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DIABETES IN SUBSAHARAN AFRICA

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Title: DIABETES IN SUBSAHARAN AFRICA


1
DIABETES IN SUB-SAHARAN AFRICA
  • Dr Kaushik Ramaiya

2
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

4
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.

5
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
6
Obesity
  • RISK FACTORS
  • NON MODIFIABLE
  • Age
  • Predisposition
  • MODIFIABLE
  • Obesity
  • Urbanization
  • Physical inactivity
  • Change in dietary habits

7
Childhood Obesity
  • RISK FACTORS
  • NON MODIFIABLE
  • Age
  • Predisposition
  • MODIFIABLE
  • Obesity
  • Urbanization
  • Physical inactivity
  • Change in dietary habits

8
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

9
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)
10
TYPE 1 DIABETES INCIDENCE
INCIDENCE/100,000 of Type 1 diabetes in Sudan (El
Amin et al.)
11
Type 1 DM in Africa- Clinical characteristics of
Type 1 diabetes in Africa Patients
12
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

13
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


14
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

15
Acute complications of diabetes
  • Diabetic ketoacidosis
  • Hyperosmolar non-ketotic coma
  • Hypoglycaemia

16
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

17
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

18
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

19
Microvascular complications of diabetes RETINOPATH
Y
20
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.

21
Microvascular complications of diabetes
NEPHROPATHY
microabuminuria
22
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)

23
Microvascular complications of diabetes NEUROPATHY

24
NEUROPATHY
  • Prevalence varies widely depending on method
    used.
  • Poor glycaemic control and inadequate foot care
    are risk factors for diabetic foot.

25
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

26
MACROVASCULAR COMPLICATIONS OF DIABETES
27
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

28
Diabetes - Clinical CourseSouth Africa
29
Clinical course of DiabetesTanzania (Dar es
Salaam)
30
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
31
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.

32
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
29
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
33
  • 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.

34
Prevention StrategiesProblems in Africa
  • Mortality
  • Poorly skilled or inadequate providers
  • Delay - attention
  • Drugs availability
  • - affordability
  • Complications
  • ? awareness
  • ? facilities detection
  • - monitoring
  • economics

35
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

36
IDF AFRICA REGION - RESPONSE
  • Diabetes Practice Guidelines.
  • Diabetes Education Training manual
  • African Declaration on Diabetes
  • Training
  • Strengthening national diabetes associations
  • Research / data
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