DIABETES IN SUB-SAHARAN AFRICA

Dr Kaushik Ramaiya

GLOBAL PROJECTIONS FOR THE GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions)DIABETES EPIDEMIC: 2003-2025 (millions)

25.0 39.759%

25.0 39.759%

38.244.216%

38.244.216%

1.11.7

59%

1.11.7

59%WorldWorld

2003 = 189 million2003 = 189 million 2025 = 324 million2025 = 324 million

Increase 72%Increase 72%

10.419.788%

10.419.788%

13.6 26.998%

13.6 26.998%

81.8156.191%

81.8156.191%

18.235.997%

18.235.997%

Deaths by broad cause group and WHO region

AFR EMR EURSEAR WPR AMR

25

50

75

%

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies

Noncommunicableconditions

Injuries

Age

RISK 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

• MODIFIABLE Obesity Urbanization

Physical inactivity

Change in dietary habits

Sobngwi E, et al. Int J Obes 2002

Childhood ObesityRISK FACTORS

• NON MODIFIABLE Age Predisposition

• MODIFIABLE Obesity Urbanization

Physical inactivity

Change in dietary habits

Prevalence of Systolic, Diastolic and Both (Systolic and Diastolic) Hypertension in the Three School

Settings

29.6

4.8 4

20.4

3 3.5

11.3

1.2 10

5

10

15

20

25

30

Systolic Diastolic Both

ULD

UHD

Rural

%

Prevalence of Obesity in the three school settings

16.9

1.800

2

4

6

8

10

12

14

16

18

ULD UHD Rural

%

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

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

• NON MODIFIABLE Age Predisposition

• MODIFIABLE Obesity Urbanization

Physical Inactivity

Change in dietary habits

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%

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 South Africa 37

1997 South Africa 55

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.

year country prevalence (%)

1996 Kenya 41*

1996 Burkina Faso 25

1996 Cameroon 46*

1997 South Africa 37

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)

year country prevalence (%)

1988 Zambia 31

1991 Ethiopia 36

1991 Sudan 31.5

1994 Tanzania 25

1995 South Africa 42

1997 South Africa 28

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.

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 % Cirrhosis10 % Stroke 8 %

Other 12 %Not known 15 %

•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

AWARENESS AND MANAGEMENT OF AWARENESS AND MANAGEMENT OF DIABETES:DIABETES:The Cameroon Diabetes Study 2004The Cameroon Diabetes Study 2004

4

80

11

5

0 10 20 30 40 50 60 70 80 90

Tr eat ed cont r ol ed

Tr eat ed notcont r ol ed

Aknowl edge nott r eat ed

Newl y det ect ed

%

75% of all the known cases of diabetes were treated

Only 27% of the treated cases were controlled by medical treatment

Patients knowledge of diabetes

0

10

20

30

40

50

60

Knowledge

Medicine

Diet

Complications

Total

%

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.

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

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

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

• NATIONAL RESPONSE

Primary prevention:

• Diet

• Physical activity

• Maintaining ideal body weight

• Life-style modification

LIFE STYLE GUIDANCE

• Advice on:-

EXERCISE

DIET

SMOKING

CHANGE IN GLUCOSE TOLERANCE

1986 Lifestyle Intervention

1992 No Intervention

2000

% % %

Normal 61.8 81.1 66.7

IGT 26.5 10.0 21.1

DM 11.8 8.2 12.2

Secondary Prevention

Prevalence (%) of diabetes in different communities in Tanzania

% Mara 0.6 Kilimanjaro 0.7 Morogoro 0.8 Urban Africans (Dar es Salaam) 1.0 - 5.0

African nuns (Dar es Salaam) 4.3 Ithna-asheri Asians (Dar es Salaam) 8.8 Hindu Asians (Dar es Salaam) 9.8 African Priests (Dar es Salaam) 10.0 Bohra Asians ({Dar es Salaam) 11.0

African Executives 12.0

Tanzania Diabetes Association Ministry of Health Donors

World Diabetes FoundationNovo Nordisk Fund Raising

Dr Zolli – Venice,Italy NN World Partnership Project

Curriculum developmentTraining

Capacity building- toolsEstablishment of Association Branches

Monitoring & EvaluationSupply & logistics system

Human resourcesClinic space

“Seed” funding

SUSTAINABLE QUALITY DIABETES SERVICE

MULTI-SECTORAL PARTNERSHIP

Demographics Tanzania

Area (sq km) 945,100

Population

32,900,000

25% urban

GNP per capita US $240

Human

Development Index

0.358

(150/174)

Literacy rate

Male: 84%

Female: 65.7%

Infant mortality rate 94.8 per 1,000

Life expectancy 47 years

Tanzania

Musoma

No. of patients seen 186No. of new cases 50 26.9%Type 1 or Insulin requiring 48 25.8%Type 2 136 74.2%Patients under 45 yrs of age 44 23.6%No. of Women 62 33.3%No.of Men 124Obesity 13 7.0%Hypertension 36 19.3%Foot complication 1 0.5%Eye complication 1 0.5%Kidney complications NilOther complications NilNeuropathy NilHypoglycaemia Nil

Distance from other diabetes clinic

Community awareness

IDF AFRICA REGION - RESPONSE

• Diabetes Practice Guidelines.

• Diabetes Education Training manual

• African Declaration on Diabetes

• Training

• Strengthening national diabetes associations

• Research / data

AFRICAN DECLARATION ON DIABETES

Regional Council

Workshop to draft the concept

Steering committee

Final draft

WHO-AFRO

Review by stake-holders

Document

Implementation Monitoring & evaluation

Ministry of HealthAfrican Union

WHO Regional AssemblySADAC

Mission

• Access to quality and affordable services for prevention and care of diabetes

11 key requirements• Organisation of the Health System• Data Collection• Prevention• Diagnostic tools and infrastructure• Drug procurement and supply• Accessibility and affordability of medicines and care• Healthcare workers• Adherence issues• Patient education and empowerment• Community involvement and diabetes associations• Positive policy environment

THANK YOU