DIABETES%20IN%20SUB-SAHARAN%20AFRICA

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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
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• 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
year country prevalence ()
1988 Zambia 34
1993 Ethiopia 13
1995 South Africa 52
1996 Cameroon 37
1996 Cameroon 37
1996 Burkina Faso 16
1997 South Africa 37
1997 South Africa 55
1997 Ethiopia 36
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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
year country prevalence ()
1996 Kenya 41
1996 Burkina Faso 25
1996 Cameroon 46
1997 South Africa 37
1997 Ethiopia 33
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

year country prevalence ()
1988 Zambia 31
1991 Ethiopia 36
1991 Sudan 31.5
1994 Tanzania 25
1995 South Africa 42
1997 South Africa 28
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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
COMPLICATION COUNTRY YEAR PREVALENCE ()
Lower Limbs Vascular Disease (PVD) Senegal 1994 28
Lower Limbs Vascular Disease (PVD) South Africa 1997 8
Lower Limbs Vascular Disease (PVD) Sudan 1995 10
Lower Limbs Vascular Disease (PVD) Tanzania 1997 12
Coronary Artery Disease (CVS) Bukina Faso 1996 8
Coronary Artery Disease (CVS) Uganda 1996 5
Cerebrovascular Disease Sudan 1995 5
Cerebrovascular Disease Zambia 1988 1
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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