DIABETES IN SUBSAHARAN AFRICA

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DIABETES IN SUB-SAHARAN AFRICA

• Dr Kaushik Ramaiya

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The future burden of diabetes in sub-Saharan
Africa
2030
2025
2010
3

• Africa is experiencing a rapid epidemiological
  transition with the burden of non-communicable
  diseases esp. diabetes that will overwhelm the
  health care systems which is already overburdened
  by HIV/AIDS, TB and Malaria.
• This is due to
• Rapid urbanization and westernization of
  lifestyle
• Rapidly decreasing physical activity
• Changes in dietary habits
• Ageing of the population

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What is different about DM in Africa?

• Decreases survival from the disease.
• Most countries do not have national diabetes
  programmes.
• Medications are unavailable or irregularly
  available and unaffordable.
• Well-structured educational programs for the
  patients and health professionals are lacking..
• Unequal distribution of facilities and providers.
  

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Age

• RISK FACTORS
• NON MODIFIABLE
• Age
• Ethnicity/predisposition
• MODIFIABLE
• Obesity
• Urbanization
• Physical inactivity
• Change in dietary habits

Prevalence of diabetes by age group in a
population of Cameroon
Mbanya JC et al
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Obesity

• RISK FACTORS
• NON MODIFIABLE
• Age
• Predisposition
• MODIFIABLE
• Obesity
• Urbanization
• Physical inactivity
• Change in dietary habits

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Childhood Obesity

• RISK FACTORS
• NON MODIFIABLE
• Age
• Predisposition
• MODIFIABLE
• Obesity
• Urbanization
• Physical inactivity
• Change in dietary habits

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Average percentage annual increase in urban and
rural populations, 1995-2000

• RISK FACTORS
• NON MODIFIABLE
• Age
• Predisposition
• MODIFIABLE
• Obesity
• Urbanization
• Physical Inactivity
• Change in dietary habits

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Physical Inactivity

• RISK FACTORS
• NON MODIFIABLE
• Age
• Predisposition
• MODIFIABLE
• Obesity
• Urbanization
• Physical Inactivity
• Change in dietary habits

Daily walking time in a sample of 2465 urban and
rural Cameroonians (Sobngwi E, et al Int J Obes
2002)
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TYPE 1 DIABETES INCIDENCE
INCIDENCE/100,000 of Type 1 diabetes in Sudan (El
Amin et al.)
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Type 1 DM in Africa- Clinical characteristics of
Type 1 diabetes in Africa Patients
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Type 2 DM in Africa

• Data
• increasing but limited
• Not rare
• low in rural areas
• moderate in rural and urban areas with
  development
• high in urban areas
• Urban gt Rural
• IGT
• early stage of epidemic
• Increasing in same population
• Ethnicity
• Modifiable risk factors

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SUMMARY OF CURRENT PREVALENCE OF TYPE 2 DIABETES

• Rural Sub Saharan Africa 1 3.5
• Urban Sub Saharan Africa 3 7.7
• Republic of South Africa 4.8 8.0
• Maghrebian countries 6.3 9.3
• Indian origin populations 8.6 13.3

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Complications of diabetes

• Increasing prevalence of diabetes and their
  complications in Sub-saharan Africa are a major
  drain on health resources in addition to physical
  and social impact on an individual and community
  

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Acute complications of diabetes

• Diabetic ketoacidosis
• Hyperosmolar non-ketotic coma
• Hypoglycaemia

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Diabetic ketoacidosis

• Common emergency
• High mortality 25 in Tanzania, 33 in Kenya
• Contributing factors
• Lack of insulin availability
• Delay in diagnosis
• Misdiagnosis
• Economics
• Poor healthcare system
• infections

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Hyperosmolar non-ketotic coma

• Complication of type 2 diabetes
• Less common
• Accounts for about 10 of all hyperglycaemic
  emergencies (Zouvanis et al, 1987)
• Contributing factors
• Infections
• Non-compliance
• First presentation
• Mortality high 44 - studies from South Africa
  (Rolfe et al, 1995) patients usually elderly
  and have other major illness

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Hypoglycaemia

• Serious complication of OHA therapy
• In South Africa (Gill Huddle,1993) 33 of cases
  associated with sulphonylurea treatment
• Other precipitating causes
• Missed meal (36)
• Alcohol (22)
• GI upset (20)
• Inappropriate treatment

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Microvascular complications of diabetes RETINOPATH
Y
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RETINOPATHY

• In South Africa, at diagnosis, 21-25 of type 2
  diabetes and 9.5 of type 1 diabetes have
  retinopathy (Kalk et al,1997).
• ? Genetic predisposition africans more affected
  
• Poor/inadequate access to healh care leading to
  inadequate control of blood glucose and blood
  pressure.

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Microvascular complications of diabetes
NEPHROPATHY
microabuminuria
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NEPHROPATHY

• Diabetes contributes to 35 of all patients
  admitted to dialysis unit (Diallo et al,1997)
• In South African series, 50 of all causes of
  mortality in type 1 diabetes was due to renal
  failure (Gill, Huddle Rolfe, 1995)

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Microvascular complications of diabetes NEUROPATHY

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NEUROPATHY

• Prevalence varies widely depending on method
  used.
• Poor glycaemic control and inadequate foot care
  are risk factors for diabetic foot.

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Epidemiology of Diabetic Foot(Abbas ZG)

• 40-60 of all non-traumatic amputations
• 85 of diabetes related lower extremity
  amputations
• The prevalence of foot ulcer is 4-15 of diabetes
  population

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MACROVASCULAR COMPLICATIONS OF DIABETES
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Diabetes - Clinical course

• ETHIOPIA Causes of death in 100 Ethiopian
  diabetic patients 1976 - 1983.
• At death- 45 of patients below age 50
  years 46 below 10 years of diabetic duration
• Causes of death- Metabolic 47 Renal
  Failure 26 Infective 12
  Cirrhosis 10 Stroke 8
  Other 12 Not known 15
• Lester FT. Ethiopian Med J 1984 2 61-68

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Diabetes - Clinical CourseSouth Africa
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Clinical course of DiabetesTanzania (Dar es
Salaam)
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Insulin / OHA costs

• Tanzania (1989-90)-
• Average annual direct cost of diabetes care US
  287.00 IRDM US 103.00 NIDDM
• Purchase of insulin accounted for US 156.00
  (68.2) of the average annual outpatient costs
  for IRDM.
• OHA accounted for US 29.30 (42.5) of the
  average annual outpatient costs for NIDDM.

Chale SS et al. For Med J 1992 304 1215-8
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Costs of treatment

• In Cameroon (Nkegoum, 2002) in the year 2001
• Average direct medical cost of treating a patient
  with diabetes was USD 489.
• 56 -hospital admission
• 33.5 - anti-diabetic drugs
• 5.5 -laboratory tests
• 4.5 on consultation fee.

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Indirect cost of diabetes (Tanzania 1989-90)
Future Healthy Life Days (HLDs) lost per patient
with diabetes during the 8 years of follow-up
.
IRDM
NIDDM
Uncertain
Overall
Reason for lost days
(n3626)
(n2390)
(n1974)
(n4100)




Premature death
55.1
39.7
96.8
69
Disability before death
0.5
3.9
0.4
1
Chronic disability
43.3
55.7
2.4
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Acute Illness
1.1
0.6
0.4
1
Chale SS. A study of the Economic Costs of
Diabetes Mellitus in Tanzania in 1989/90. UDSM
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• This increasing burden is against a background of
  decreasing resources.
• Therefore primary prevention must be the
  cornerstone of policies aimed at combating these
  lifestyle related diseases.

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Prevention StrategiesProblems in Africa

• Mortality
• Poorly skilled or inadequate providers
• Delay - attention
• Drugs availability
• - affordability
• Complications
• ? awareness
• ? facilities detection
• - monitoring
• economics

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Barriers to Quality care

• Irregular supply of medicines (including insulin)
  
• Inadequate health-care infrastructure and
  disproportionate distribution of the facilities
• Affordability
• Lack of adequate training and retraining of
  health care providers
• Lack of education to the people living with
  diabetes their families
• Differing government priorities

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IDF AFRICA REGION - RESPONSE

• Diabetes Practice Guidelines.
• Diabetes Education Training manual
• African Declaration on Diabetes
• Training
• Strengthening national diabetes associations
• Research / data