009;12:105e8.
Annals of Global Health, VOL. 81, NO. 6, 2015 Noshad et al.
NovembereDecember 2015: 839–850 Diabetes Care in Iran
849
51. (ABIM) ABoIM. Number of Candi-
dates Certified. 2015. Available at:
http://www.abim.org/pdf/data-candidates-
certified/State-Number-of-Certificates-
Issued.pdf. Accessed August 28, 2015.
52. Centers for Disease Control and Pre-
vention. National diabetes statistics
report: estimates of diabetes and its
burden in the United States, 2014.
Atlanta, GA: US Department of
Health and Human Services; 2014.
53. Aeenparast A, Farzadi F, Maftoon F.
Waiting time for specialist consulta-
tion in Tehran. Arch Iran Med
2012;15:756e8.
54. Ho M, Marger M, Beart J, et al. Is the
quality of diabetes care better in a dia-
betes clinic or in a general medicine
clinic? Diabetes Care 1997;20:472e5.
55. Phillips LS, Ziemer DC, Doyle JP,
et al. An endocrinologist-supported
intervention aimed at providers
improves diabetes management in a
primary care site: improving primary
care of African Americans with diabe-
tes (IPCAAD) 7. Diabetes Care
2005;28:2352e60.
56. Leinung M, Matthew C,
Gianoukakis M, et al. Comparison of
diabetes care provided by an endocri-
nology clinic and a primary-care clinic.
Endocr Pract 2000;6:361e6.
57. Khunti K, Wolden ML, Thorsted BL,
et al. Clinical inertia in people with
type 2 diabetes: a retrospective cohort
study of more than 80,000 people. Dia-
betes Care 2013;36:3411e7.
58. Ziemer DC, Miller CD, Rhee MK,
et al. Clinical inertia contributes to
poor diabetes control in a primary
care setting. Diabetes Educ 2005;31:
564e71.
59. Peimani M, Tabatabaei-Malazy O,
Heshmat H, et al. Knowledge, attitude
and practice of physicians in the field of
diabetes and its complications: a pilot
study. J Diabetes Metab Disord 2010;9:10.
60. Tabatabaei-Malazy O, Nedjat S,
Majdzadeh R. Which information
resources are used by general practi-
tioners for updating knowledge
regarding diabetes? Arch Iran Med
2012;15:223e7.
61. Student R, Mojtaba M,
Khamseh ME. General practitioners’
knowledge and clinical practice in
management of people with type 2
diabetes in Iran: the impact of
continuous medical education pro-
grams. Arch Iran Med 2015;18:582.
62. American Diabetes Association. Gly-
cemic targets. Diabetes Care
2015;38:S33e40.
63. Delavari A, Alikhani S, Nili S, et al.
Quality of care of diabetes mellitus
type II patients in Iran. Arch Iran
Med 2009;12:492e5.
64. World Health Organization. 2008-
2013 action plan for the global strat-
egy for the prevention and control of
noncommunicable diseases prevent
and control cardiovascular diseases,
cancers, chronic respiratory diseases
and diabetes. Geneva, Switzerland:
WHO; 2009.
65. Delavari A, Mahdavihazavei A,
Norouzinezhad A, et al. The national
program for prevention and control
of diabetes. Tehran: Seda Publication
Center; 2004.
66. Azizi F, Gouya MM, Vazirian P,
Dolatshahi P, Habibian S. The diabe-
tes prevention and control programme
of the Islamic Republic of Iran. East
Mediterr Health J. 2003. 9, 1114-21.
67. Alavi Nia M, Ghotbi M,
Kermanchi J, Mahdavi Hazaveh A,
Nasli Esfahani A, Yarahmadi S.
National program for prevention and
control diabetes type II in urban areas.
Tehran, Iran: Department of Endocri-
nology and Metabolism, Center for
Non-Communicable Disease Control,
Office of hospital administration and
clinical service excellence, Treatment
Deputy, Ministry of Health and Med-
ical Education; 2012.
68. Azizi F, Guoya MM, Vazirian P,
Dolatshahi P, Habibian S. Screening
for type 2 diabetes in the Iranian
national programme: a preliminary
report. East Mediterr Health J 2003;
9: 1122e27.
69. Ravaghi H, Sajadi HS, Ghotbi M,
et al. Evaluation of an urban phase
of the Specialized Care Program
for Diabetes in Iran: providers’per-
spectives. Int J Prev Med 2014;5:
1013.
70. Alavinia SM, Ghotbi M, Mahdavi-
Hezaveh A, Kermanchi J, Nasli-
Esfahani E, Yarahmadi S. National
comprehensive program for prevention
and control of diabetes mellitus Type
II in urban areas. Tehran, Iran: Ministry
of Healthand Medical Education; 2012.
71. World Health Organization. Guide-
lines for the development of a national
programme for diabetes mellitus.
Geneva, Switzerland: World Health
Organization; 1991.
72. World Health Organization. Global
action plan for the prevention and
control of noncommunicable diseases
2013e2020. Geneva, Switzerland:
World Health Organization; 2013.
73. Faraji O, Etemad K, Sari AA, et al.
Policies and programs for prevention
and control of diabetes in Iran: a
document analysis. Glob J Health Sci
2015;7:187.
74. Mirzazadeh A, Baradaran HR,
Haghdoost AA, et al. Related factors
to disparity of diabetes care in Iran.
Med Sci Rev 2009;15:PH32e6.
75. Farzadfar F, Murray CJ,
Gakidou E, et al. Effectiveness of
diabetes and hypertension manage-
ment by rural primary health-care
workers (Behvarz workers) in Iran:
a nationally representative observa-
tional study. Lancet 2012;379:
47e54.
76. Javanbakht M, Mashayekhi A,
Baradaran HR, et al. Projection of
diabetes population size and associated
economic burden through 2030 in
Iran: evidence from micro-simulation
Markov model and Bayesian meta-
analysis. PLoS One 2015;10:
e0132505.
77. Rashidian A, Khosravi A,
Khabiri R, et al. Islamic Republic
of Iran’s Multiple Indicator Demo-
grapphic and Healh Survey
(IrMIDHS) 2010. Tehran, Iran:
Ministry of Health and Medical
Education; 2012.
78. Ministry of Health and Medical Edu-
cation. Health Sector Evolution.
2014. Available at: http://tahavol.
behdasht.gov.ir/index.aspx?siteid¼426
&fkeyid¼&siteid¼426&pageid¼52663.
Accessed July 6, 2015.
79. Mainous AG, Diaz VA, Saxena S,
et al. Diabetes management in the
USA and England: comparative anal-
ysis of national surveys. J R Soc Med
2006;99:463e9.
80. Brown DS. Impact of the Afford-
able Care Act on access to care
for US adults with diabetes, 2011-
2012. Prev Chronic Dis 2015;12:
1e11.
Noshad et al.AnnalsofGlobalHealth,VOL.81,NO.6,2015
Diabetes Care in Iran NovembereDecember 2015: 839–850
850
