DIABETES IN SUB-SAHARAN AFRICA

1. DIABETES IN SUB-SAHARANAFRICA Dr Kaushik Ramaiya

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

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

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

5. RISK FACTORS • NON MODIFIABLE • Age • Ethnicity/predisposition • MODIFIABLE • Obesity • Urbanization • Physical inactivity • Change in dietary habits Age Prevalence of diabetes by age group in a population of Cameroon Mbanya JC et al

6. RISK FACTORS • NON MODIFIABLE • Age • Predisposition • MODIFIABLE • Obesity • Urbanization • Physical inactivity • Change in dietary habits Sobngwi E, et al. Int J Obes 2002 Obesity

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

8. RISK FACTORS • NON MODIFIABLE • Age • Predisposition • MODIFIABLE • Obesity • Urbanization • Physical Inactivity • Change in dietary habits Average percentage annual increase in urban and rural populations, 1995-2000

9. RISK FACTORS • NON MODIFIABLE • Age • Predisposition • MODIFIABLE • Obesity • Urbanization • Physical Inactivity • Change in dietary habits Physical Inactivity Daily walking time in a sample of 2465 urban and rural Cameroonians (Sobngwi E, et al Int J Obes 2002)

10. TYPE 1 DIABETES:INCIDENCE INCIDENCE/100,000 of Type 1 diabetes in Sudan (El Amin et al.)

11. Type 1 DM in Africa- Clinical characteristics of Type 1 diabetes in Africa Patients

12. Type 2 DM in Africa • Data • increasing but limited • Not rare • low in rural areas • moderate in rural and urban areas with development • high in urban areas • Urban > Rural • IGT • early stage of epidemic • Increasing in same population • Ethnicity • Modifiable risk factors

13. SUMMARY OF CURRENT PREVALENCE OF TYPE 2 DIABETES • Rural Sub Saharan Africa 1 – 3.5% • Urban Sub Saharan Africa 3 – 7.7% • Republic of South Africa 4.8 – 8.0% • Maghrebian countries 6.3 – 9.3% • Indian origin populations 8.6 – 13.3%

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

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

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

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

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

19. Microvascular complications of diabetes RETINOPATHY

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

21. Microvascular complications of diabetes NEPHROPATHY *microabuminuria

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

23. Microvascular complications of diabetes NEUROPATHY

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

25. Epidemiology of Diabetic Foot(Abbas ZG) • 40-60% of all non-traumatic amputations • 85% of diabetes related lower extremity amputations • The prevalence of foot ulcer is 4-15% of diabetes population

26. MACROVASCULAR COMPLICATIONS OF DIABETES

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

28. Diabetes - Clinical CourseSouth Africa

29. Clinical course of DiabetesTanzania (Dar es Salaam)

30. Insulin / OHA costs • Tanzania (1989-90):- • Average annual direct cost of diabetes care US $ 287.00 IRDM US $ 103.00 NIDDM • Purchase of insulin accounted for US $ 156.00 (68.2%) of the average annual outpatient costs for IRDM. • OHA accounted for US $ 29.30 (42.5%) of the average annual outpatient costs for NIDDM. Chale SS et al. For Med J 1992; 304: 1215-8

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

32. Indirect cost of diabetes (Tanzania 1989-90) Future Healthy Life Days (HLDs) lost per patient with diabetes during the 8 years of follow-up . IRDM NIDDM Uncertain Overall Reason for lost days (n=3626) (n=2390) (n=1974) (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 Chale SS. A study of the Economic Costs of Diabetes Mellitus in Tanzania in 1989/90. UDSM

33. This increasing burden is against a background of decreasing resources. Therefore primary prevention must be the cornerstone of policies aimed at combating these lifestyle related diseases.

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

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

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