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DIABETES IN SUB-SAHARAN AFRICA

DIABETES IN SUB-SAHARAN AFRICA. Dr Kaushik Ramaiya. 38.2 44.2 16%. 25.0 39.7 59%. 81.8 156.1 91%. 18.2 35.9 97%. 13.6 26.9 98%. 1.1 1.7 59%. 10.4 19.7 88%. GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions). World 2003 = 189 million

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DIABETES IN SUB-SAHARAN AFRICA

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  1. DIABETES IN SUB-SAHARANAFRICA Dr Kaushik Ramaiya

  2. 38.2 44.2 16% 25.0 39.7 59% 81.8 156.1 91% 18.2 35.9 97% 13.6 26.9 98% 1.1 1.7 59% 10.4 19.7 88% GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions) World 2003 = 189 million 2025 = 324 million Increase 72%

  3. Deaths by broad cause group and WHO region Noncommunicable conditions % 75 Injuries Communicable diseases, maternal and perinatal conditions and nutritional deficiencies 50 25 EMR SEAR WPR EUR AFR AMR

  4. 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

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

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

  7. Prevalence of Systolic, Diastolic and Both (Systolic and Diastolic) Hypertension in the Three School Settings %

  8. Prevalence of Obesity in the three school settings %

  9. 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

  10. 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)

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

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

  13. 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

  14. 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%

  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. MACROVASCULAR COMPLICATIONS OF DIABETES

  26. 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

  27. Diabetes - Clinical CourseSouth Africa

  28. Clinical course of DiabetesTanzania (Dar es Salaam)

  29. AWARENESS AND MANAGEMENT OF DIABETES: The Cameroon Diabetes Study 2004 75% of all the known cases of diabetes were treated Only 27% of the treated cases were controlled by medical treatment

  30. Patients knowledge of diabetes 60 50 % Knowledge 40 Medicine 30 Diet Complications 20 Total 10 0

  31. 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

  32. 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.

  33. The increasing burden of T2D is against a background of decreasing resources Therefore primary prevention must be the cornerstone of policies aiming to tackle diabetes in Africa Country level: Time for a national diabetes program Regional level: Time for an African Diabetes Declaration

  34. The increasing burden of T2D is against a background of decreasing resources Therefore primary prevention must be the cornerstone of policies aiming to tackle diabetes in Africa Country level: Time for a national diabetes program Regional level: Time for an African Diabetes Declaration

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

  36. 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

  37. NATIONAL RESPONSE

  38. Primary prevention: • Diet • Physical activity • Maintaining ideal body weight • Life-style modification

  39. LIFE STYLE GUIDANCE • Advice on:- EXERCISE DIET SMOKING

  40. CHANGE IN GLUCOSE TOLERANCE

  41. Secondary Prevention

  42. Prevalence (%) of diabetes in different communities in Tanzania % Mara 0.6 Kilimanjaro 0.7 Morogoro 0.8 1.0 - 5.0 Urban Africans (Dar es Salaam) African nuns (Dar es Salaam) 4.3 Ithna-asheri Asians (Dar es Salaam) 8.8 Hindu Asians (Dar es Salaam) 9.8 10.0 African Priests (Dar es Salaam) Bohra Asians ({Dar es Salaam) 11.0 African Executives 12.0

  43. MULTI-SECTORAL PARTNERSHIP Tanzania Diabetes Association Ministry of Health Donors World Diabetes Foundation Novo Nordisk Fund Raising Dr Zolli – Venice,Italy NN World Partnership Project Curriculum development Training Capacity building- tools Establishment of Association Branches Monitoring & Evaluation Supply & logistics system Human resources Clinic space “Seed” funding SUSTAINABLE QUALITY DIABETES SERVICE

  44. Tanzania

  45. Community awareness

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