DIABETES IN SUB-SAHARAN AFRICA Dr Kaushik Ramaiya

DIABETES IN SUB-SAHARAN AFRICA

Dr Kaushik Ramaiya

The future burden of diabetes in sub-Saharan Africa

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Amos et al, 1997 WHO, King et al,1998

WHO, Wild et al,2003

mil

lion

s

2010

2025

2030

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.

AgeRISK FACTORS

• NON MODIFIABLE Age Ethnicity/

predisposition

• MODIFIABLE Obesity Urbanization

Physical inactivity Change in dietary

habits

Prevalence of diabetes by age group in a population of Cameroon

Mbanya JC et al

ObesityRISK FACTORS

• NON MODIFIABLE Age Predisposition


Physical inactivity

Change in dietary habits

Sobngwi E, et al. Int J Obes 2002

Childhood ObesityRISK FACTORS



Physical inactivity


Average percentage annual increase in urban and rural

populations, 1995-2000

RISK FACTORS



Physical Inactivity Change in dietary

habits

0

1

2

3

4

5

6

7

8

Cameroon Kenya Nigeria South Africa Tanzania

UrbanRural

Physical Inactivity

Men

0

20

40

60

80

100

120

< 30y 30 - 49y >= 50y

Da

ily m

inu

tes

of

wa

lk

Rural

Urban

p<0.0001

p<0.0001p<0.0001

Women

0

20

40

60

80

100

120

< 30y 30 - 49y >= 50y

Da

ily m

inu

tes

of

wa

lk

Rural

Urban

p<0.0001

p<0.0001

p<0.0001

Daily walking time in a sample of 2465 urban and rural Cameroonians (Sobngwi E, et al Int J Obes 2002)

RISK FACTORS



Physical Inactivity


COUNTRY YEAR AUTHOR AGE

RANGE

INCIDEN

CE/100,000

NIGERIA 1990-1992 Osa 7.2

SUDAN 1987-1990 Elamin 0-14 5.7-10.1

TANZANIA 1982-1991 Swai 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 1991-1995

Jamal Kadiki

0-18 0-19

5.2 8.1

ALGERIA 1979-1992 1993-1997 1993-1997

Bessaoud Malek Malek

0-14 0-14 15-19

7.2 4.8 6.5

TYPE 1 DIABETESTYPE 1 DIABETES:: INCIDENCE

5.8

7.7

10.2

8.1

0

2

4

6

8

10

12

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 group (yr)

M:F Age of onset (yr)

Peak age of onset (yr)

Duration of diabetes (yr)

South Africa Durban 86 <35 1:1.2 23.5 21-30 3.8 Johannesburg 176 <35 1:1.3 22.0 22-23 4.0

Tanzania 272 All

ages 2:1 29.4 15-19 New

Ethiopia 431 All ages

1:1.1 21.4 M 18.1 F

20-25 M 10-17 F

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

year country prevalence (%)

1988 Zambia 34

1993 Ethiopia 13

1995 South Africa 52

1996 Cameroon 37

1996 Cameroon 37

1996 Burkina Faso 16



1997 Ethiopia 36

Microvascular complications of diabetesRETINOPATHY

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.


1996 Kenya 41*

1996 Burkina Faso 25

1996 Cameroon 46*


1997 Ethiopia 33

*microabuminuria

Microvascular complications of diabetes NEPHROPATHY

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)


1988 Zambia 31

1991 Ethiopia 36

1991 Sudan 31.5

1994 Tanzania 25



Microvascular complications of diabetesNEUROPATHY

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

Coronary Artery Disease (CVS)

Bukina Faso 1996 8

Uganda 1996 5

Cerebrovascular Disease

Sudan 1995 5

Zambia 1988 1

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 known15 %

•Lester FT. Ethiopian Med J 1984; 2: 61-68

Diabetes - Clinical CourseSouth Africa

Number recruited 88 patients Lost to follow-up - moved out

24 patients

Mean age at follow-up 32 years Mean duration Type 1 DM (at follow-up)

14 years

Mortality 10/64 (16 %) Causes of death Nephropathy 5

Hypoglycaemia 2 Ketoacidosis 2

Ten year follow-up study of Type 1 DM patients in Soweto, South Africa, 1982-92.

Gill GV et al. Diabetic Med, 1995; 12:546-550

Clinical course of DiabetesTanzania (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

Chale SS. A study of the Economic Costs of Diabetes Mellitus in Tanzania in 1989/90. UDSM

Reason for lost days

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 StrategiesProblems 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

Documents

DIABETES IN SUB-SAHARAN AFRICA Dr Kaushik Ramaiya