Download Rising number of diabetes cases cause for concern

editorial
Rising number
of diabetes
cases cause
for concern
D
iabetes refers to diabetes mellitus or, less often, to
diabetes insipidus and occurs when the body lacks
insulin. This can be as a result of the pancreas not
producing any insulin, or producing only a small amount. The
cells in the body may also resist the insulin produced.
The symptoms of diabetes are typically extreme thirst,
frequent passing of water and heavy weight loss over a short
period of time. Other symptoms include tiredness, frequent
infections, itching and rashes as well as disturbed vision.
However, some people show none of these symptoms. It is
therefore important to get tested for diabetes as its presence is
sometimes only known after complications arise, sometimes
leading to death.
There are two main types of full-blown diabetes. People
with Type 1 diabetes are completely unable to produce insulin
while those with Type 2 diabetes produce insulin but their
cells don’t respond to it. In either case, glucose does not move
CHAK Times May - August 2009
into cells in the body and blood glucose levels can become
high. Over time, these high glucose levels can cause serious
complications. Gestational diabetes affects pregnant women
and disappears soon after child birth.
It is estimated that in 2007, more than 246 million people
were suffering from diabetes worldwide. In Kenya alone,
about 1.3 million people suffer from diabetes.
The World Health Organization (WHO) projects that the
number of diabetics worldwide will exceed 350 million by
2030 due to a combination of population ageing, unhealthy
diets, obesity and a sedentary lifestyle. The WHO predicts
that developing countries will bear the brunt of the diabetes
epidemic. This would further push up the ever increasing
cost of health care provision, burdening already impoverished
populations.
Church health facilities in Kenya cannot, therefore, afford
to ignore the emerging threat posed by diabetes not only to
the population but also to the entire health sector. No age
group is safe from this potentially debilitating disease. Indeed,
diabetes is a largely unrecognized cause of millions of deaths
worldwide each year.
It is worth noting that some CHAK hospitals have set up
diabetes clinics. However, for the majority of health care
workers in dispensaries and health centres in the rural areas,
tackling diabetes remains a challenge.
In this issue of CHAK Times, we examine this life
threatening condition in depth with input from experienced
practitioners in various fields.
Nutritional management of diabetes is key as is clinical
management. Understanding how to manage diabetes is
especially critical within the family or community setting
where the patient lives.
With modern treatment, a person with
diabetes can lead a normal, active life.
However, when diabetes goes undetected,
and consequently untreated, the likelihood of
medical complications increases.
In addition to focusing on diabetes
management, we also focus on the complications
that may arise where proper care is not taken,
including the effects of the disease on the
eye.
Correct information and community
education is critical when dealing with any
disease. In the case of diabetes, information is
even more crucial for patients and their families
as this determines how well they manage the
disease and ultimately, the patient’s overall
health status.
Unfortunately, due to heavy workloads,
many health care workers may not be able
to dedicate much time to giving relevant
information to their diabetic clients.
It is our hope that you will find this an
informative and educative read.
God bless you. r
from the general secretary
Government, FBOs sign MOU to
guide health sector partnership
A
photo: CHAK
Memorandum of
Understanding to guide
partnership between the
Government and Faith Based
Health Services providers has
been signed.
The historic signing ceremony
was held at Afya House, Nairobi,
on July 9, 2009. The signing
of this partnership framework
marks the end of a long journey
towards strengthening partnership
and collaboration between the
Government and FBOs which was
Religious leaders and Government officials after the historic signing of the partnership MoU at Afya House
started in July 2004.
The faith based health services Conference Room on July 9, 2009. From right - Dr Samuel Mwenda, Rt. Rev. Philip Sulumeti, Rt. Rev.
Michael Sande, HE John Cardinal Njue, Prof. James Ole Kiyiapi, Prof. El-Busaidy, Very Rev. Fr Vincent
are represented by Christian Health Wambugu, Dr Marin Awori and Dr David Kiima.
Association of Kenya (CHAK),
Kenya Episcopal Conference of
The Government delegation included Government Medicothe Catholic Church (KEC) and Supreme Council of Kenya
Legal Advisor Dr Martin Awori, Dr David Kiima who is the
Muslims (SUPKEM).
chairman of the MOH-FBHS-TWG, Elkana Onguti, the head
The signing ceremony was attended by prominent religious
of the planning department, Chris Rakuom, the Chief Nursing
leaders from CHAK, KEC and SUPKEM while the Government
Officer and the Deputy Director of Medical Services.
side was led by Prof. James Ole Kiyiapi, Permanent Secretary
in the Ministry of Medical Services.
Collaboration between FBOs and Government
Religious leaders who signed the MoU included His
Religious leaders from the three organisations who spoke on
Eminence John Cardinal Njue who is the chairman of KEC, Rt.
behalf of the faith-based health service providers thanked the
Rev. Michael Sande, the CHAK chairman, Prof. Abdul-Ghafur
Government for facilitating finalization of the MoU. They
El-Busaidy, the chairman of SUPKEM, Very Rev. Fr Vincent
expressed optimism that the partnership would enhance
Wambugu, the Secretary General of KEC, Dr Samuel Mwenda,
collaboration with Government towards sustaining and scaling
the General Secretary of CHAK and Abdulatiff Shaban the
up health service delivery in the country.
Director General of SUPKEM.
H.E. Cardinal Njue said the Church had a long-term
Others present to witness the occasion included Rt. Rev.
commitment to serving the people of Kenya and therefore
Philip Sulumeti who is the chairman of MEDS, Dr Robert Ayisi,
valued collaboration and support from the Government. CHAK
Executive Secretary of Catholic Health Commission, Jonathan
General Secretary Dr Mwenda, who has also served as the
Kiliko and Ruth Njoroge, both from MEDS.
secretary of the MOH-FBHS-TWG, gave an overview of the
process of the MoU’s development, consensus building and
finalization.
The religious leaders
expressed optimism that
the partnership would
enhance engagement
and collaboration with
Government towards
sustaining and scaling up
health service delivery
The journey
The journey begun with meetings of church leaders from
CHAK, KEC and MEDS held in July 2004 and February 2006
with the Minister for Health. It is here that the idea to develop
a formal partnership framework between the Government and
FBHS was mooted.
The Ministry of Health-Faith Based Health Services-
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CHAK Times May - August 2009
feature
Diabetes mellitus
An overview
By Dr. Patrick M. Chege - Moi University, School of Medicine
Introduction
iabetes is a chronic disease that occurs when the
pancreas does not produce enough insulin or
when the body can not effectively use the insulin it
produces. Its current global spread has the characteristics of a
pandemic. Insulin is the hormone that regulates blood sugar
and it absence or poor function leads to elevated blood sugar
(hyperglycaemia) which over time leads to serious damage to
many body systems, especially the nervous and cardiovascular
systems.
The main types of diabetes are type 1, characterized by lack
of insulin and is rapidly fatal without insulin administration.
Type 2 results from the body’s ineffective use of insulin and
comprises over 90 per cent of the cases. Gestational diabetes
is hyperglycaemia that is first recognized during pregnancy
and is usually diagnosed through prenatal screening. It has
symptoms similar to type 2 diabetes. According to the World
Health Organization (WHO) November 2008 report:
u More than 180 million people worldwide have diabetes
and the number is likely to double by 2030
u In 2005, an estimated 1.1 million deaths resulted from
diabetes with 80 per cent of these occurring in developing
countries. Nearly half of these deaths affected people
under 70 years old and 55 per cent were women.
u Diabetes deaths will increase by more than 50 per cent in
the next 10 years if urgent action is not taken to control
and prevent the disease in developing countries.
u
WHO aims to stimulate and support the adoption of
effective measures for surveillance, prevention and control
of diabetes and its complications in the developing
countries by:
a) Providing scientific guidelines for diabetes prevention
b) Developing norms and standards for diabetes care
c) Conducting surveillance of diabetes and its risk factors
d) Building awareness on the global epidemic of diabetes
D
Priority interventions
WHO Africa Regional director’s office on 27th – 31st August
2007 proposed the following priority interventions:
u Creation of conditions that enhance advocacy and actions
for diabetes
u Prevention of diabetes and its associated factors
u Targeted screening of people at risk for early diagnosis and
treatment of diabetes and its complications
u Building and strengthening the capacity of the health
workforce
u Support for operational research to control and prevent
diabetes.
CHAK Times May - August 2009
The disease burden of diabetes in Africa is not well documented
with studies in Cameroon, Ghana and Tanzania pointing out
that health records could only account for less than 50 per
cent of the actual cases.
This implies that about half of diabetes cases are not
diagnosed and end up in health facilities with advanced
disease and its complications.
WHO Global InfoBase on diabetes and other noncommunicable diseases yields 22 documented surveys in
Tanzania, one in Uganda and none in Kenya. The Ugandan
survey was a cross-sectional one on rural and urban
populations. It estimated the prevalence (proportion of disease
in the population) of diabetes in those above 35 years old as
8.1 per cent.
The Tanzanian surveys were carried out between 1983
and 1997. Some compared prevalence of diabetes in rural
Population surveys
report that diabetes
prevalence among
higher socioeconomic
urban residents in
Kenya is higher than
20 per cent.
and urban populations and came up with evidence that
the prevalence was higher in the urban population which
had different risk factors. The prevalence varied between
4.5 to 16.7 per cent with the lower value being in the rural
populations.
In Kenya, population surveys conducted by the Kenya
Diabetes Management and Information center (KDMI) report
prevalence rising from 3 per cent in 2003 to 6.7 per cent in
2007 among rural Kenyans. In some rural districts such as
Nyeri in Central Kenya and Kilifi at the Coast, the prevalence
is 11.6 per cent. Prevalence among higher socioeconomic
urban residents is higher than 20 per cent.
The 20 per cent prevalence rate means that 20 in 100
persons may be affected in certain populations. Our population
distribution is such that the majority is aged below 15 years
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...continued from page 4
and probably not at risk.
This may mean that over 40 per cent of the adult population
may be diabetic or at risk of developing diabetes in some
these groups.
More research needs to be carried out to determine the
actual prevalence of the disease in different social classes and
communities in our country.
These finding should documented in newsletters, journals
and local media to promote awareness of the disease among
Kenyans.
Predisposing factors to adult (type 2) diabetes
Studies conducted in the past have identified the following
factors as increasing the risk of developing this condition
Conditions that can be modified (avoidable to some extent)
u Obesity: excessive accumulation of fat especially in the
abdomen (the pot belly)
u Poor dietary habits including ingestion of food that is
rich in low density lipoprotein (LDL). This is found in red
meat, eggs, and dairy products. Refined starches as found
in refined sugars (candy, cakes, etc.) are also associated
with increased risk for type 2 diabetes. While foods rich
in green vegetables, unrefined starches (whole grains),
high density lipoproteins (HDL) (found in fish and marine
meat, chicken whose skin is stripped before cooking)
and fresh fruits delay onset of diabetes and improves its
control in those affected
u
Sedentary lifestyles: with
urbanization and the busy office
jobs, the tendency to inactivity
has significantly risen. People ride
vehicles to work, take lifts to their
offices and spend hours seated.
Physical activity has been proven
to delay onset of diabetes and
improve it control in diabetics.
u Secondary diabetes that may result
from medication administered
by self or clinicians to treat other
health conditions e.g. the use
of steroids to treat rheumatoid
arthritis.
Conditions that may not be modified
u Diabetes in a first degree relative
(parent or sibling): These groups
stand a higher chance of developing
adult diabetes that the ordinary
population. What is remarkable is
that this group can delay or prevent
the disease by avoiding the above
modifiable risk factors while those
that may not have a similar risk
factor may increase their chances
of developing the disease by not observing the same.
uIncreasing age: The risk of developing adult diabetes
increases with aging. It has been observed that as one
grows older (past the age of 40), there is increase in risk
factors such obesity and inactivity.
uThose who may not have any of the above risk factors but
still develop the disease
uSome diseases have diabetes as components of a syndrome
including such endocrinopathies as acromegaly, Cushing’s
syndrome, e.t.c.
Symptoms of diabetes mellitus
Those due to elevated blood sugars include:
u Excessive thirst and dry mouth
u Excessive urination, both in the night and day
u Tiredness, fatigue, irritability and apathy
u Recent change in weight (loss)
u Poor vision (blurring)
u Itchiness of female external genitalia or foreskin in males
(due to candidiasis)
u Hyperphagia or predilection for sweet foods
Those due complications of the disease
u Loss of consciousness (diabetic coma) due to very high
blood sugars
u Poor healing of ulcers in the feet
u High blood pressure
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c
Poor dietary habits including ingestion
in unhealthy portions of food that
is rich in low density lipoprotein
(LDL) found in red meat, eggs,
and dairy products may predispose
one to diabetes. Obesity is also a
predisposing factor.
photos: Internet
CHAK Times May - August 2009
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...continued from page 5
no screening protocols recommended for type 1 diabetes.
u Stroke
u Loss of function of body systems; amputations, impotence,
Management of diabetes mellitus
General principles
a. Knowledge of risk factors for type two diabetes and ways
to manage them
b. For those who already have the disease:
i. involvement of family members enhances the patient’s
sense of control and well being
ii.Maintaining normal blood sugars and lipid levels
iii.Involvement of a dietician in management of the condition.
This will ensure regulation of snacking and other measures
to avoid hypoglycemia or hyperglycemia in young type 1
diabetics on insulin or continued weight gain and poor
control of diabetes in adults.
iv.Special precautions are observed in managing diabetes
among children, pregnant mothers and the elderly.
blindness, kidney failure are among many debilitating
complications of diabetes
u Increased frequency of hospitalization, with economic
consequences
u Poor quality of life
u Premature death
A glucometer can be used by
diabetes patients to self monitor
in the home environment.
Diagnosis of diabetes mellitus
Any of the following are diagnostic of diabetes:
1. Symptoms of excessive thirst, excessive urination,
unexplained weight loss and a random blood sugar test
that is higher than 11.1 mmol / liter.
or
2. A fasting (at least eight hours without caloric intake) blood
sugar more than 7.0 mmol /liter.
or
3. Blood sugar higher than 11.1 mmol / liter 2 hours after
ingestion of 75 g of glucose
Impaired glucose tolerance (having difficulty in blood sugar
control and tending to diabetes) is diagnosed when fasting
blood sugar is between 6.1 to 6.9 mmol /l. or 7.8 to 11.0 mmol
/ l two hours after ingestion of 75g of glucose.
Who should be screened for diabetes mellitus?
Diabetes, though an important non communicable disease
(cannot be transmitted), would be very expensive to screen
the entire population for.
Consensus has, however, been developed in the more
developed countries as to who qualifies for routine screening.
This includes the following:
u Fasting blood sugar determination on all individuals above
40 years of age every three years (if found to be normal
at time of testing)
uMore frequent and earlier testing of individuals with
increased risk of diabetes such as:
a. First degree relative of a diabetic
b. Overweight persons
c. Persons with abdominal obesity, hypertension, high levels
of triglycerides, high LDL, low HDL and impaired glucose
tolerance.
d. Mothers with history of giving birth to babies weighing
more than 4000g
Note: The screening above is for type two diabetes. There are
CHAK Times May - August 2009
Management of diabetes in children and adolescents:
This is mainly insulin requiring diabetes type 1
a. On diagnosis of the condition, the initial goals include
timely initiation of insulin therapy to relieve diabetic
ketoacidosis, hyperglycemia and metabolic instability
if present.
b. Long term goals include:
i. Prevention of acute complications such as diabetic
ketoacidosis and severe hypoglycemia through education
touching on self monitoring of blood glucose and self
administration of insulin.
ii. Identification, avoidance and treatment of hypoglycemia,
basic nutritional needs and effects of exercise on blood
sugar levels.
Foot care is an
integral part of
diabetes management.
photos: Internet
iii. Maintenance of life and quality of life and reduction of
early mortality
iv. Introduction to insulin - type, dose, frequency and
injection sites
v. Monitoring of disease progress by self and the health care
provider, frequency of laboratory testing, evaluation of
body systems such as renal, cardiovascular, vision and
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...continued from page 6
neurological for complications
vi. Foot care
Management of adult type diabetes
a. The goals of therapy include:
i. To achieve optimal or normal levels of blood glucose
in order to decrease the occurrence or progression of
complications
ii. To minimize hypoglycemia
iii. To use appropriate medication to reduce complications
b. The initial management should emphasise on lifestyle
modification including weight reduction, dietary habit
change, and stopping alcohol use for those who imbibe.
c. Use of pharmacologic agents which bring down blood
sugar
The patient, their family
and to some extent the
community they live in
play a significant role
in the management of a
diabetic patient
Home based /community based management of
diabetes
The patient, their family and to some extent the community
they live in play a significant role in the management of a
diabetic patient.
In the past, patients experienced a lot of difficulty as
management of the disease was done with laboratory results
and medicines. During scheduled or appointment visits to
healthcare facilities, the diabetic would be expected to first
go for a blood sugar determination, followed by a nurse taking
vital signs such as blood pressure before seeing the doctor
who would use these figures to decide whether the condition
was controlled or not. The patients therefore learned how
to impress their doctors to earn nice remarks and doctors
continued to manage ‘numbers or results’ instead of human
beings. The outcome was therefore wanting.
The emphasis now tends to be on stricter glycemic control
and monitoring by involving the patient and family more
closely and with early introduction of insulin supplementation
before meals depending on the individual patient.
The use of HbA1c, which determines blood sugar control
over long periods (months) is now common in clinics while the
patients are encouraged to self monitor with home glucometers
and adjust medications accordingly.
This results in better understanding of the disease by the
patient and their families. However, this is yet to start with the
majority of patients due to the challenges that confront our
public health management
In Moi Teaching & Referral Hospital and Webuye district
hospital (where the author works) have started home based
care for diabetes patients (with glucometers, and mobile
phones provided to some patients with diabetes that has been
difficult to control) with very impressive results.
The author is involved in determination of the prevalence
of diabetes, STEPwise study of risk of factors, and the health
seeking behavior of patients with diabetes in Bungoma east
district (population of about 70,000 people). We also hope
to apply community oriented patient care for diabetes and
other chronic diseases in this community. r
The writer, Dr. Patrick M. Chege, MBChB, MMed. is a lecturer,
Family Medicine, at the Moi University School of Medicine
[email protected]
CHAK TIMES issue 32
Call for Articles
The next issue of CHAK Times will focus on ‘medical education’.
We invite articles, photographs, experiences and letters from our readers on this subject. CHAK members are also invited to send information about the services they offer, training activities, new projects,
job vacancies and other developments that they wish to share with the rest of the network.
Send your articles to:
The Editor, CHAK Times
P.O. Box 30690 - 00100 GPO, Nairobi
Email: [email protected]
To reach the editor by September 2009
CHAK Times May - August 2009
feature
Diabetes and the eye
By Dr. K. H. Martin Kollmann
Introduction
iabetes mellitus currently affects more than 170
million people worldwide. This scale is estimated
to touch 366 million by 2030 with more than 75
per cent living in developing countries. Up to 50 per cent of
diabetics are thought to be unaware of their condition. The
highest percentage rise is expected for the Mediterranean
Crescent and sub-Saharan Africa (SSA). The prevalence of
diabetes in persons 35-64 years in sub-Saharan Africa in 2000
was estimated 3-5 per cent(1).
The eye is the organ most commonly affected by diabetes.
More than 75 per cent of patients with diabetes mellitus for
more than 20 years will have some sort of diabetic retinopathy
and everyone has the potential to develop it over time(2).
Diabetic retinopathy is a leading cause of new onset
blindness in industrialized countries and an increasingly
frequent cause of blindness in middle-income countries. The
WHO has estimated that diabetic retinopathy is responsible
for almost 5 per cent of the 37 million cases of blindness
throughout the world. It may account for up to 10 per cent of
blindness in intermediate economies(3).
D
Diabetic eye care in Kenya
Diabetes mellitus and related eye complications are considered
emerging problems not only for the industrialised world but
especially for countries with high urbanisation rates such as
Kenya. However, there is scarcity of good published data on
this epidemic from the region.
were found to have diabetic retinopathy. More than 80 per
cent had no previous eye examination and almost half of
the patients needed some form of treatment. One third had
potentially blinding diabetic retinopathy and almost 20 per
cent had potentially blinding conditions(4).
Almost one third of newly diagnosed diabetics at the
same referral hospital had diabetic retinopathy, 12.5 per cent
with potentially blinding conditions(5). However, in a survey
of rural diabetics, the prevalence of diabetic retinopathy
was significantly lower (below 20 per cent), 5 per cent had
potentially blinding conditions(6).
At present, pregnancy appears not to be a significant factor
for diabetic retinopathy in our setting(7). Surveys from South
Africa (RSA) and Kenya suggest the estimates shown in figure
1 for diabetic retinopathy in sub-Saharan Africa (4,5,8).
b) Other diabetic eye complications
At least 25 per cent of diabetics have other ocular complications
such as cataract, glaucoma and vascular complications. An
estimated 40-45 per cent need referral for comprehensive eye
examination, preferably by a trained ophthalmologist (10-15
per cent acute, 30 per cent non-acute). These figures need to be
considered when planning for diabetic eye care services(8, 9).
c) Diabetic eye care
A recently concluded situation analysis of diabetic retinopathy
services in Kenya revealed that most services are facility based
rather than community based.
Screening for diabetic retinopathy is mainly done by
a) Diabetic retinopathy
ophthalmologists and ophthalmic clinical officers by direct
Almost 50 per cent of diabetics at Kenyatta National Hospital
ophthalmoscopy which is not sensitive to detect sight
threatening macula oedema early enough.
Fig. 1: Diabetic retinopathy in sub-Saharan Africa: one million model
Most (98.6 per cent) clinicians refer patients
for diabetic retinopathy screening only when they
report eye complaints. In many cases, this is too
late for optimal treatment preventing permanent
“One Million Model”
loss of vision.
Most facilities lack standard management
guidelines for diabetic retinopathy. While
diabetes mellitus (DM)
3 – 5%?
currently all postgraduates in ophthalmology are
trained in basic diabetes eye care including laser
diabetic retinopathy (DR)
 20%
therapy, specialised centres for the management
(urban 50% / rural 20%)
of diabetic retinopathy are few and concentrated
sight - threatening DR
10%
in major towns, making them inaccessible to many
patients from peripheral districts. Diabetes support
blindness from DR
 5%
groups are few and concentrated in Nairobi and
other urban centres (10).
MAGNITUDE & PATTERN
similar conservative estimates for Kenya & RSA
CHAK Times May - August 2009
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Diabetic retinopathy
Diabetic retinopathy (DR) is symptomless in its early stages.
Qualified screening of diabetics is the only way to identify
patients to prevent visual impairment and blindness. Timely
treatment has been proven to prevent vision loss from diabetic
retinopathy in the vast majority of patients.
Diabetes mellitus causes a typical microangiopathy with
changes in the blood vessel structure and haemodynamics.
These may lead to leakage, closure and neovascularisation as
it progresses from stage to stage.
Types of diabetic retinopathy
There are two main categories of diabetic retinopathy. In
nonproliferative diabetic retinopathy, changes in the structure
of small blood vessels lead to leakage and progressive
closure of blood vessels. Progressive ischemia and release
of angiogenic factors lead to growth of new blood vessels
(neovascularisation) in proliferative diabetic retinopathy.
a) In Nonproliferative Diabetic Retinopathy (NPDR) the retina
may develop focal or diffuse capillary leakage, capillary
closure, or a combination of the two. Clinical features
may include microaneurysms, macula oedema, lipid (hard)
exudates, and intraretinal haemorrhages. The early stage is
also known as background retinopathy while the advanced
stage is known as preproliferative retinopathy. About 15 per
cent of patients with advanced nonproliferative retinopathy
progress to proliferative retinopathy within one year.
Fig. 2: Retinal oedema (seen as swelling of the retina)
and hard exudates in NPDR
At this stage, blindness may be caused from macula
oedema or ischemic maculopathy.
b) Progression to Proliferative Diabetic Maculopathy (PDR) is
common in longstanding and poorly controlled diabetics.
Besides having changes from nonproliferative retinopathy,
new vessels may grow on the optic disc, on the retina and
into the vitreous.
Fig. 3: Extensive neovascularisation and fibrovascular
membranes in PDR
Proliferative diabetic retinopathy affects 5-10 per cent of the
diabetic population. At this stage, blindness may be caused
by vitreous haemorrhage, fibrovascular membrane formation
and tractional retinal detachment.
Risk factors for diabetic retinopathy
There are a number of well established risk factors for the
development and progression of diabetic retinopathy.
Type 1 diabetics are usually free of retinopathy during
the first five years or before puberty. About 90 per cent have
retinopathy after 15 years. However, they are at a particular
risk for proliferative retinopathy with an incidence of about
60 per cent after 30 years.
Type 2 diabetics may have diabetic retinopathy on
diagnosis; 30 per cent will develop retinopathy within five
years and 80 per cent within 15 years.
Other risk factors are disease duration (see above), poor
metabolic control (HBA1C higher than 7 per cent), obesity
(BMI 20 per cent above ideal), hypertension (140/90 mmHG
or more), low HDL (35 mg/dl or less) and high triglyceride
levels (250 mg/dl or more). Family history and ethnicity (e.g.
African) also play a role.
Symptoms of diabetic retinopathy
Diabetic retinopathy usually has no early warning signs. There
is no pain and vision may remain unaffected for a long time.
In macula oedema, blurred central vision makes it hard
to see clearly when reading or driving. Vision may fluctuate
depending on the severity of retina oedema and lens changes.
Small bleeds into the eye may appear as floaters and go away
within hours, days or weeks. More severe bleeds may take
months to clear or not clear at all. Traction to the retina may
cause flashes and loss of vision from retinal detachment or
extensive haemorrhage.
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CHAK Times May - August 2009
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Evaluation for diabetic retinopathy
Diabetic retinopathy may progress rapidly without much
warning. Periodic qualified evaluation is the only way to
identify and treat vision threatening complications in good
time.
The evaluation includes history taking (e.g. family history,
type and duration of diabetes, systemic complications, ocular
problems) and a comprehensive eye examination including
best corrected vision (far and near), anterior segment
evaluation (including evaluation of tearfilm, intraocular
pressure, iris and lens), and a detailed evaluation of the vitreous
and retina through dilated pupils.
This should be done preferably by slitlamp - biomicroscopy
using a magnifying lens (e.g. 60D, 78D or 90D). Alternatively,
modern digital fundus photography with transmission for expert
reading is an emerging alternative in suitable circumstances.
Fluorescein angiography is a magnified photography or
video of the retina after injecting a dye. It can be particularly
useful when other methods do not give a clear understanding
of the condition (e.g. ischemic maculopathy, very early
neovascularisation).
Ultrasound examination is particularly useful in patients
with dens cataract or vitreous haemorrhage, where the
posterior segment may not be readily visible otherwise.
General guidelines for the screening
and evaluation of diabetics
a)N ewly diagnosed Type 1 diabetics
should be referred for a detailed fundus
evaluation five years after onset or at
puberty (whatever comes first)
b)Newly diagnosed Type 2 diabetics
should be referred for a detailed fundus
evaluation on diagnosis
c)Type 1 and Type 2 diabetics should
be referred for follow up examinations
annually. Intervals may be shorter
depending on their systemic condition
and local findings (e.g. in macula oedema,
rapid progression, and poor systemic
control 2 – 6 monthly examinations may
be initiated)
d)D iabetics who are pregnant or are
planning for a pregnancy should be
referred for a baseline evaluation and/or
early treatment as pregnancy and any
associated rapid metabolic adjustment
may worsen retinopathy
e)Intervals after laser, surgery or
intraocular injections will be advised by
the ophthalmologist.
Treatment for diabetic retinopathy
A polypragmatic vasoprotective approach including strict
metabolic control, a balanced diet, control of dyslipidemia,
hypertension and kidney function, together with regular
exercise and stress reduction has proven to be efficient and
cost-effective in reducing cardio-vascular mortality and
diabetic retinopathy.
This, together with evidence based timely and adequate
local treatment of ocular complications, can reduce the risk
of severe loss of vision and blindness dramatically.
a) Laser treatment
Laser is widely used in treating diabetic retinopathy. It can slow
down progression of the disease, stabilize vision and lead to
regression of neovascularisation. The chief objective for laser
treatment is to reduce the long-term risk for loss of vision from
retinopathy compared to the natural course of the disease.
In certain circumstances it may improve visual acuity or
lead to some initial worsening. There are three principal modes
of laser treatment: focal and grid pattern for central changes,
and panretinal lasercoagulation for (high risk) proliferative
disease. Early laser treatment for clinically significant macula
oedema reduces severe visual loss by 50-75 per cent. Timely
laser treatment for proliferative diabetic retinopathy reduces
severe visual loss by 65-75 per cent and blindness by 90 per
cent.
b) Intraocular triamcinolone injection
This can reduce macula oedema and improve vision
temporarily. It is increasingly used in conjunction with laser
treatment. It is necessary to follow up patients closely for
increased intraocular pressure and glaucoma.
c) Intraocular Anti-VEGF injection
These often expensive drugs can reduce macula oedema and
improve vision temporarily (usually less than Triamcinolone).
However, their main use is the regression of neovascularisation.
It is often applied in conjunction with laser or vitrectomy
surgery. Use in vascular high-risk patients may lead to serious
complications and should be avoided or used with caution.
d) Vitrectomy
In patients with severe vitreous haemorrhage, tractional
fibrovascular membranes and retinal detachment, vitrectomy
may be used to restore or save sight. The complex intraocular
procedure may include the removal of the vitreous (and
sometimes the lens) and membranes, endolaser application,
and an intraocular tamponade with gas or silicon oil.
Sometimes more than one surgery may become necessary.
The successrate (anatomical and functional) largely depends
on the indications.
Other causes of visual loss in diabetics
There are other causes of visual loss than retinopathy in
diabetics and 40-45 per cent of patients need referral for a
comprehensive eye examination, preferably by an experienced
ophthalmologist.
These include cataract, glaucoma, refractive changes,
(non-arteritic) ischemic optic neuropathy, dry eye syndrome,
turn to page 11
10 CHAK Times May - August 2009
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...continued from page 10
recurrent corneal epithelial erosion, corneal ulcers, severe
posttraumatic inflammation, uveitis and endophthalmitis.
Diabetic eye care: programme guidelines
Comprehensive national intervention strategies are
recommended where diabetes mellitus accounts for 5 per
cent of blindness.
1. Disease control
It is essential to develop comprehensive and patient centred
diabetes mellitus and diabetic retinopathy services near the
community to facilitate participation and compliance.
a) Primary level (screening): The principal goal is to reduce
the incidence of preventable eye diseases and visual
impairment. In the context of diabetes, the focus is on
education, case identification and referral of persons with
diabetes mellitus and visual impairment from retinopathy
or other diabetes associated complications.
b) Secondary level (medical and laser): This level provides
for case confirmation and base line systemic and local
treatment and follow up of patients with diabetes and ocular
complications (e.g. laser treatment).
c) Tertiary level (laser, injections and surgery): Centres at this
level provide all types of investigations and treatments
necessary for the management of complex complications,
including laser, intraocular injections and vitrectomy
surgery.
2. Human Resource development
The human resources required for the timely management
of patients with ocular complications from diabetes mellitus
include primary care workers, counselors, technicians, nurses,
clinical officers, physicians / diabetologists, ophthalmologists
(general and with vitreoretinal sub-specialty training) and
managers. Currently, there is scarcity of human resources,
uneven distribution and inadequate empowerment.
3. Infrastructure and equipment
It is recommended to have one laser for every one million
people (e.g. in Provincial and District hospital with a well
equipped eye unit) and one fully equipped vitreoretinal
centre for every ten million population located strategically
at regional centres (e.g. national referral hospitals).
4. Health information and behaviour change
Any successful programme to combat diabetic eye disease
relies on the level of awareness in and participation of the
community. The following aspects of health information for
behavioural change need to be considered:
a)Assessment of existing awareness (KAP)
b)Targeting awareness needs through appropriate key
messages (mass-, group-, individual approaches)
c)Training (trainers, trainees on all levels)
d)Periodic evaluation (KAP)
Conclusion
Contrary to traditional belief, diabetic retinopathy is not a late
manifestation of diabetes mellitus. It is an emerging cause of
preventable blindness in Kenya.
Diabetic retinopathy must also be considered an early
and sensitive indicator for the cardio-vascular risk, assisting
in the precise categorisation of vascular high-risk diabetics.
Chronic hyperglycaemia and hypertension are most important
risk factors.
An evidence based polypragmatic vasoprotective approach
with timely and adequate local treatment is efficient and
cost-effective. A functional sector wide team approach
with bidirectional communication and cooperation (e.g.
diabetologist, ophthalmologist) is essential. Systematic
research and national planning are important in addressing
the epidemic proportion of diabetes and diabetic eye disease
in Kenya. r
Article by Dr K. H. Martin Kollman
MBChB (Goettingen), MD (Goettingen), DTMMP
(Hamburg),
MMed Ophthalmology (Munich), MBA Health Care
Management (Durban), FEACO
Senior Lecturer / Consultant Ophthalmologist
Department of Ophthalmology, University of Nairobi
CBM Advisor for Medical Eye Care (Kenya / Global
Advisory Working Group)
Email: [email protected]
References
1. WHO/IDF: Diabetes action now: an initiative of the World Health
Organization and the International Diabetes Federation 2004:6
2. WHO: Report of WHO consultation in Geneva, Switzerland, 0-11
November 2005
3. Resnikoff S, Etyaale D, Kocur I, Pararajasegaram R, Pockharel GP,
Mariotti SP: Global data on visual impairment in the year 2002.
Bulletin of the World Health Organization, 2004, 82: 844-851
4. Kariuki MM, Kollmann KHM, Adala HS: The prevalence, pattern
and associations of diabetic retinopathy among black African
diabetics attending the medical diabetes clinic at the Kenyatta
National Hospital. MMed Dissertation 1999, University of
Nairobi
5. Nkumbe E, Kollmann KHM, Gäckle HC: Fundus findings in
black Africans with newly diagnosed diabetes mellitus. MMed
Dissertation 2002, University of Nairobi
6. Githeko AK, Kollmann KHM, Adala HS, Courtright P: Prevalence,
pattern and risk factors of diabetic retinopathy among diabetic
patients attending rural health institutions in central Kenya. East
African Journal of Ophthalmology 2007, Vol 13, No 2
7. Wachira JW, Kollmann KHM, Kimani K: Diabetic retinopathy in
pregnant and non-pregnant diabetic women of child bearing age in
Nairobi, Kenya; MMed Dissertation 2006, University of Nairobi
8. Read O, Cook C: Retinopathy in diabetic patients evaluated at
a primary care clinic in Cape Town, Journal of Endocrinology,
Metabolism and Diabetes of South Africa, 2007, Vol 12, No 2
9. Gichuhi S, Kollmann KHM, Choksey PV: The prevalence of primary
open angle glaucoma in black diabetics, East African Journal of
Ophthalmology 2000, Vol 10, No1
10.Ekuwam DN, Kollmann KHM, Masinde SM: Situation analysis of
diabetic retinopathy services in Kenya; MMed Dissertation 2009,
University of Nairobi
CHAK Times May - August 2009
11
feature
Diabetes in pregnancy
By Njoki Kigutha - Lecturer, Kenya Institute of Professional Counseling
Introduction
e usually think of our
nutrition as personal,
affecting only our own
lives. However, a woman who is
pregnant, or who soon will be,
must understand that her nutrition
today is critical to the health of her
future child throughout life. And
as such the nutritional demands of
pregnancy are extraordinary.
Many physiological changes
occur in the body of a pregnant
woman. These include weight
gain, increased blood volume and
composition, cardiovascular and
pulmonary changes, gastrointestinal
and renal changes, to name but a
few.
These come as a result of
added demands on the body’s
requirements and functions to cater
for those of the growing foetus. Fetal
needs for oxygen, nutrients and waste excretion increase the
burden on the mother’s lungs, heart and kidneys.
During this time, the mother’s digestive and metabolic
processes work very efficiently. However, some discomforts
accompany the changes her body undergoes. These include
heartburn, constipation, hemorrhoids, edema, morning
sickness, anemia, pregnancy-induced hypertension and
gestational diabetes.
W
What is diabetes?
Diabetes is a condition in which the blood sugar level is high
because there isn’t enough insulin in the body, or the insulin
isn’t working properly. Insulin is a hormone that enables the
body to break down sugar (glucose) in the blood to be used as
energy. Diabetes can be classified into three categories: Type1
or Juvenile Onset or Insulin Dependent Diabetes Mellitus
(IDDM), Type 2 or Mature Onset (or Non Insulin Dependent
Diabetes Mellitus (NIDDM) and Gestational Diabetes.
Gestational diabetes
During pregnancy, various hormones block the usual action of
insulin. This ensures the growing baby gets adequate glucose.
The mother’s body needs to produce more insulin to cope with
these changes. Gestational diabetes develops when the body
cannot meet the extra insulin demands of pregnancy.
Gestational diabetes usually begins in the second half of
12 CHAK Times May - August 2009
pregnancy, and goes away after the baby is born. If gestational
diabetes doesn’t go away after the baby is born, it’s possible
that the mother already had diabetes that was picked up
during pregnancy.
Symptoms of gestational diabetes
Gestational diabetes doesn’t usually have noticeable symptoms.
However, a pregnant mother with gestational diabetes may
exhibit symptoms of high blood sugar such as:
• increased thirst
• increased hunger
• need to urinate frequently
• tiredness
However, these are also common symptoms in normal
pregnancy.
Gestational diabetes does not pose an immediate threat
to a mother’s health. However, poorly controlled diabetes
in pregnancy may lead to a higher risk of various problems
including pre-eclampsia which causes high blood pressure,
premature labour and having too much amniotic fluid. Such
a mother is also more likely to develop gestational diabetes in
future pregnancies and is at a higher risk of developing type
2 diabetes later in life.
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Gestational diabetes and the baby
Having high blood sugar can cause the baby to grow larger,
which can make delivery difficult. This may cause problems
for both mother and baby. Sometimes, a caesarean delivery
is needed. A mother with gestational diabetes is more likely
to have a caesarean delivery than one who does not.
The baby makes extra insulin to respond to the mother’s
high blood sugar levels and may therefore have low blood
sugar (hypoglycemia) after birth. This is likely to be the case
for a short while after the child has been born.
The newborn baby’s blood sugar level should therefore
be checked regularly. Regular normal feeding - either
breastfeeding or formula milk - may be adequate to correct
the baby’s low blood sugar.
However, sometimes such babies are given sugar (dextrose)
solution through a drip, directly into a vein. The newborn baby
is also at risk of jaundice or yellowing of the skin and whites
of the eyes. This isn’t serious and usually fades without the
need for medical treatment.
More seriously, there is an increased risk that such a baby
will be born with congenital problems, such as a heart defect.
Sometimes, babies can be born with respiratory distress
syndrome characterized by breathing problems because the
lungs have not matured. This usually clears up with time,
although it may mean that the baby needs to be ventilated with
a machine. There is also a higher risk of the baby becoming
obese as a child, although this may be due to the family’s eating
habits rather than any effect on the baby in the womb.
Causes of gestational diabetes
No-one knows why some women develop gestational diabetes
and others don’t, but you are more at risk if you:
• Have a family history of gestational diabetes, i.e. mother,
grandmother or sister had it
• African-Americans, Afro-Caribbean’s, Native Americans,
Hispanics, Pacific Islanders, and people originating from
the Indian subcontinent are at higher risk
• Have previously given birth to a large baby (weighing over
4.5kg/9lb 14)
• Have previously had a stillbirth
• are overweight or obese
Diagnosis of gestational diabetes
One way to diagnose gestational diabetes is with a glucose
tolerance test, which needs to be carried out in the morning.
The patient should not have eaten anything overnight.
The patient drinks a glucose solution after which the doctor
takes blood samples at different intervals to see how the body
is dealing with the glucose over time. Patients at high risk of
developing gestational diabetes should be offered a glucose
tolerance test.
Treatment of gestational diabetes
Pregnant women with gestational diabetes have more frequent
antenatal appointments than their counterparts without. It is
important for patients diagnosed with gestational diabetes to
control their blood sugar levels. This means regular testing
of blood sugar (glucose) levels, a carefully planned diet and
keeping active.
A meal plan will probably consist of a variety of foods,
including plenty of starchy foods such as whole meal bread,
pasta, rice and potatoes, and at least five portions of fruit and
vegetables each day.
Regular moderate intensity exercise, such as walking or
cycling, can help reduce blood sugar levels and promote a
sense of well being. At least 30 minutes of activity that gets
one slightly breathless each day is recommended.
turn to page 14
c
Benefits of proper blood sugar control during pregnancy
• Reduces the risk of miscarriage and stillbirth which are the primary concerns for diabetic pregnant
mothers.
• Reduces the risk of birth defects, particularly those affecting the brain, spine and heart.
• Reduces the risk of excessive growth for the baby: Where a mother has poor blood sugar control, extra
glucose can cross the placenta. This triggers the baby’s pancreas to make extra insulin, which can
cause the baby to grow too large. A large baby makes vaginal delivery difficult and puts the baby at
risk of injury during birth. Fortunately, keeping your blood sugar under control can make excess growth
less likely.
• Prevent complications for mom: Blood sugar control decreases the risk of high blood pressure and
other potentially serious pregnancy complications.
• Prevents complications for baby: Sometimes babies belonging to mothers who have diabetes develop
low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Good
blood sugar control can help assure that a baby is born with healthy blood sugar level and prevents
jaundice after birth.
CHAK Times May - August 2009
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Prevention of diabetes
Healthy lifestyle choices reduce the risk of getting type 2
diabetes where one had gestational diabetes. Aim to eat a
balanced diet, take regular exercise and maintain the correct
weight for your height.
Care of a diabetic during pregnancy
Whether one has type 1 diabetes or type 2 diabetes, pregnancy
presents unique challenges. Naturally, a mother is concerned
about the effect diabetes may have on her health and your
baby.
A pregnant woman may be assigned a number of specialists
that can include an endocrinologist or other diabetes specialist,
a diabetes educator and a registered dietitian. As the pregnancy
progresses, this health care team can help the mother manage
her blood sugar level and adjust her diabetes treatment plan
as needed.
During pregnancy, the patient may need to consult other
specialists such as:
• An obstetrician who handles high-risk pregnancies
and has cared for other diabetic pregnant women. The
obstetrician will carefully monitor mother and baby’s
health throughout the pregnancy.
• An eye specialist who will monitor diabetes-related
damage to the small blood vessels in the eyes as this can
progress during pregnancy.
• A pediatrician who will care for the baby after birth.
The main goal of having such a team is to control the woman’s
blood sugar level to prevent diabetes complications. In fact,
when it comes to pregnancy and diabetes, blood sugar control
is more important than ever. The diabetes specialist will help
a pregnant mother establish her target blood sugar range.
However, it is up to the mother to make healthy lifestyle
choices and follow her diabetes treatment plan.
A diabetic pregnant woman should follow the following
pointers:
• Check her blood sugar level often. Frequent blood sugar
monitoring — perhaps up to eight times a day — can
help her prevent low blood sugar and high blood sugar
(hyperglycemia). Remember, controlling blood sugar
level is the best way to promote a healthy pregnancy and
prevent diabetes complications.
• Take insulin or other medications as directed. Although
oral diabetes medications are sometimes used during
pregnancy, the doctor may recommend switching to
insulin. Some medications — including certain drugs to
treat high blood pressure or kidney problems — shouldn’t
be taken during pregnancy.
• Flexibility: The mother will need to adjust her insulin
dosage depending on her blood sugar level, what she eats,
whether she’s vomiting and various other factors. The stage
of pregnancy also matters. During the last three months of
pregnancy, hormones made by the placenta to help the
baby grow can block the effect of insulin in the mother’s
body. As a result, she may need significantly more insulin
than usual.
14 CHAK Times May - August 2009
• Remember healthy-eating principles. Diabetes diet
probably includes plenty of fruits, vegetables and whole
grains. Although a pregnant woman can eat the same
foods during pregnancy, a doctor or registered dietitian
may suggest changes to her meal plan to help her avoid
problems with low blood sugar or high blood sugar. It’s
also important to take prenatal vitamins containing folic
acid.
• Physical activity is another important part of a diabetes
treatment plan, even during pregnancy. A pregnant
woman should get her doctor’s OK to exercise and choose
activities she enjoys such as walking, swimming or biking.
She should aim for at least 30 minutes of aerobic exercise
most days of the week. Stretching and strength training
exercises are important, too. If she has not been active for
a while, she should start slowly and build up gradually.
photo: Internet
A pregnant mother. Poorly
controlled diabetes in pregnancy may lead to higher risk
of various problems. Such a
mother is also at higher risk
of developing Type 2 diabetes later in life.
• The mother needs to see her obstetrician for regular
prenatal checkups. The obstetrician may recommend
regular ultrasounds or other prenatal screening tests to
monitor the baby’s growth and development.
The mother’s health care team will help her determine the
best time and safest way to deliver her baby. Sometimes
labor is allowed to begin naturally. In other cases, labor is
induced early to reduce the risk of complications for mother
or baby. During labor, the health care team will closely
monitor the mother’s blood sugar level and adjust her insulin
dosage accordingly. If the baby is too large, the induction isn’t
successful or complications develop, a C-section delivery may
be the best option.
After delivery, it is still important for the mother to take
good care of herself. She should continue to check her blood
sugar level often, especially if she is breast-feeding. Staying
healthy is the best thing she can do for her baby. r
feature
Diabetes: the myths
and the facts
Myths
Facts
•
•
•
Only wealthy people get diabetes
Diabetes is caused by eating too much sugar
Being overweight causes diabetes
Diabetes can affect anyone, and is not simply caused by eating too much sugar
or being overweight. However, eating more food than the body requires and
being physically inactive increase the risk of developing Type 2 diabetes.
•
•
Diabetes is always inherited
Obesity is hereditary, so dieting and exercising
are useless
There does seem to be a genetic element to both Type 2 diabetes and
obesity, which is why they can sometimes run in families. However,
environmental factors, including diet and exercise, play a huge part in the
development of both these conditions. It is important to eat healthy and
exercise regularly to reduce the risk of developing Type 2 diabetes or obesity.
•
Women with diabetes shouldn’t have babies —
it’s too risky
This used to be true up to about 30 years ago. However, it is now possible for
all women with diabetes to have babies without endangering their health. The
key is to achieve very good blood glucose control before becoming pregnant
and take care to maintain that control throughout the pregnancy.
•
Taking insulin or tablets allows people with
diabetes to eat anything they want
Even if a person with diabetes is taking insulin or tablets, they still need to
regulate their food intake. Diabetes therapies aim to bring abnormally high
blood glucose levels to near normal levels rather than offset any extra glucose
load caused by an unhealthy diet. Meal time insulin doses can be adjusted for
larger or smaller meals.
•
People with diabetes cannot drink alcohol
Drinking a moderate amount of alcohol with food has no adverse effect on
blood glucose or insulin levels in people with Type 1 or Type 2 diabetes.
However, alcohol can cause low glucose levels (hypos) if taken on an empty
stomach or excessively. Drinking alcohol may, however, affect the motivation
to monitor blood glucose levels and the ability to recognize hypos. Beer
contains a lot of carbohydrate, which counters the effects of the alcohol in
causing hypos, but leads to weight gain if drunk regularly. People with or
without diabetes can benefit from the heart protective effects of light to
moderate intake of alcohol. Red wine seems to be particularly beneficial.
•
People with diabetes cannot eat sugar, but pure
honey is not harmful
Both honey and sugar can be taken in moderation in the diet of a person with
diabetes but people using insulin must remember to count them as part of their
carbohydrate allowance. Honey is no ‘better’ than pure sugar for people with
diabetes; it still has very high sugar content and should be eaten sparingly.
•
Insulin use leads to increased risk of heart
disease
Insulin use does not increase the risk of heart disease, as shown in recent
studies. Indeed, insulin therapy can both help prevent heart disease and has
proved useful in treating heart attacks in people with diabetes.
•
Diabetes is contagious
Both Type 1 and Type 2 diabetes are diseases of metabolism and are not
contagious.
•
Diabetes can be caused by a traumatic incident
or by being bewitched or cursed
The underlying causes of diabetes do not include a curse or a traumatic
incident. Type 1 diabetes is a result of the body’s own immune system
destroying the insulin-producing cells in the pancreas.
Type 2 diabetes is due to the body becoming insensitive to its own insulin and
then being unable to produce sufficient insulin to overcome that insensitivity.
Stresses, such as an infection, can reveal diabetes that is already present but
had not been recognized as can an injury or operation.
Source: Kenya Diabetes Management Information Centre
http://www.dmi.or.ke/factsheet.php
CHAK Times May - August 2009
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feature
The role of nutrition in the
battle against diabetes
By Zachary Ndegwa Muriuki - Ministry Of Public health and Sanitation
D
ietary modification is one of the cornerstones of
diabetes management, and is based on the principle
of healthy eating in the context of social, cultural
and psychological influences of food choices. Dietary
modification and increasing levels of physical activity should
be the first step in the management of diabetes mellitus and
have to be maintained.
Nutrition therapy aims to enable people with diabetes
to make appropriate changes to their lifestyle to reduce the
risks of both micro and macro vascular complications. This
involves recommending change and facilitating it through
behavioural interventions, such as identifying barriers to
change, motivational interviewing and goal setting.
Nutrition therapy involves modifying both diet and
patterns of physical activity. Positive outcomes of the therapy
include:
• Improved metabolic control
• Decreased risk of micro- and macro vascular
complications
• Quality of life and life expectancy similar to that of the
general population
Aims of nutrition therapy
Diet therapy aims at tailoring the care plan in accordance
with the prevailing clinical situation. It sets out to:
• Attain and maintain blood glucose levels as close to normal
as possible using appropriate carbohydrate management
•Prevent hypo and hyperglycaemia through diet and
treatment, prevent swings in blood sugar and minimize
the risk of developing diabetes complications
•Attain optimum blood lipids and blood pressure control
and so reduce the risk of macro vascular disease
•Assess energy intake to achieve optimum body weight.
This can mean taking action to either increase or decrease
body weight.
It is understood that this therapy will be conducted alongside
appropriate changes in lifestyle to improve diabetes outcomes.
Diet therapy is not only concerned with the prevention of
micro and macro vascular complications but also chronic
complications of diabetes.
A behavioral approach to change should be used and
acceptable quality of life maintained at all times. The diet
should be modified to prevent and treat chronic complications
of diabetes by:
• Encouraging healthy food choices and physical activity
• Preparing individual diet plans that suit the person’s
lifestyle as well as respecting his/her wishes and desire to
change
Individual assessment
It is important that an individual assessment of each person is
done before a dietary plan can be agreed upon. The following
issues need to be explored before educational intervention,
agreed goals or advice can be given:
• Weight (and preferably weight history) of the patient
• Most recent and previous HbA1c (haemoglobin A1c)
• Diabetes medication
•
Diet assessment
•
Lifestyle and physical activity
•
Cultural, social and economic
issues
An individual plan enhances dietetic
outcomes and consequently influences
diabetes complications. It is important that
the plan is practical, realistic, and avoids
setting perfection as a goal.
Periodic review of the plan is essential
because it will need to evolve as the person
goes through different life stages and their
circumstances change. Dietary consultation
should include information on healthy food
choices in order to promote health and
reduce macro vascular complications.
turn to page 17
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Components of a health diet for the diabetic person
A ‘diabetic diet’ is not a special ‘diet’; it is rather a healthy
eating plan. When planning a meal for a diabetic person
there is need to consider the following basic principles of a
healthy eating plan:
A ‘diabetic diet’ is not a special ‘diet’; it
is rather a healthy eating plan.
Complications
associated with
diabetes
• To balance energy intake and energy expenditure
• To provide adequate quality and quantity of macro
and micronutrients to meet nutritional requirements
• To integrate a healthy meal plan in accordance with
culture, beliefs, taboos, values and socio economic status.
It is important to eat a variety of foods.
• Make starchy foods the basis of all meals.
• Limit intake of fatty foods and simple sugars
• Include two to four fresh fruit for the day. When drinking
fruit juice, choose the juice that says ‘no sugar added’ but
dilute the juice (half glass of water and half glass of juice)
before drinking it.
The following food groups needs to be included in the diet:
• Starchy foods
• Animal products e.g. meat, poultry and eggs
• Plant proteins e.g. legumes
• Fruits (Consider the fruits in season)
• Vegetables (include both the green leafy and yellow or
orange vegetables)
• Fats and oils
• Fiber (Both soluble and insoluble)
• Water
Conclusion
Dietary modification is one of the cornerstones of diabetes
management. Diabetes nutrition therapy aims at enabling
people with diabetes to make appropriate changes to
their lifestyle to reduce the risks of both micro- and macro
vascular complications. Positive outcomes of the therapy
are improved metabolic control, decreased risk of micro
and macro vascular complications and quality of life and life
expectancy similar to that of the general population. r
Zachary Ndegwa Muriuki is a Diabetes Program Officer with
the Ministry Of Public health and Sanitation
By James Mwangi - DMI Centre
D
iabetes is one of the most common non-communicable
diseases globally. It is the fifth leading cause of death in
most developed countries and there is substantial evidence
that it has reached epidemic levels in many developing
countries.
Developing countries presently face the greatest burden
of diabetes. However, many governments and public health
planners remain largely unaware of the current magnitude or
more importantly the future potential for increase in diabetes
and its serious complications.
Diabetes patients are found around the world. There
is no cure for diabetes; it can only be kept under control.
Unfortunately, most diabetics are diagnosed when the
devastating complications of the disease are already
evident.
Over the last 30 years, diabetes has been identified as
a major contemporary cause of premature mortality and
morbidity in many countries. Diabetes is in fact ranked among
the leading causes of blindness, heart attacks, stroke, renal
failure, impotence and lower limb amputation.
Continuous elevation of the blood sugar, (normal range is
3.5-6.7 mmol/s) eventually leads to tissue damage in most
body organs.
Among the major complications of diabetes are:
• Cardiovascular disease - damage to the blood vessels
• High Blood pressure
• Stroke
• Blindness
• Nephropathy - kidney damage
• Neuropathy - nerve damage
• Amputations
Cardiovascular diseases
These occur due to hardening of blood vessels after continuous
elevation of blood glucose. Cardiovascular diseases account
for over 50 per cent of all diabetes deaths. Among the
cardiovascular problems associated with diabetes are angina,
turn to page 21
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CHAK Times May - August 2009
17
feature
Living with diabetes
Mwangi Maina recalls his initial fear, diagnosis and how he has succeeded in making
life “sweet” for over 20 years despite being diabetic
Introduction
much water. I could not sleep because the water just drained
y first encounter with diabetes was in 1979 at the
from my body as soon as I drank it. My fellow college students
tender age of 18. I was reading a form three biology
kept commenting that I was losing weight despite the large
textbook in preparation for an exam.
food rations I took and the strong urge to eat and drink sweet
Biology was my favourite subject and I found a passage in
things. They did not understand that no amount of fluids and
the book about a condition called “Diabetes Mellitus”. The
food seemed to relieve my thirst and hunger pangs. As the
disease was described in a rather crude manner, as a “fatal
symptoms continued, I found myself too frightened to think
condition” that was caused by insufficient production or lack of
about diabetes. Exams were nearing and the prospect of
insulin in the body. Insulin was a hormone produced by some
the “fatal disease” catching up with me at this time was not
cells in the pancreas and any abnormality in its production
conceivable.
rendered the body unable to regulate blood sugar. Such a
However, l knew I had to seek medical assistance. One
person was said to suffer from a serious problem known as
day, my lecturer took me to Kenyatta National Hospital where I
diabetes. The book went on to say that diabetes caused a
was diagnosed with the ‘fatal” disease I had dreaded for seven
myriad of disabilities and physiological failures that eventually
years. I was admitted and started on daily insulin injections
led to death.
and strict blood sugar testing and meal regimens. I thought I
More information was provided, but it was not until
was counting days before my extinction.
much later that I found out how erroneous the statements in
But the ‘crazy’ nurses kept on saying that one could live
the book were. Everything about this
with the condition for as long as life
disease seemed frightening. The word
lasted. Further, they knew people
“fatal” lingered in my mind for seven
who had lived with the condition
years before I was diagnosed with the
for over 20 years.
Morbid thoughts
same ailment.
Had they not removed the old
dominated my mind
Just before I was diagnosed with
man at the far end of the ward who
until an old man in the
diabetes, my elder brother suffered from
had died the previous night from
a strange disease that affected his legs,
diabetes? What insincerity; how
neighbouring bed told me
toes, sight, and numerous other body
insensitive! After all, were they
he had lived with diabetes
functions. He worked as a policeman
smarter than my old biology book?
for 20 years
in Mandera, and I was not able to
They should let me die in peace
clearly ascertain the disease afflicting
instead of giving me false hope, I
him. However, I knew he had to have
thought to myself.
repeated injections at home.
Eventually, he died in 1985 after a strange episode of
The truth
vomiting, gut pain, unconsciousness and convulsions.
A week after my admission, however, I began to doubt that
Somebody hinted to me that he had opted for certain herbal
death was coming, realising for the first time that the nurses
concoctions in place of “inconveniencing injections”.
could have been speaking the truth. .
From basic pharmacy training, I now knew diabetes patients
Old biology book
survived on regular injections of insulin. The only problem was
I did not, however, link my brother’s condition to the
that they became slaves to these injections, meal timetables,
information in my old biology book. Aside from exaggerating
hospital visits, and food that wasn’t very good - small rations
the negative aspects of the “fatal condition” the book had not
of boiled rice or ugali, beans, vegetables and water.
mentioned the use of injections by diabetics. At my brother’s
In my thinking at the time, a diabetic could only watch
burial, nobody mentioned diabetes. It is only after some time
helplessly as others enjoyed unlimited quantities of soda,
that I began to realise that diabetes could have caused his
candy, sausages, margarine, alcohol and all the ‘good things
death. As this conviction was building up, I found myself
of life’. And if I got through all this, how was I going to survive
praying to God to spare me from this disease that I learned
amputated limbs and loss of my reproductive capacity, which
was genetic. Was I going to be the next after my brother? I
turn to page 19
wondered. God forbid!
A year after my brother’s death, I found myself drinking too
M
c
18 CHAK Times May - August 2009
feature
...continued from page 18
I knew would not allow me to marry? I wondered.
These and other equally morbid thoughts dominated
my mind while I was in the hospital until an old man in the
neighbouring bed told me he had lived with diabetes for 20
years. Now here was a living testimony to the claims of the
nurses. I had by then survived ten days and was preparing
to leave hospital, alive! Twenty-three years later, I’m alive,
healthy, with a good career, married, and a father of two boys
and a daughter who is waiting to join university! How wrong
my old biology book was!
After diagnosis
After being discharged, one would say, the rest is history.
However, I refused to make the rest history. I stopped believing
the old biology book and decided that I was going to read
widely about the condition afflicting me. This resolve became
my turning point in living and coping with insulin-dependent
diabetes mellitus (IDDM).
Today, I’m no longer scared of the disease and find my
life quite interesting, especially when people marvel at how I
have survived this long with diabetes. Presently, thank God,
I have no real diabetic complication except a faulty heart
rhythm that was present even before the sickness set in. I do
not take drugs for this heart condition but use life-giving insulin
and medication to protect my kidneys, as the condition and
increasing age may expose these vital organs to damage.
Occasionally, I use high-potency Vitamin B complex to
protect and maintain nerve integrity, which has prevented
diabetes-induced loss of sex drive. I attribute small changes
in my health and physiological profile to age more than
diabetes.
My experience has taught me that diabetics can live without
complications and problems associated with the diease as long
as they maintain good blood sugar control. With repeated
insulin jabs, the body learns not to sense pain caused by
pricking. In addition, one need not worry about cold storage
of insulin vials, given that the medication can last up to 28
days outside the refrigerator as long as it is not exposed to
direct heat or light that may denature it.
Additionally, it is wise to tell the people around you about
your condition. However, do not let their pity and indulgence
distract you. A diabetic can live a perfectly normal life and
achieve their life goals just like any other
person. Feelings of self-pity and isolation
dissipate as soon as the patient accepts
that diabetes is a sickness like any other for
which treatment exists. The ultimate victory
in managing your condition lies with you,
the patient. You are your own best doctor.
‘Secrets’ of living with diabetes
Seek information
After being diagnosed with diabetes, the
patient needs to find as much information
as they can get about the disease from
reliable sources.
The clinician is one source. Others sources are books,
medical literature, diabetes educators and nutritionists. In
addition, talk to patients who have lived with the condition.
However, the latter source can be misleading and should not
be the only one used.
In my case, I talked to my doctor, read more “informed”
medical books, talked to other patients at the diabetic clinic
and listened to radio topics on the disease. Information has
empowered me more than anything else.
One of course needs to be careful about false ‘herbal
doctors’ who promise to wean you out of regular medication
and tell you eat whatever you want. Be careful about selfdeclared healers who “pray” and advise you to forgo your
regular medicine doses.
Accept your condition and tell
people about it
Accepting that you are diabetic
is an important step to managing
the condition. Denial only makes
you reluctant to observe the strict
discipline associated with diabetes
control. It is the principal recipe for
making diabetes mellitus “fatal”.
One way of helping a patient accept his or her status is to
tell family, relatives, friends, workmates and even strangers
about the condition. Let people know that when they are
in your company, they will have to cope with your slightly
different lifestyle. You may require a meal that is different from
theirs and will not indulge in eating and drinking at will.
Let them not insist that you eat or work outside your
schedules but should instead support you to keep to your
timetable. In my case, when I left hospital, I told literally
everybody about my condition. Before I married, I told my
would-be wife everything about my disease and how I would
expect her to help me manage it.
Today, she is so good that she can tell when my blood sugar
is falling during sleep. The same applies to my children and
other close acquaintances. When the children were growing
up, they found it so interesting that I drunk sugarless tea that
they, on their own accord, opted out of sugar, soda, candy
and other sweets.
Sugar in my house is for visitors and unsweetened “uji”
is everybody’s favourite
breakfast.
Be disciplined
You will need to change
your pre-diabetes lifestyle
and maintain a disciplined
routine, irrespective of
the pressure that you experience. Injections, must be taken
turn to page 22
c
CHAK Times May - August 2009
19
pictorial
Official opening of new CHAK offices, gue
1
2
5
8
6
3
14
20 CHAK Times May - August 2009
6
pictorial
est house and training centre
4
10
11
13
9
7
12
1. Chief Guest Mr. Gottfried von Gemmingen, Head of the Department of Economic Cooperation, signs
the visitors’ book as outgoing CHAK chairman Bishop Joseph Wasonga looks on.
2&3. Guests enjoy the tunes of Kayamba Africa
4. Chief Guest Mr. Gottfried von Gemmingen, unveils a plaque to mark the official opening as CHAK
chairman Bishop Sande looks on.
5. CHAK Trustee Rev. Dr George Wanjau delivers the day’s devotional which was on thanksgiving.
6. The Kayamba Africa group entertains guests during the event.
7. CHAK vice chair Nancy Ng’ang’a presents EED’s Monika Hoffman-Kuenhel with a token of appreciation.
8. One of the meeting rooms at the CHAK conference centre. The facility boasts three meeting rooms
while the guest house has a capacity of over 70.
9. CHAK Trustees Rev. Joseph Maswai and Pastor Paul Muasya lead the closing prayers.
10. Outgoing CHAK chairman Bishop Wasonga, Chief Guest Mr. Gottfried von Gemmingen, EED’s
Monika Hoffman-Kuenhel cut a cake to mark the official opening as General Secretary Dr Mwenda
looks on.
11. CHAK staff Felister Gitau and Ruth Kagure prepare for the cutting of the cake to mark the occassion
12. CHAK members turned out in large numbers for the event.
13. Outgoing chairman Bishop Wasonga presents the chief guest with a token of appreciation.
14. A front view of the new CHAK offices, guest house and conference centre
CHAK Times May - August 2009
21
feature
...continued from page 19
as scheduled, followed by meals and physical exercise at
stipulated times. You will be required to avoid sugary foods,
animal fat, alcohol and heavy meals, among other things.
You may have time out with friends, but should not be
side-tracked by their excesses; do not forget at any time that
you are diabetic. If you take sugary foodstuffs (and alcohol
sometimes), skip or change your insulin doses without your
doctor’s advice, your blood sugar may rise and make you
hyperglycaemic, that is, having too much sugar in the blood.
This may be followed by poor vision, weakness, sleepiness and
other symptoms that eventually cause coma and death.
Not observing meal times while taking insulin or varying
doses may cause hypoglycaemia or too little sugar in your
blood. The outcome is confusion, irritability, disordered
movement, shakiness, coma, brain damage and death.
To appreciate discipline, sample this. I inject
myself in the morning and take breakfast
exactly 45 minutes later. I know that my
blood sugar is likely to rise if I am immobile,
so I walk for twenty minutes after my wife
who goes ahead in the car to her work place.
From here, I take snacks, lunch, and supper
in controlled quantities. My meals and drinks
are free of animal fat, egg yolk, too much milk,
oily foods like sausages and French fries,
alcohol and many others things. However,
I use little amounts of corn or sunflower oil.
I also consume some carbohydrates, lots
of vegetables, just enough proteins, certain
fruits and water. For 23 years, I have not
had an after-meal siesta, which may derange
sugars.
Plan your travel
Travel can be quite a problem to an uninformed diabetic. My
most challenging moment was when I traveled in a plane for
the very first time to the United Kingdom for studies.
My very wise wife advised me to avoid plane food and
instead packed some for me. Her rationale was that although
airlines served food for diabetics, it could end up being
inappropriate for me. How right she was! The food turned out
to be an upsetting mixture of things I did not even recognise.
The lunch she had packed for me not only lasted me up to the
end of the journey, but kept me going for a few hours before I
discovered the places that served my favourite foodstuffs.
She had gone a step further. In my luggage, she had packed
a packet of Jogoo maize flour, just in case I did not find any
where I was going. That flour served me for two weeks before
I learnt that “unga” was only available in London, hundreds of
kilometers from where I was living, and that only one Asian
shop brought it to town on order from African students. I
continued to enjoy my ugali far away from home and did not
even care when my Russian roommate wondered aloud how
a human being could survive on “animal feed”.
Nothing could alter my resolve to eat whatever would keep
my blood sugar in control. Nowadays, if I deem it necessary, I
carry food, take injections, and eat anywhere - while walking,
in the car, taking public transport, in the plane. The presence
of people does not prevent me from doing what I must do.
Consult your doctor
As a diabetic, always listen to your body. If you are in doubt
or convinced something is wrong, visit your doctor. Trying to
alter your medicine dose or meal plans without professional
advice may spring serious problems.
Attending routine clinics is not a choice; it is mandatory.
This is the only way you can tell if harmful changes are taking
place in your body and take prompt action to reverse or stop
them. In addition to checking your blood sugar regularly, visit
your doctor for blood pressure, kidney function, eyes, and feet
check, among other things. Do not ignore deceitfully minor
problems. A thorn prick on the small toe can make you lose
the entire leg.
What you must do
A diabetic patient can
live as long as any other
person. The secret to
a long fruitful life is to
know your condition
and accept it. Like in all
other things, discipline
is most important.
Observe medication, meal, and physical activity schedules.
Plan your travel and do not allow people or situations to sidetrack you. Above all, as your own best “doctor”, listen to your
body and keep on “disturbing” your other doctor.
Of course, you will need to be checked regularly to detect
any adverse changes in the body. Believe it or not, sometimes,
you will find it funny that you are diabetic.
If you are not diabetic, then act as a “source” of information
that cheers up and “sweetens” the life of a diabetic. r
Mwangi Maina is a pharmacist with Kenyatta National Hospital.
He consults on Health Systems, Drug Management and Rational
Drug Use for Mission for Essential Drugs & Supplies (MEDS),
Christian Organizations Research and Advisory Trust for Africa
(CORAT Africa), Centre for Drug Management and Policy
(CEDMAP) and Management Sciences for Health (MSH) among
others.
22 CHAK Times May - August 2009
feature
PCEA Kikuyu
Hospital
Diabetes Clinic
Introduction
CEA Kikuyu Hospital is situated in Kikuyu Division of
Kiambu West District and lies on the outskirts of Nairobi,
about five kilometres from the Nairobi-Naivasha
highway.
The diabetes clinic was started in 1993 as a small offshoot
of the eye unit after many patients presented with diabetes
related problems. Many patients were unaware that their eye
problems were as a result of poorly controlled blood sugar.
Much effort was put into management of patients by treating
and educating them about diabetes. As a result, the clinic
continued to grow.
In 1997, the clinic was moved to the Outpatient Department
from where it operates to date. It is manned by:
• One clinical officer
• Two nurses
• One chiropodist/podiatrist (visiting)
• One nutritionist
• A visiting physician who attends to patients with
complications.
The Diabetes Clinic also works closely with other consultants
and departments for holistic care of patients.
P
A glance at Diabetes Mellitus
This is a metabolic disorder characterized by high blood sugars
as a result of little or no insulin production/insulin resistance.
It is classified into two types - Type I and Type II. Another
subtype is gestational diabetes.
• Type I – Insulin dependant
• Type II – Non insulin dependant
• Gestational diabetes – occurs in pregnancy
Signs and symptoms
• Thirst (polyclipsia)
• Hunger
• Excess urination (polyuria)
• Weight loss (mostly in Type I Diabetes)
• Blurred vision
• Poor healing of wounds, and many others
Complications
• Neuropathy
• Infertility
• Renal failure
• Erectile dysfunction
• Hypertension
• Retinopathy
• Gum disease
Activities at the PCEA Kikuyu Hospital Diabetes Clinic
Objective
To promote health, prevent illness and complications to our
clients by empowering them with knowledge on how to take
care of themselves.
Vision
“Sensitizing as many people as possible on diabetes mellitus
how to control and how to prevent those who do not have
from getting it”
Triage
Patients are served on the basis of first come first served
whereby they pick numbers as they come into the clinic.
Observations taken at the nurse’s desk include blood pressure,
blood sugar, (postpradial sugar or fasting blood sugar) weight,
height (for the newly diagnosed).
These observations are a routine for every patient who
comes to the clinic. In the process, very sick patients are
identified and prioritised to be seen by the clinician.
Assessment, treatment and management
New patients are assessed for:
• Peripheral, neuropathy (numbness, burning sensation),
peripheral vasculization (poor wound healing, muscle
cramps)
• Sexuality (loss of libido, vaginal infections)
• Gastrointestinal involvement(constipation, heartburn,
abdominal fullness)
• Hypertension and medication they are currently taking
• Eye (cataracts and retinopathy)
• Dental (tarter, caries)
Known cases of diabetes are assessed for compliance and
complications. The above assessment helps the clinician to
determine the type of treatment education to be given and
duration of subsequent visit.
Education
Patients are equipped with basic knowledge on diabetes, diet
and exercise, foot care, compliance and its benefits and long
range complications.
Diabetes being a progressive condition, they are counseled
on the need to start insulin early before complications set in.
They are also educated about hypoglacaemia, hyperglacaemia
and weight management. Individual needs are identified
and appropriate information given. For example, patients to
be started on insulin are educated on self administration of
the drug, storage and dosage. During subsequent visits, the
patient’s needs are identified and advice given accordingly.
Referral
The clinic receives patients from other departments e.g. eye,
turn to page 25
c
CHAK Times May - August 2009
23
update
Celebration as CHAK guest house and
conference centre is officially opened
By Dr Samuel Mwenda-General Secretary, CHAK
C
elebration and dance marked the official opening of
the CHAK offices, guest house and training centre.
The chief guest during the occasion was H.E. Walter
Lindner, Ambassador of the Federal Republic of Germany,
represented by Mr. Gottfried von Gemmingen, Head of the
Department of Economic Cooperation.
The occasion was also graced by Monika Hoffman-Kuenhel
from EED, CHAK’s main partner in the project. The celebration
held on on April 21, 2009, marked the achievement of a
major milestone in CHAK’s development. The celebration
marking the achievement of a vision that was over 20 years
old was indeed befitting of the occasion. Guests could not
resist getting onto their feet to dance to melodious tunes from
a local band.
The occasion was hosted by CHAK Trustees with the
support of the Secretariat and attended by CHAK members,
representatives of the Ministry of Medical Services, Ministry
of Public Health and Sanitation and National AIDS Control
Council. Partner representatives in attendance included
Dr Klaus Hornetz, chair of the Health Sector Development
Partners, and Civil Society partners.
The thanks giving sermon was delivered by CHAK Trustee,
the Very Rev. Dr. George Wanjau. His message was based
on Luke 17:11-19, which talks about the healing of the ten
men with leprosy and how they gave thanks to God for the
miracle. A cake with the themes of the biblical foundation of
photos: CHAK
Mr. Gottfried von Gemmingen, representative of H.E. Walter Lindner,
Ambassador of the Federal Republic of Germany, the chief guest at
the event, signs the visitors book as outgoing CHAK chairman Bishop
Joseph Wasonga looks on.
CHAK based on Rev.22:2 and African hospitality was cut and
joyfully shared by all present.
Outgoing CHAK Chairman Bishop Joseph Wasonga
delivered the welcoming remarks, thanking the German
Government’s Ministry of International Cooperation and
Development and EED for their generous funding of the
project. He reported that the project had
cost a total of Ksh126m of which 65 per cent
came from EED/German Government and the
remaining 35 per cent from CHAK.
The CHAK Guest House and Conference
Centre boats the following facilities:
• Fully equipped kitchen and support
facilities
• Fully equipped laundry
• Executive self contained accommodation
rooms served by solar and electric water
heaters
• Three meeting rooms with a seating capacity
of 30-80 people
• Reception lobby with gift shop
• Resource centre with cyber café and wireless
Internet access
• Backup borehole water source and 100KVA
generator for power backup
From left: CHAK General Secretary Dr Mwenda, chief guest Mr. Gottfried von Gemmingen, outgoing CHAK chairman Bishop Wasonga, Dr Kiima and other guests do a jig during
the event.
24 CHAK Times May - August 2009
turn to page 31
c
update
Policy documents
launched at
Annual Health
Conference
photo: CHAK
C
HAK launched its published health systems
strengthening policy documents at its Annual Health
Conference and Annual General Meeting held at
Jumuia Conference Centre, Limuru.
The documents were developed through a participatory
process involving CHAK’s member network, the secretariat
and Executive Committee (EXCO). The process of developing
the documents was facilitated by consultants from the
University of Nairobi and Capacity Project.
The Theme of the AHC/AGM was “Sustainability of
church health services: enhancing efficiency, quality and
sustainability through innovative health financing strategies
and Health Systems Strengthening”. The AHC/AGM had a
...continued from page 23
dental, orthopaedic, the general unit and other hospitals.
These patients are either newly diagnosed or known cases
that are not on follow up. Patients are referred to other units
for annual check up e.g. dental, eye, renal, lipids profile and
HBAIC every three months.
The visiting chiropodist does feet assessment on all patients
as well as management of neuropathy, ulcers and education
on foot care.
Patients served
All patients sent from other departments within the hospital
are attended to. In addition, there are referrals from other
institutions and hospitals as well as individuals seeking better
management of their condition.
PCEA Kikuyu Hospital Diabetes Clinic emphasises on
patients’ education, conducted on a one-on-one basis, as we
believe knowledge is power and helps patients stick to their
treatment plan.
The clinic attends to an average of 30 -35 patients daily. The
staff also attend outreaches to identified areas where known
cases are assessed and new ones identified. The outreaches are
organized by the hospital outreach co-ordinator. Sometimes,
the clinic receives invitations to facilitate outreaches. We
welcome you to our clinic to learn more about us. We are
open every Monday to Friday from 7.30am to 4.30pm. r
Prepared by:
P. Kimpiatu M.D, FRCSI, FCS-ECSA & Diabetes Team
Chief Medical Officer
PCEA Kikuyu Hospital
From left: Mr Stephen Cheruiyot, Dr. David Kiima who is also the chairman of MOH-FBHS-TWG and Mr. Mogere, all from the Ministry of
Health with CHAK chairman Bishop Michael Sande during a question
and answer session at the Annual Health Conference.
record attendance of 270 participants from CHAK member
health units and churches countrywide as well as partner
organisations.
The policy documents launched included:
• Human Resource Management Generic Policy Manual
and Tools
• Governance Policy Manual for Hospitals
• Governance Policy Manual for Health Centres &
Dispensaries
• HIV Workplace Policy
• Financial Management and Procurement Procedure
Manual and Tools
Printed and electronic copies of the policy documents were
disseminated to the entire CHAK network. The Secretariat has
offered to support members wishing to adapt the policies in a
bid to enhance management and accountability in MHUs.
The keynote address from the Permanent Secretary,
Ministry of Medical Services, Prof. James Ole Kiyiapi, was
presented by Mr. Mogere accompanied by Dr. David Kiima
who is the chairman of MOH-FBHS-TWG.
The key note address highlighted new policy developments
at the Ministry of Medical Services and reiterated Government
commitment to partnership with faith based organisations and
other stakeholders in the health sector.
Partnership and collaboration in the health sector
The second part of the conference involved dialogue with
Government on partnership and collaboration in the health
sector. Mr. Kimani and Mr Stephen Cheruiyot from the
Department of Planning made a presentation on the Health
Sector Services Fund (HSSF) which is anticipated to be
rolled out from July 2009. The fund has created a window
of opportunity for direct funding to public and faith-based
health facilities.
turn to page 26
c
CHAK Times May - August 2009
25
update
...continued from page 25
Dr. Wanjau Mbuthia from KEMSA presented feedback on
the distribution of Essential Drugs or dispensary kits to FBO
dispensaries since the support was initiated by the MOH in
April 2008. Despite initial teething problems, he reported
that this support was going well and had created notable
impact in the utilization of FBO dispensaries following the
implementation of the Ksh50 fee policy.
Health financing
New and innovative health financing initiatives were
presented by Jack Kinuthia of Jamii Bora Trust, Kenya Women
Finance Trust, Michael Gitau of Afya Yetu Initiative (CBHFI)
and Stanley Mung’athia of Maua Methodist Hospital who
spoke on community mobilization for National Hospital
Insurance Fund (NHIF) membership.
Mr Kinuthia inspired participants with the testimony of
the humble beginnings of Jamii Bora Trust which began on
the streets of Nairobi. The trust would assist street families to
save-borrow-invest and has today grown into a nationwide
microfinancing and health insurance agency with over
200,000 members. The trust supports health services in 45
accredited hospitals.
The Kenya Women Finance Trust introduced its Afya Card
Health Cover which targets its 300,000 members. The scheme
provides NHIF cover, personal accident cover and funeral
expenses support all at a premium cost of Ksh10 per day.
The Afya Yetu Initiative based in Nyeri educated members
on the strategy of risk pooling using a community-based health
financing initiative. Mr. Gitau shared the process involved
in setting up a CBHFI and measuring its performance. The
mobilization and empowerment of community members to
manage a CBHFI were highly appreciated.
Mr. Stanley Mung’athia from Maua Methodist Hospital
inspired the AHC delegates with the hospital’s strategy to
address bad debts and sustainability through a new-found
partnership with NHIF. Maua has partnered with churches, the
Provincial Administration and NHIF to scale up recruitment
of workers in the informal sector to NHIF.
The hospital has provided NHIF with office space and
equipped a community mobilization team with a vehicle,
camera and photocopying machine to facilitate completion
of registration of newly recruited members at the community
outreach sites. This investment has borne fruit; hospital
inpatient members have increased steadily and revenue
generated from NHIF clients has dramatically increased from
15 per cent to 43 per cent in 2009.
Mr. Justus Marete of AIC Kijabe Hospital presented an
overview of health care financing and cost control in a teaching
and referral mission hospital. Kijabe hospital has managed to
finance its annual budget of Ksh390 million through a business
model of financial management and partnerships.
photo: CHAK
Jack Kinuthia of Jamii Bora Trust makes his presentation.
Health systems strengthening
Other member hospitals shared their experiences with health
systems strengthening and health care financing.
Dr. Mutembei Ringera, MO/IC, St Lukes Hospital
Kaloleni, gave a moving testimony of the “re-birth” of the
facility from a dilapidated and condemned institution to a
vibrant, community-engaging mission hospital with purpose,
inspiration and results. He attributed the successful turn
around at St. Luke’s to team work, focus on health systems
strengthening and partnerships.
Mr Kiburi Thambura, Director of Human
Resource and Administration at Friends Lugulu
Graph showing increase in NHIF revenue and inpatient numbers at Maua
Hospital, shared on the facility’s experience
Methodist Hospital in Eastern Province
with computerization. Within six months
50000
of implementation of the computerization
45000
programme, revenue increased by 75 per cent
40000
due to enhanced efficiency. Mr Thambura
took special note of improved monitoring
35000
through the LAN and timely release of financial
30000
information which was subsequently used to
25000
INPATIENTS.
support management decision making.
NHIF
20000
ACK Maseno Hospital shared on the
15000
exciting developments in their HIV/AIDS
10000
Comprehensive Care Services and Male
5000
turn to page 27
0
2005
26 CHAK Times May - August 2009
2006
2007
2008
c
update
MEDS quality control laboratory receives
WHO pre-qualification
T
he Mission for Essential Drugs and Supplies’ (MEDS)
pharmaceutical quality control laboratory has become
the first such faith-based facility in Africa to be prequalified by the World Health Organization (WHO).
Prequalification means that the laboratory has been found
to operate at acceptable levels of compliance with WHO
guidelines for quality control laboratories and can be used
by UN agencies in providing testing services for medicines.
The launch of the pre-qualified laboratory was officiated
by the Minister in charge of Medical Services Hon. Prof.
Peter Anyang’ Nyong’o and attended by several dignitaries
including the WHO Kenya country director, Dr Okello.
The new status involved systematic upgrading of the
laboratory’s infrastructure, training of staff, documentation
and implementation of a Quality Management System as well
as improvement of processes to meet WHO requirements.
The new status is expected to raise the level of confidence
for both internal and external clients concerning the quality
and reliability of results generated by the laboratory. This
would be achieved through the use of competent technical
staff, properly maintained equipment, consistent and
repeatable processes as well as better management control
and reporting. The pharmaceutical drugs supply agency is
owned by CHAK and the Kenya Episcopal Conference (KEC)
of the Catholic Church. r
...continued from page 26
Rachel Waireri from Kenya Methodist University, Department
of Health Systems Management made a presentation on the
nursing, medical and health systems management programmes
being offered at KEMU at diploma, postgraduate diploma,
degree and Masters level. These include:
• BSC in Nursing – both basic and upgrading from KRCHN
• Masters in Nursing Executives
• Diploma in Clinical Medicine (Clinical Officer)
• BSC in Medical Laboratory Sciences
• BSC in Heatlh Systems Management
• MSC in Health System Management
The University has developed three modes of study: e-learning,
part-time/intensive programme and full time.
Managing Director, MEDS, Mr. Pascal Manyuru, gave an
overview of the drug supply agency’s growth and sustainability
challenges over the past year.
Medical Circumcision programme. The Hospital has evolved
as a Centre of excellence in HIV/AIDS Services.
Partners
The conference also gave an opportunity to CHAK partners to
speak on opportunities for collaboration and lessons learnt.
The CBM Country Director Nat Bascom and Sabatia Eye
Hospital CEO Dr Dimmissie spoke on opportunities for training
and equipping CHAK MHUs to scale up eye care services.
The MHUs would be linked to specialized eye care centres
in a referral system.
A skills building exercise for Registered Nurses and Clinical
Officers was already being offered at Sabatia Eye Hospital at a
cost of Ksh70,000, which covered all expenses including full
board accommodation. Funding was being sought to provide
scholarships to selected candidates.
Dr. O. Subiri, the AIDSRelief Deputy Chief of Party, spoke
on sustainability perspectives from the AIDSRelief project.
He indicated that a sustainability task force was developing
strategies for transition and sustainability.
AMREF Training Centre gave an overview of opportunities
for certificate nurses to upgrade to diploma level through
e-learning. This was being done in collaboration with the
Nursing Council of Kenya and 105 nurse training colleges and
hospitals. Participants were enlightened on the advantages and
procedures used in e-learning.
The MEDS pharmaceutical quality control laboratory.
AGM
The AGM concluded the annual CHAK event. Members were
presented with the CHAK Annual Report and audited accounts.
The AGM gave another six year mandate to the sitting trustees
and elected some new EXCO officials.
We wish to thank all facilitators at the AHC for their
excellent contributions which made our conference a great
success. We also appreciate the Secretariat staff for their
hard work. The next CHAK Annual Health Conference and
Annual General Meeting will be held at the same venue in
April 2010. r
CHAK Times May - August 2009
27
update
Bishop Michael
Sande elected new
CHAK chairman
The Rt. Rev. Michael Sande
has been elected CHAK
chairman for a two-year
period.
Bishop Sande, who was
the only candidate to vie
for the position, received
Bishop Sande
a unanimous endorsement
from delegates at the CHAK
Annual General Meeting
held in April. Bishop Sande’s election followed the retirement
of Bishop Joseph Wasonga who had served the association for
the maximum allowable term of six years.
Bishop Sande is the Anglican Bishop of the Diocese of
Butere in Western Kenya. Prior to his election as chairman,
Bishop Sande had served very effectively as the Association’s
treasurer for four years.
He has a professional background in science and the
pharmaceutical industry in addition to theological training
and experience. Before his ordination as a clergy, Bishop
Sande served as the managing director of Faizal International
Pharmaceutical Company and brings to CHAK a wealth of
experience in the health and pharmaceutical sector.
Making his acceptance speech, Bishop Sande thanked
CHAK members for the honour accorded to him and indicated
his commitment to serve with dedication and humility.
Elections
Elections were also held for other
officials. Mr Geoffrey Lang’at, the
Tenwek Mission Hospital CEO, was
elected treasurer. He previously served
as the vice treasurer.
Mr Stanley Mung’athia, Maua
Methodist Hospital administrator, was Mr Langat
elected vice treasurer while Mr Barnabas
Agar and Mr Stanley Gitari were reelected regional chairmen for Nyanza/South Rift and Eastern/
North Eastern respectively. Other Executive Committee
members who continue in office include:
• Mrs Nancy Ngang’a – Vice chairman,
• Mrs Rose Muhanda – RCC chair for Western/North Rift
Region
• Dr James Kariithi – RCC chairman for Central/Nairobi/South
East and Coast region
• Dr Samuel Mwenda – General Secretary and secretary
The AGM also extended the terms of trustees for another
six years. However, Bishop Horace Etemesi retired with
28 CHAK Times May - August 2009
immediate former CHAK chairman Bishop Joseph Wasonga
taking his place.
According to the CHAK Constitution, the new chairman also
becomes the chairman of the Board of Trustees. The complete
list of trustees for the next six years is as follows:
• Rt. Rev. Michael Sande - Anglican Church
• Rt. Rev. Joseph Wasonga – Anglican Church
• Rev. Prof. Zablon Nthamburi – Methodist Church
• Very Rev. Dr George Wanjau – Presbyterian Church of
East Africa
• Rev. Joseph Maswai – Africa Inland Church
• Pastor Paul Muasya – Seventh Day Adventist Church
• Rev. Joseph Rono – Africa Gospel Church
CHAK Secretariat welcomes on board the team of EXCO
and trustees and assures them of all necessary support as
they guide CHAK to greater heights of prosperity in Christ’s
healing ministry. r
Mr Gitari
Mr Agar
...continued from page 3
The MoU would facilitate scale up of support to faith-based
health facilities in both cash and kind from Government
and Development Partners. The support will however be
linked to performance against set service delivery targets
as in annual workplans submitted through the District
Health Management Teams (DHMT).
Performance would be monitored through submission
of monthly statistics to the MOH through the District
Medical Records Officer. The MoU recognizes a health
financing mechanism from various sources:
• User fees
• Government grants through the Health Sector Service
Fund (HSSF)
• National Hospital Insurance Fund (NHIF)
• Donor funding
Financial accountability will be essential and regular
reports submitted through the secretariats. Human
resource support through secondment of health workers
will be better structured and managed. An effective and
accountable Governance structure must be maintained in
all health facilities. The MOH-FBHS-TWG will coordinate
and provide oversight to implementation of the MoU. Its
new mandate and terms of reference have been stipulated
in the MoU. We wish to congratulate all partners for this
public-private-partnership milestone for Kenya and indicate
our full commitment to ensuring effective implementation
of the MoU. r
update
Bishop Joseph Wasonga retires
as CHAK chairman
T
trustee and in any other capacity
as needed.
Bishop Wasonga leaves
behind a legacy of a facilitatory
and enabling leadership that
allowed space for participation
and development of new ideas.
During his tenure, CHAK made Bishop Wasonga
major strides in organizational
development with some key
highlights as follows:
• Amendments were made to the CHAK Constitution
• Development and Implementation of CHAK Strategic
Plan 2005-2010
• Development of a Memorandum of Understanding
between the Government and Faith Based Health
Service providers
• Development of new CHAK offices, guest house and
conference centre
• Establishment of a vibrant HIV/AIDS Department at
CHAK
• Steady growth of CHAK assets portfolio
• Development of health systems strengthening
policies and capacity enhancement at the
Secretariat
• Development of plans and financing
arrangement for New MEDS
On behalf of the Secretariat, EXCO, Trustees
and CHAK members, we thank Bishop Wasonga
for his humble and inspirational leadership of
CHAK. He certainly leaves behind a legacy to be
remembered and emulated. We hope to continue
enlisting his support in our various high level
advocacy engagements.
Bishop, may the Lord who has called you
to this service bless you with good health and
wisdom as you lead His people in various other
CHAK Net Assets Growth in Kenya shillings over the period 2001-2008
capacities. r
he Rt. Rev. Joseph Wasonga has retired from the
chairmanship of CHAK after serving the maximum
allowable term of six years. His third and final two-year
term formally came to an end at the AGM held on April 23,
2009, at the Jumuia Conference Centre, Limuru.
In his final remarks to the AGM as CHAK chairman, Bishop
Wasonga said he had found leading the Association a great
joy and rewarding experience due to the dedication of EXCO
members, Trustees, management and staff.
He observed that much progress had been made through
teamwork. He particularly thanked the General Secretary Dr.
Samuel Mwenda for his dedicated leadership of the Secretariat
and support to the governance structures of CHAK.
Bishop Wasonga added that he was retiring a happy man
following the steady growth and development achieved at
both CHAK and MEDS where he also served as chairman for
three years.
He wished the new CHAK chairman Bishop Michael Sande
success and God’s blessings as he took over leadership and
indicated that he would remain available to serve CHAK as a
Nurse educator receives Head of State commendation
J
anet Nyanga Mwamuye, a nurse educator and nurse
administrator at Maua Methodist Hospital School of Nursing,
recently received the Head of State Commendation (HSC)
Award for her significant contribution to nursing in Kenya.
The prestigious award was presented to her in Nairobi.
Sr. Mwamuye was also chosen as the keynote speaker for
the 50th anniversary NNAK Golden Jubilee at the conclusion
of Nurses Week.
Janet has an extensive work history in Government and the
faith based sector. She has worked as a clinical nurse, midwife,
community health nurse, nurse educator and in management
and leadership roles.
Janet has been actively involved in nursing and midwifery
activities nationally and within the eastern, central and
southern African region.
She received a recognition certificate and letter from
the Eastern Central Southern African College of Nursing
(ECSACON) for her contribution to the organisation, as well
as a Certificate of Merit from the Nursing Council of Kenya
for her exemplary service to the council, nurses and nursing
as the Registrar of the Nursing Council of Kenya. r
CHAK Times May - August 2009
29
update
Swine flu: what you need
to know
Definition
Novel HINI (referred to as “swine flu” early on) is a new
influenza first detected in people in the United States in
April 2009. Many other countries have reported people
sick with this virus. This virus is spreading from person-toperson, probably in much the same way as regular seasonal
influenza viruses.
This virus was originally referred to as “swine flu” because
laboratory testing showed that many of the genes in this new
virus were very similar to influenza viruses that normally
occur in pigs in North America. But further study has shown
that the virus is very different from what normally circulates
in North American pigs.
Epidemiology
The first novel H1N1 patient in the United States was
confirmed by laboratory testing at CDC on April 15, 2009.
The second patient was confirmed on April 17, 2009. It
was quickly determined that the virus was spreading from
person-to-person. On April 22, CDC activated its Emergency
Operations Center to better coordinate the public health
response. On April 26, 2009, the United States Government
declared a public health emergency and has been actively
and aggressively implementing the nation’s pandemic
response plan.
On June 11, 2009, the World Health Organization
(WHO) signaled that a global pandemic of novel influenza
A (H1N1) was underway by raising the worldwide pandemic
alert level to Phase 6. This action was a reflection of the
spread of the new H1N1 virus, not the severity of illness
caused by the virus. At the time, more than 70 countries had
reported cases of novel influenza A (H1N1) infection and
there were ongoing community level outbreaks in multiple
parts of the world.
Since the WHO declaration of a pandemic, the new
H1N1 virus has continued to spread, with the number of
countries reporting cases of novel H1N1 nearly doubling.
The Southern Hemisphere’s regular influenza season has
begun and countries there are reporting that the new H1N1
virus is spreading and causing illness along with regular
seasonal influenza viruses.
In the United States, significant novel H1N1 illness has
continued into the summer, with localized and in some cases
intense outbreaks occurring. The United States continues to
report the largest number of novel H1N1 cases of any country
worldwide. However, most people who have become ill
have recovered without requiring medical treatment.
By June 19, 2009, all 50 states in the United States, the
District of Columbia, Puerto Rico, and the U.S. Virgin Islands
have reported novel H1N1 infection. While nationwide U.S.
influenza surveillance systems indicate that overall influenza
30 CHAK Times May - August 2009
activity is decreasing in the country at this time, novel H1N1
outbreaks are ongoing in parts of the U.S., in some cases
with intense activity.
Given novel H1N1 activity to date, CDC anticipates that
there will be more cases, more hospitalizations and more
deaths associated with the pandemic. The novel H1N1 virus,
in conjunction with regular seasonal influenza viruses, has
the potential to cause significant illness with associated
hospitalizations and deaths.
In Kenya, the first case of H1N1 was reported in June
2009 in a student who had travelled from the UK. With
this confirmation, Kenya joins South Africa, Ethiopia, Ivory
Coast and Cape Verde as countries hit by the flu in the SubSaharan Africa. South Africa became the first sub-Saharan
African country to confirm a case of swine flu.
The World Health Organization says many African
nations are particularly vulnerable due to poor health care
systems, poverty and the presence of other respiratory
illnesses, such as tuberculosis and asthma. According to
the WHO’s latest figures, there have been 59,814 cases of
swine flu and 263 deaths worldwide.
The second major swine flu scare in Kenya occurred on
July 30, 2009, in Butere District, western Kenya when 14
patients were admitted at Namasoli Health Centre with very
high fever, headache and joint pain. However the diagnosis
was negative for H1N1.
Signs and symptoms of swine flu
CDC has determined that novel H1N1 virus is contagious
and is spreading from human to human. However, at this
time, it is not known how easily the virus spreads between
people. It spreads like ordinary flu, i.e. in viral particles
expelled in coughs and sneezes that are then breathed in by
someone nearby, or deposited on surfaces that are touched
by the hand and transmitted to the mouth, nose or eyes.
People with the virus may be able to infect others beginning
a day before the symptoms develop and up to seven days or
more after becoming sick.
The symptoms of novel H1N1 flu virus in people are
similar to the symptoms of seasonal flu and include sudden
fever (above 380 C), cough, sore throat, runny or stuffy
nose, body aches, headache, chills and fatigue. A significant
number of people who have been infected with this virus also
have reported diarrhea and vomiting. Also, like seasonal
flu, severe illnesses and death has occurred as a result of
this virus.
turn to page 31
c
update
...continued from page 30
Prevention and treatment
No vaccine is currently available to protect against novel
H1N1 virus. However, there are everyday actions that can
help prevent the spread of germs that cause respiratory
illnesses like influenza. Take these everyday steps to protect
your health:
• Cover your nose and mouth with a tissue when you cough
or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially
after you cough or sneeze. Alcohol-based hand cleaners
are also effective.
• Avoid touching your eyes, nose or mouth.
• Try to avoid close contact with sick people.
• Stay home if you are sick for seven days after your
symptoms begin or until you have been symptom-free for
24 hours, whichever is longer. This is to keep from infecting
others and spreading the virus further.
• Follow public health advice regarding school closures,
avoiding crowds and other social distancing measures.
• Be prepared in case you get sick and need to stay home
for a week or so.
• If you are sick, limit your contact with other people as
much as possible. Clean your hands, and do so every time
you cough or sneeze.
Employees who are well but have an ill family member at home
with novel H1N1 flu can go to work as usual. They should
however monitor their health every day, and take everyday
precautions including washing their hands often with soap
and water, especially after they cough or sneeze.
If they become ill, they should notify their supervisor
and stay home. Employees who have an underlying medical
condition or who are pregnant should call their health care
provider for advice, because they might need to receive
influenza antiviral drugs to prevent illness
If you live in areas where people have been identified with
novel H1N1 flu and become ill with influenza-like symptoms,
including fever, body aches, runny or stuffy nose, sore throat,
nausea, or vomiting or diarrhea, you should stay home and
avoid contact with other people. Staying at home means that
you should not leave your home except to seek medical care.
This means avoiding normal activities, including work, school,
travel, shopping, social events, and public gatherings.
If you have a severe illness or are at high risk of flu
complications, contact your health care provider or seek
medical care. Your health care provider will determine
whether flu testing or treatment is needed. If you become
ill and experience any of the following warning signs, seek
emergency medical care.
In children, emergency warning signs that need urgent
medical attention include:
• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and
worse cough
In adults, emergency warning signs that need urgent medical
attention include:
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever
and worse cough
Medication
The CDC recommends the use of oseltamivir or zanamivir
for the treatment and/or prevention of infection with novel
H1N1 flu virus. Antiviral drugs are prescription medicines
(pills, liquid or an inhaled powder) that fight against the flu by
keeping flu viruses from reproducing in your body.
If you get sick, antiviral drugs can make your illness milder
and make you feel better faster. They may also prevent serious
flu complications. During the current outbreak, the priority use
for influenza antiviral drugs during is to treat severe influenza
illness. r
Compiled by Dr Stanley Kiplagat - Health Services Support Department Manager, CHAK
...continued from page 24
Monika Hoffman of EED congratulated CHAK for
completing the facility despite numerous challenges.
She narrated to the guests the partnership dialogue that
eventually led to approval and funding of the project.
She hoped that the spacious and better equipped offices,
guest house and training centre would strengthen CHAK’s
institutional capacity to effectively play the roles of capacity
building and advocacy in order to facilitate MHUs to deliver
quality, affordable and accessible health care services.
Delivering the opening remarks on behalf of the German
Ambassador, Mr. Gottfried said the successful partnership
with CHAK had led to notable gains in the health sector. He
reiterated the commitment of the German Government to
continue supporting the health sector by collaborating with
both Government and civil society/private sector.
He affirmed the German Development Corporation’s
confidence in the Faith Based Health Sector, which covers
a substantial part of health services in the country.
CHAK Secretariat is grateful to all members, friends
and partners who came to share in the celebration.
This development will go a long way in strengthening
the institutional capacity of CHAK towards long term
sustainability. We wish to express our sincere thanks to
Felister Gitau who chaired the event planning committee
together with all her committee members for an excellent
job done.
All are welcome to enjoy our facilities and hospitality
in a serene and quiet Christian environment. r
CHAK Times May - August 2009
31
update
16 Days of Activism against
Gender – Based Violence
‘Commit, act and demand to end violence against women’ using a
biblical approach
T
he 16 days of activism against gender- based violence
came about as a United Nations initiative to ensure that
gender violence was put as a topic at international level.
It starts on November 25 which is marked as the International
Day against Gender Violence and ends on December 10 which
is marked as the International Day of Human Rights. This
year’s theme is ‘Commit, Act and Demand to end violence
against women’.
The Church acknowledges that there is gender violence but
there are attempts to cover up the issue especially when done
by their own. Examples can be quoted of instances where the
Church has been intimidated into silence by illegal organized
gangs either by accepting financial support or through fear of
personal injury or death.
Everyone agrees that it is time for the Church to come out
strongly and talk against gender violence. This can be done
through the “Tamar Campaign”, which was launched in Kenya
in 2005 and originated in South Africa. This campaign seeks
to acknowledge the existence of Gender-Based Violence in
African society with particular focus on sexual and domestic
violence and to challenge churches and religious institutions
to address the crisis.
Tamar campaign focuses on using the Contextual Bible
Study Method to filter the message of healing, restoration
and hope to the survivors of Gender-Based Violence at the
local level of the church. Contextual Bible Study emphasises
on active and equal participation where all group members
are engaged in bringing the scripture to life through their own
story. The Bible study is therefore done through facilitation.
The church is uniquely placed in society to play a decisive
role in the prevention and elimination of the different forms
of violence against women and children and possesses moral
authority, responsibility and capacity to minister to the needs
of those who have been abused, as well as deal with the
perpetrators.
It is important for pastors, lay leaders and Bible study
group members to actively engage each other in dialogue
on Gender-Based Violence which is present in the Bible and
active in our communities today.
Through guiding Bible study group members in interpreting
the text for its historical, literary and reader/reception resources,
facilitators can guide the group in further understanding both
the positives and negatives of specific Bible stories and the
hope and love of God shown in each. Also known as “behind
the text”, “on the text” and “in front of the text”, this method
allows members to apply the message of each story to their
own cultural, religious, economic and social context.
32 CHAK Times May - August 2009
To guide us on the activities for the 16 days of activism, a
Contextual Bible Study Manual on Gender-Based Violence is
available. This manual has been prepared under the guidance
of the Fellowship of Christian Councils of Churches in the
Great Lakes and Horn of Africa (FECCLAHA) on behalf of the
Tamar Campaign Working Group.
The book encourages people to consider gender based
violence from a biblical perspective. The emphasis is on
allowing the readers to read and interpret biblical text
within their own context, cultural background and life
experience, all with the aim of achieving personal and societal
transformation.
Church leaders can commit to preach against gender
violence during the 16 days of activism. Awareness creation
and sensitization of communities around the churches about
Gender-Based Violence can also be done. Addressing gender
based violence in a responsible and respectful manner that
both affirms the survivors and condemns the actions of the
perpetrators is the call of the Church. We cannot remain silent;
we are called to act.
The contextual bible study
manual on gender violence encourages readers
to consider gender based
violence from a biblical
perspective as it relates to
their life and context.
Article complied By Maria Mutiga-CHAK Secretariat
profile
AIC CURE International
Children’s Hospital
Introduction and background
IC-CURE International Children’s
Hospital (AIC-CURE) was built in
1998 as a collaborative effort between
CURE International and the African Inland
Church (AIC) in order to serve both the
medical and spiritual needs of disabled
children in Kenya.
A disabled child has both social and
medical implications. A child with a neglected
disabling condition may suffer ridicule by
peers and discrimination. A family with a
disabled child spends more time in child
care activities, which reduces the amount
of time spent on economic activities. Given
the high prevalence of disability in poor
A front view of AIC-CURE International Children’s hospital.
communities, this situation reinforces the
cycle of poverty.
AIC-CURE is a unique highly specialized hospital. This
A good number of these physical disabilities can be
30-bed, paediatric orthopaedic hospital provides state-ofcorrected through surgery, thus allowing a child to lead a
the-art care for children suffering from clubfoot, cleft lip and
normal life. However, surgical correction is expensive and
cleft palate, curvature of the spine and disabilities stemming
requires a high level of specialization. Medical facilities in
from polio, cerebral palsy, muscular dystrophy and other
Kenya are already overwhelmed by primary healthcare needs
congenital abnormalities. Located in Kijabe, it is the only
and other more prevalent conditions such as HIV/Aids, Malaria
hospital in Kenya exclusively dedicated to treating children
and TB.
with orthopedic related disabilities.
The Founder of CURE International, an American
Since being opened, the hospital has performed more
Orthopedic Surgeon and his wife, Dr. Scott and Sally Harrison
than 22,000 surgeries and treated more than 68,000 patients.
realized this need and thus CURE International was formed.
Annually, about 8,000 patients are seen through outpatient and
Since opening the first hospital in Kenya in 1998, other similar
mobile clinics and 2,500 surgical procedures are undertaken at
hospitals have been established in different parts of the world
the facility. In partnership with Kijabe Mission Hospital, AICincluding Uganda, Malawi, Zambia, Ethiopia, parts of the
CURE provides adult orthopaedic care for conditions resulting
Middle East and South America.
from accidents and injuries as well as sports medicine.
With assistance from various partners, subsidized medical
AIC-CURE places great emphasis on the spiritual aspect of
care is provided to all patients and no patient is turned away
its work. The hospital has a dedicated Spiritual Department
due to inability to pay for the services. Notable sponsors who
that works hand in hand with the medical team to provide
have supported the work of AIC CURE include the Christian
spiritual guidance and counseling to the disabled children
Blind Mission (CBM), Liliane Fonds, Johanniter International,
and their families.
AO Foundation and Smile Train.
Activities include a Ward Ministry, Children’s Playroom,
The primary medical goal of AIC-CURE is provide “first
Staff Spiritual Development and Mobile Clinic Support.
world” quality care to physically disabled children in Kenya,
Recently, the Spiritual Department teamed up with the
and enhance the skills of Kenyan physicians and nurses in
Clubfoot Care for Kenya Program described further below,
paediatric rehabilitation medicine through various training
to provide education and counseling to children undergoing
programs.
treatment. This has resulted in fewer patients dropping out of
the treatment program.
Facilities and Services
AIC CURE facilities include 30 beds, four new state of the art
Mobile clinics
operating rooms that were built through a donation from the
To ensure as many children with disabilities as possible
Caris Foundation and an orthopaedic workshop that produces
orthopedic appliances and aids such as artificial limbs, braces
and crutches. The is an outpatient clinic that is open on
turn to page 33
Wednesdays and Fridays.
A
c
CHAK Times May - August 2009
33
profile
...continued from page 32
are reached, AIC-CURE offers weekly outpatient services
and conducts mobile clinics. Over 50 mobile clinics are
undertaken every year at 10 different locations in the country,
ensuring that services are accessible to the people that need
them most.
The mobile clinics are conducted in the Kenyan towns of
Machakos, Kitale, Eldoret, Mombasa, Nakuru, Kisumu, Embu,
Thika and Nairobi. The hospital team which consists of an
orthopaedic surgeon and physican, occupational therapist,
orthopaedic technologist and social worker travel to the mobile
clinic and work with various partners. Among those who
host the clinics are Government health facilities, Association
of Physically Disabled of Kenya (APDK) centres, churches
and NGOS. The purpose of the mobile clinic is to schedule
prospective patients, review patients returning for follow-up
care as well as provide necessary orthopaedic appliances.
Surgery is done at the facility in Kijabe as well as measurement
and fitting of the more sophisticated orthopaedic aids.
AIC-CURE partners in the mobile clinics who include
medical professionals, pastors and social workers help
identify new patients and inform the patients’ families about
the medical and social issues that they may face. After
surgery, patients and their families are referred to people and
organizations that assist them with rehabilitation, schooling
and other needs.
Club foot Care for Kenya program (CCK)
The CURE Clubfoot Care for Kenya (CCK) Program is a nonsurgical treatment and training program managed by AICCURE. Its aim is to correct clubfoot in young children through
an out-patient system. Physicians and physiotherapists are
trained on how to use the Ponseti Method to correct clubfoot.
The Ponseti Method involves physical manipulation and
plaster casting techniques to correct the anomaly in young
children. This program which started as a pilot project has
been running for the last four years through sponsorship from
Johanniter International. Implementation partners include
Government Hospitals, Association for the Physically Disabled
of Kenya (APDK), Moi Teaching and Referral Hospital – Eldoret
as well as a number of Mission Hospitals. To date, over
1,800 children have enrolled for this program and over 150
healthcare workers have been trained.
Due to the success of this program, CURE International
together with other partners such as CBM established the
Cure Clubfoot Worldwide Program (CCW) which is currently
running in a number of countries including Zambia, Malawi,
Ghana, Ethiopia, Rwanda, India, Afghanistan, Cambodia,
Honduras and Haiti.
COSECSA orthopedic training program
A primary goal of AIC-CURE is training Kenyan orthopaedic
surgeons. Since the hospital began operations in 1998, a
number of Kenyan doctors have gone through an initial two
years of training at AIC-CURE and thereafter been sponsored by
CURE International for a Masters of Medicine in Orthopaedics
at Makerere University in Kampala, Uganda.
In 2007, AIC-CURE was accredited by the College of
Surgeons of East, Central and Southern Africa (COSECSA) as
a training centre for orthopaedic surgeons in partnership with
Moi Referral Hospital, Eldoret, and Kijabe Mission Hospital.
Currently there are six physicians enrolled for this five-year
orthopedic residency training program. The program allows
the residents more practical exposure in a busy hospital
setting. Those who complete this program will be recognized
as COSECSA fellows and orthopedic specialists within the
region.
turn to page 35
c
Inside the orthopaedic
workshop (left) and operating theatre at AICCure International Children’s Hospital.
34 CHAK Times May - August 2009
tea break
Crostic puzzle
By Carol Trachsel - Formerly of Tenwek Hospital
Worth the Risk?
Use the clues to fill in the words on the numbered spaces. Then transfer the letters to the appropriate numbered square in
the puzzle. A black square indicates the end of a word.
___ ___ ___ ___
1-d
2-a
___ ___
18-b 19-e
3-e
4-a
___ ___
5-b
6-a
___ ___
7-c
___ ___ ___ ___ ___ ___ ___ ­­­___ ___
8-d
9-d 10-e 11-c 12-c 13-b 14-b 15-a 16-d 17-e
____ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ .
20-b
21-a 22-a 23-d 24-b 25-c 26-d 27-b 28-b 29-e 30-a
Clues a. Sober
b. Endless
c. Control mechanism
d. Line of mountains e. Keeps something off
___
6
___
5
___
11
___
16
___
3
___
4
___
27
___
7
___
9
___
17
Words
___ ___
22 2
___ ___
20 18
___ ___
1
25
___ ___
8 23
___ ___
19 10
___
21
___
13
___
12
___
26
___
29
___
15
___
24
___
30
___ ___
14 28
See answer to the puzzle on a separate
page of this newsletter
CHAK Times May - August 2009
35
tea break
MEDICAL QUIZ
Send your responses to:
The Editor, CHAK Times, P.O. Box 30690 - 00100 Nairobi; E-mail: [email protected]
The first five correct entries will receive a CHAK gift pack
Remember to include your name, health facility, mobile phone number and full postal address
1. Define the following:
a)Insulin
b)Hyperglycaemia
c)Microsomia
d)Gangrene
e)Normal blood glucose (1 mark each)
2. Explain how your facility is implementing the community strategy in the delivery of Kenya
Essential Package for Health (5mks).
3. Outline the management of diabetes mellitus in pregnancy till end of peuperium.(10mks)
Answers to Medical Quiz 30
1.Define the following:
a) Community Unit:
This is the grass root service delivery point at the community
comprising of 10 households.
b)Community Health Extension Worker (CHEW):
A Community Health Extension Worker (ECN or PHT)
is based at a level two health facility and supervises 50
Community Health Workers.
c) District Health Stakeholders Forum:
This is a meeting of representatives of all organizations that
provide health care services in a district.
d)Kenya Essential Package for Health:
This is the basic minimum health care service provided to
individuals according to their life cohort.
e) Pentavalent:
This is a combined vaccine for under fives composed of
Diphtheria, Pertussis, Tetanus, Hepatitis B and Haemophilus
Influenza type B (Hib) antigens.
2. Describe how you would use Government support in the
form of facility drug kits to ensure the sustainability of your
dispensary.
• Sensitize the community on availability of the drugs and
reduction of patient fees
• Improve on customer care and ensure efficient delivery of
quality health care
• Equip the unit with modern diagnostic equipment for
income generation
• Work with community health workers to promote
community involvement in health care
3. Explain your response to a massive accident or tragedy
that unfortunately occurs next to your health facility on a
Friday evening.
• Call for assistance from all health workers and board
members from the facility
36 CHAK Times May - August 2009
• Contact the DMOH, police and administrators (assistant
chief, chief, DO, DC, teachers, media officials, political
leaders etc) for support in communication, First Aid and
referral.
• Request health facilities nearby to send assistance in the form
of human resources, medical and non medical supplies.
• Evacuate injured individuals to a safe place and quickly
triage them to detect those requiring emergency care
• Record vital information about those affected on the
patients’ notes and in the OPD register clearly indicating
the provisional diagnosis, expected action and the referral
facility
• Come up with a report for relevant authorities and document
lessons learnt in disaster preparedness for future use
There were no winners for Medical Quiz 30.
...continued from page 33
LEGs program
Since 2004, AIC CURE has partnered with Le Tourneau
University Engineering Faculty to develop an affordable
improved artificial leg for above knee amputees. The
polycentric knee is simple and can be produced with
materials procured locally. The LEGs knee has passed ISO
quality tests and is now being produced in Sierra Leone and
Bangladesh. The Le Tourneau Team has partnered with a
number of organizations in these countries.
Recently, a technology demonstration clinic was held
at AIC-CURE, Kijabe where top orthopaedic technologists
from APDK, Kenyatta Hospital, Kenya Medical Training
College, Kikuyu Hospital, Mbagathi Hospital, National
Spinal Injury Centre, Nyabondo Rehabilitation Centre as
well as Government Ministry of Medical Services Officials
got a chance to see how the knee works. r
samaritan
the Samaritan
A good samaritan stopped to help a stranger. he took on
the burden of caring for someone he did not know. If you
have a burden that you cannot bear on your own, share it
with the Samaritan. Send your questions to:
The Samaritan, CHAK Times, P.O. Box 30690 - 00100, Nairobi. Email: [email protected]
Q
DEAR SAMARITAN, I am a young man
aged19 years and born again. My father
has had diabetes for quite a long time now
although he manages to control it well by eating a proper
diet. In fact, he rarely goes to the hospital except for routine
clinics.
However, sometimes he gets quite upset to the point
where I think he is depressed. During such times, he can
often be seen talking to himself and complaining about
everything under the sun. Sometimes, I think it is because he
is stressed about providing for our family, especially given
that mom is a house wife.
He even shouts at my mother and threatens to beat her
up. At such times, my three siblings and I take cover from
his wrath, often avoiding him by staying in our rooms and
pretending to be busy.
I have never been able to establish whether this anger and
depression is related to his diabetes problem. I would like to
be able to understand his problem so that I can help him and
make our home a better place for me and my siblings.
I have always wondered if it is possible to make him
happy to a point where he will not experience such mood
swings. I’m afraid that his anger combined with his diabetes
may lead to more serious problems for him in future. I’m
also scared that I may develop the condition and behave
in the same way.
Please advise me on how I can help my father and ensure
a better life for our family.
Worried man
A
DEAR WORRIED MAN, Thank you for
trusting us and sharing your issues with
us. We are going to work together and see
how we can help you and your family to live a fulfilling,
satisfying life.
It is encouraging to note that your father, despite having
had diabetes for many years, has managed to control it
through diet and goes to hospital for routine check-ups
only.
I would like to bring to your attention the fact that one
of the symptoms of diabetes is an altered mental state,
where the patient becomes agitated, has unexplained
irritability, extreme lethargy or even confusion. Your father
could be in such a state and you may be interpreting this as
depression.
You state that you think he is stressed because of providing
for your family. Think about that once more because I imagine
he had provided for your family since the beginning and if he
has not been behaving that way all along, something must be
amiss, the prime suspect here being his illness. Try thinking
positively to find the root cause of his behavior.
You did not tell us how old you father is, because apart
from diabetes, your father could be having other problems
like midlife crisis or old age, which may cause irritability.
For you to understand your father, you need to establish
a free non-judgmental relationship with him. Encourage him
to share his feelings about the illness and how it affects him
and all of you as a family.
You may also want to consider involving other family
members especially your mother because it is said that a
sickness or problem with one member of the family affects
all. Look at your family in comparison with the passage in the
Holy Bible in 1st Corinthians 12:12-26. We are likened to the
different parts of the body that cannot ignore one another
but are dependent on each other to function satisfactorily.
Free meaningful communication is very important in any
given relationship.
You shared your fear of developing diabetes and behaving
like your father. There are several causes of diabetes and
heredity is one of them. You don’t have to be worried
though because you can prevent diabetes. You only need to
be vigilant and in case you suspect anything seek medical
attention. Having regular medical check–ups can also help
detect the disease early and facilitate treatment.The right diet,
exercise and having a healthy lifestyle may delay the onset of
diabetes. Lastly, to help your father and the rest of the family, it
is advisable to consult a counselor or family therapist. It would
be more beneficial if the whole family is involved because
you all need the support of each other to get through this. It
is ideal for each one of you to have regular medical check-ups
to detect any problem and treat it early. r
Answer to the crostic puzzle
Life is an adventure in forgiveness
(www.alwaysbesidesme.com)
CHAK Times May - August 2009
37
devotional
Health and the Church
By Rev. Peter K. Osundwa - ACC Western /North rift Representative
“
For I was hungry and you gave me something to eat, I was
thirsty and gave me something to drink, I was a stranger
and you invited me in, I needed clothes and you clothed
me, I was sick and you looked after me, I was in prison and
you came to visit me”. (Matthew 25:35-36)
Brethren, God has many ways to make His healing power
available to us. It’s true He can work in any way He desires.
He knows best and I believe our help comes from Him.
One of the reasons I’m convinced that God is a healer is
the natural recuperation of humans. The body has amazing
resistance and recovery powers and if given a chance can
restore itself to health from certain conditions.
Think for a moment of a wonderful substance God has
placed in the blood - fibrin, a substance naturally formed in
our bodies. It is a soluble protein polymerized to form a “mesh”
that forms a clot in conjunction with platelets over a wound
site. When a person is wounded, fibrin sticks together forming
a clot that prevents excessive bleeding, hence beginning the
healing process. This and other examples show how God
works in our bodies when we fall sick.
If our bodies are inadequately cared for, frequent visits to
a doctor will be unavoidable. When this happens, the body
not only requires physical healing, but also extreme care
and attention. For example, a person who has suffered from
malnutrition understands the effects of poor feeding habits.
.
okes..
J
The accountant goes to heaven
An accountant dies and goes to Heaven. He is met by St
Peter who goes through the usual questionnaire.
“What sort of accountant are you?” says St Peter
“Public practitioner,” is the reply.
“Name?”
He gives his name. St Peter goes through some files and pulls
one out.
“Oh, yes. We’ve been expecting you. You’ve reached your
allotted span,” says St Peter.
Eating a balanced diet means choosing a wide variety of
food and drinks from all groups including vitamins, proteins,
carbohydrates, fat, mineral salts and fibre in the correct
proportions.
In addition to encouraging people in spiritual matters, the
church has a role to play in ensuring that people are healthy
and physically fit. In the book of Mt. 25:35-36 the Bible tells
us to do pastoral work which entails hospitality to strangers,
visiting the sick, those imprisoned and above all providing
for the less fortunate.
Once we invite God into our lives, He will give us the desire
to love Him and our neighbors. For our brothers and sisters,
He is always with them to love, comfort and fill their hearts
with His peace. Jesus said “I tell you the truth, whatever you
do to the least of my brothers that you do unto me.
Church leaders need to come out strongly to preach the
Word of God and educate their congregations about farming,
hygiene, proper diet and other issues related to health. Let us
identify with everyone who suffers, regardless of the cause.
We should be a community that encourages just as Christ
himself did. He willingly took the risk, crossed barriers, touched
leapers, met freely with the despised, took the blame, bore the
stigma and finally went outside the camp to cleanse our sins.
Thanks to CHAK for its relentless effort and commitment in
ensuring that quality health care is accessible to all. r
“Well we’ve been looking at your time sheets and the hours
you’ve charged your clients. By our reckoning you’re at least
ninety three.”
“Sorry. I didn’t recognize you.”
As Bill was approaching mid-life, physically he was a mess.
Not only was he going bald, but years of office work had
given him a large pot belly. The last straw came when he
asked a woman co-worker out on a date, and she all but
laughed at him. That does it, he decided. I’m going to start a
whole new regimen. He began attending aerobics classes. He
started working out with weights. He changed his diet. And
he got an expensive hair transplant.
In six months, he was a different man. Again, he asked his
female co-worker out, and this time she accepted. There he
was, all dressed up for the date, looking better than he ever
had. He stood poised to ring the woman’s doorbell, when a
bolt of lightning struck him and knocked him off his feet.
“How can that be?” says the accountant. “I’m too young to go.
I’m only forty-eight”
As he lay there dying, he turned his eyes toward the heavens
and said, “Why, God, why now? After all I’ve been through,
how could you do this to me?”
“No, that’s impossible.”
“Why do you say that?”
From up above, there came a voice, “Sorry. I didn’t recognize
you.”
38 CHAK Times May - August 2009