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DIABETES IN SUB-SAHARAN AFRICA Dr Kaushik Ramaiya millions The future burden of diabetes in sub-Saharan Africa 20 18 16 14 12 10 8 6 4 2 0 2030 2025 2010 Amos et al, 1997 WHO, King et al, 1998 WHO, Wild et al, 2003 Africa is experiencing a rapid epidemiological transition with the burden of non-communicable diseases esp. diabetes that will overwhelm the health care systems which is already overburdened by HIV/AIDS, TB and Malaria. This is due to • Rapid urbanization and westernization of lifestyle • Rapidly decreasing physical activity • Changes in dietary habits • Ageing of the population What is different about DM in Africa? • Decreases survival from the disease. • Most countries do not have national diabetes programmes. • Medications are unavailable or irregularly available and unaffordable. • Well-structured educational programs for the patients and health professionals are lacking.. • Unequal distribution of facilities and providers. RISK FACTORS Age • NON MODIFIABLE Age Ethnicity/predisposition • MODIFIABLE Obesity Urbanization Physical inactivity Change in dietary habits Prevalence of diabetes by age group in a population of Cameroon Mbanya JC et al RISK FACTORS Obesity • NON MODIFIABLE Age Predisposition • MODIFIABLE Obesity Urbanization Physical inactivity Change in dietary habits Sobngwi E, et al. Int J Obes 2002 RISK FACTORS • NON MODIFIABLE Age Predisposition • MODIFIABLE Obesity Urbanization Physical inactivity Change in dietary habits Childhood Obesity Average percentage annual increase in urban and rural populations, 1995-2000 RISK FACTORS • NON MODIFIABLE Age Predisposition • MODIFIABLE Obesity Urbanization Physical Inactivity Change in dietary habits 8 7 6 5 Urban Rural 4 3 2 1 0 Cameroon Kenya Nigeria South Africa Tanzania RISK FACTORS Physical Inactivity Women Age Predisposition • MODIFIABLE Daily minutes of walk • NON MODIFIABLE 100 p<0.0001 p<0.0001 Rural 80 Urban 60 40 20 0 < 30y Obesity Urbanization 30 - 49y >= 50y Men 120 Daily minutes of walk Physical Inactivity Change in dietary habits p<0.0001 120 100 80 p<0.0001 p<0.0001 p<0.0001 Rural 60 Urban 40 20 0 < 30y 30 - 49y >= 50y Daily walking time in a sample of 2465 urban and rural Cameroonians (Sobngwi E, et al Int J Obes 2002) TYPE 1 DIABETES: INCIDENCE COUNTRY NIGERIA YEAR AUTHOR AGE RANGE 1990-1992 Osa INCIDEN CE/100,0 00 12 10.2 10 7.2 8 SUDAN 1987-1990 Elamin 0-14 8.1 5.7-10.1 0-15 15-19 1.5 3.4 ZANZIBAR 1989-1992 Mohamed 0-19 2.1 TUNISIA 1991-1993 Nagati 0-20 5.4 LIBYA 1989-1992 Jamal 1991-1995 Kadiki 0-18 0-19 5.2 8.1 ALGERIA 1979-1992 Bessaoud 1993-1997 Malek 1993-1997 Malek 0-14 0-14 15-19 7.2 4.8 6.5 TANZANIA 1982-1991 Swai 7.7 6 5.8 4 2 0 1987 1988 1989 1990 INCIDENCE/100,000 of Type 1 diabetes in Sudan (El Amin et al.) Type 1 DM in Africa- Clinical characteristics of Type 1 diabetes in Africa Patients Country N Age M:F group (yr) Age of onset (yr) Peak age of onset (yr) Duration of diabetes (yr) Johannesburg 86 176 <35 <35 1:1.2 1:1.3 23.5 22.0 21-30 22-23 3.8 4.0 Tanzania 272 2:1 29.4 15-19 New Ethiopia 431 All ages All ages 1:1.1 21.4 M 18.1 F 20-25 M 10-17 F South Africa Durban Motala AA et al. Diabetes International, July 2000. Type 2 DM in Africa • Data • increasing but limited • Not rare • low in rural areas • moderate in rural and urban areas with development • high in urban areas • Urban > Rural • IGT • early stage of epidemic • Increasing in same population • Ethnicity • Modifiable risk factors SUMMARY OF CURRENT PREVALENCE OF TYPE 2 DIABETES • Rural Sub Saharan Africa 1 – 3.5% • Urban Sub Saharan Africa 3 – 7.7% • Republic of South Africa 4.8 – 8.0% • Maghrebian countries 6.3 – 9.3% • Indian origin populations 8.6 – 13.3% Complications of diabetes • Increasing prevalence of diabetes and their complications in Sub-saharan Africa are a major drain on health resources in addition to physical and social impact on an individual and community Acute complications of diabetes: • Diabetic ketoacidosis • Hyperosmolar non-ketotic coma • Hypoglycaemia Diabetic ketoacidosis • Common emergency • High mortality 25% in Tanzania, 33% in Kenya • Contributing factors: – – – – – – Lack of insulin availability Delay in diagnosis Misdiagnosis Economics Poor healthcare system infections Hyperosmolar non-ketotic coma: • Complication of type 2 diabetes • Less common • Accounts for about 10% of all hyperglycaemic emergencies (Zouvanis et al, 1987) • Contributing factors: – Infections – Non-compliance – First presentation • Mortality high – 44% - studies from South Africa (Rolfe et al, 1995) – patients usually elderly and have other major illness Hypoglycaemia • Serious complication of OHA therapy • In South Africa (Gill & Huddle,1993) 33% of cases associated with sulphonylurea treatment • Other precipitating causes: – – – – Missed meal (36%) Alcohol (22%) GI upset (20%) Inappropriate treatment Microvascular complications of diabetes RETINOPATHY year 1988 1993 1995 1996 1996 1996 1997 1997 1997 country prevalence (%) Zambia 34 Ethiopia 13 South Africa 52 Cameroon 37 Cameroon 37 Burkina Faso 16 South Africa 37 South Africa 55 Ethiopia 36 RETINOPATHY • In South Africa, at diagnosis, 21-25% of type 2 diabetes and 9.5% of type 1 diabetes have retinopathy (Kalk et al,1997). • ? Genetic predisposition – africans more affected • Poor/inadequate access to healh care leading to inadequate control of blood glucose and blood pressure. Microvascular complications of diabetes NEPHROPATHY year country 1996 Kenya 1996 Burkina Faso 25 1996 Cameroon 46* 1997 South Africa 37 1997 Ethiopia 33 *microabuminuria prevalence (%) 41* NEPHROPATHY • Diabetes contributes to 35% of all patients admitted to dialysis unit (Diallo et al,1997) • In South African series, 50% of all causes of mortality in type 1 diabetes was due to renal failure (Gill, Huddle & Rolfe, 1995) Microvascular complications of diabetes NEUROPATHY year country 1988 Zambia prevalence (%) 31 1991 Ethiopia 36 1991 Sudan 31.5 1994 Tanzania 25 1995 South Africa 42 1997 South Africa 28 NEUROPATHY • Prevalence varies widely depending on method used. • Poor glycaemic control and inadequate foot care are risk factors for diabetic foot. Epidemiology of Diabetic Foot (Abbas ZG) 40-60% of all non-traumatic amputations 85% of diabetes related lower extremity amputations The prevalence of foot ulcer is 4-15% of diabetes population MACROVASCULAR COMPLICATIONS OF DIABETES COMPLICATION COUNTRY YEAR PREVALENCE (%) Lower Limbs Vascular Disease (PVD) Senegal 1994 28 South Africa 1997 8 Sudan 1995 10 Tanzania 1997 12 Bukina Faso 1996 8 Uganda 1996 5 Sudan 1995 5 Zambia 1988 1 Coronary Artery Disease (CVS) Cerebrovascular Disease Diabetes - Clinical course • ETHIOPIA Causes of death in 100 Ethiopian diabetic patients 1976 1983. • At death:45 % of patients below age 50 years 46 % below 10 years of diabetic duration • Causes of death:Metabolic 47 % Renal Failure 26 % Infective 12 % Cirrhosis 10 % Stroke 8% Other 12 % Not known 15 % • Lester FT. Ethiopian Med J 1984; 2: 61-68 Diabetes - Clinical Course South Africa Ten year follow-up study of Type 1 DM patients in Soweto, South Africa, 1982-92. Number recruited Lost to follow-up - moved out Mean age at follow-up Mean duration Type 1 DM (at follow-up) Mortality Causes of death Gill GV et al. Diabetic Med, 1995; 12:546-550 88 patients 24 patients 32 years 14 years 10/64 (16 %) Nephropathy 5 Hypoglycaemia 2 Ketoacidosis 2 Clinical course of Diabetes Tanzania (Dar es Salaam) Clinical course of diabetes in the 1250 newly diagnosed diabetic patients with a follow-up period 22-94 months (to April 1989). n 5 year survival rates* Insulin requiring DM 272 59.5 % Non-insulin requiring DM 825 81.8 % Uncertain type DM 153 43.0 % *known and probable deaths Insulin / OHA costs • Tanzania (1989-90):• Average annual direct cost of diabetes care US $ 287.00 IRDM US $ 103.00 NIDDM • Purchase of insulin accounted for US $ 156.00 (68.2%) of the average annual outpatient costs for IRDM. • OHA accounted for US $ 29.30 (42.5%) of the average annual outpatient costs for NIDDM. Chale SS et al. For Med J 1992; 304: 1215-8 Costs of treatment • In Cameroon (Nkegoum, 2002) in the year 2001: – Average direct medical cost of treating a patient with diabetes was USD 489. – 56% -hospital admission – 33.5% - anti-diabetic drugs – 5.5% -laboratory tests – 4.5% on consultation fee. Indirect cost of diabetes (Tanzania 1989-90) Future Healthy Life Days (HLDs) lost per patient with diabetes during the 8 years . of follow-up IRDM (n=3626) % NIDDM (n=2390) % Uncertain (n=1974) % Overall (n=4100) % Premature death 55.1 39.7 96.8 69 Disability before death 0.5 3.9 0.4 1 Chronic disability 43.3 55.7 2.4 29 Acute Illness 1.1 0.6 0.4 1 Reason for lost days Chale SS. A study of the Economic Costs of Diabetes Mellitus in Tanzania in 1989/90. UDSM This increasing burden is against a background of decreasing resources. Therefore primary prevention must be the cornerstone of policies aimed at combating these lifestyle related diseases. Prevention Strategies Problems in Africa • Mortality – Poorly skilled or inadequate providers – Delay - attention – Drugs – availability - affordability • Complications – awareness – facilities– detection - monitoring – economics Barriers to Quality care • Irregular supply of medicines (including insulin) • Inadequate health-care infrastructure and disproportionate distribution of the facilities • Affordability • Lack of adequate training and retraining of health care providers • Lack of education to the people living with diabetes & their families • Differing government priorities IDF AFRICA REGION RESPONSE • • • • • Diabetes Practice Guidelines. Diabetes Education Training manual African Declaration on Diabetes Training Strengthening national diabetes associations • Research / data