In recent times there has been a surge in non-communicable diseases, especially Type 2 diabetes mellitus (T2DM), in sub-Saharan Africa (SSA). This is an extra burden upon the healthcare systems, which already have to cope with the high prevalence of communicable diseases such as HIV/AIDS, tuberculosis and malaria. I chose to read up on this issue as it is a topic that is not really addressed in the field of diabetes.
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There were approximately around 200 million people with diabetes worldwide. This figure is on the rise and has the potential to reach around 380 million in the year 2025. This huge increase also is expected to be seen in Africa and Asia.
T2DM is the most common form of diabetes with around 90% of diabetic patients. The current prevalence of T2DM in SSA is only a third of the HIV prevalence, however it is estimated to reach the same as current HIV prevalence by 2025. The prevalence is around 1.4% or lower in most SSA countries, however it is raised to around 3% in South Africa. There is also a greater prevalence of the disease in urbanised areas, as apposed to the more rural locations. It has been. The prevalence of diabetes in Africa was around 3 million in 1994, rising to 7.1 million by the year 2000. In 2010 the figure was around 12 million and is set to rise up to around 24 million by the year 2030. This phenomenon may be due to the rapid urbanisation these countries are facing.
These factors can be split into modifiable (i.e. can be changed) and non-modifiable. Modifiable risk factors include the rise in obesity seen in SSA. This rise can be attributed to the rapid urbanisation of SSA countries. A study in 2002 showed the extent of clinically overweight/obese people in South Africa to be 56% for females and around 29% for males. Other studies have shown diabetic patients in SSA have a higher BMI than non-diabetic patients. However, one may argue that it is truncal obesity, which is more closely linked to T2DM than BMI. One study has shown the level of truncal obesity in Cameroon to be 18% in males and 67% in females. This may be due to the consensus that women who are larger are deemed healthier and richer, especially in countries where HIV is prevalent.
The diet of the people of SSA is becoming more westernised including the rise of saturated fats, sugars and lower levels of fibre. This paired with rapid urbanisation leading to a more inactive lifestyle is likely to contribute to the rise in T2DM seen.
Countries of SSA are also increasing their GDP and so are becoming more prosperous. This is linked with the urbanisation, which has been mentioned. This has lead to the rise in processed foods consumed, inactive lifestyle and inevitable increase in obesity.
Non-modifiable risk factors include age and ethnicity. The most common age group for T2DM was 45-65 year. Some studies showed that more women had T2DM than women in certain SSA countries. There is also an effect from ethnic origin, for example some countries have a higher population of Indian people, where the prevalence of T2DM is higher.
Other risk factors include TB or the use of antivirals, which may increase the likelihood of contracting T2DM.
Complications arising from T2DM can either be classified as macrovascular or microvascular. Macrovascular complications include cardiovascular disease and stroke. Microvascular complications include nephropathy, neuropathy and retinopathy. Patients from developed countries have greater macrovascular morbidity, whereas in SSA the opposite is true.
In developed countries T2DM mortality is due to CVD and renal complications, however in SSA the mortality is greatly due to infections and metabolic problems. Infections include sepsis and TB. Metabolic problems are usually keto-acidosis and hyperosmolar non-ketotic coma.
However there is still a lot of un-obtained data, which is due to the poor documentation of the cause of death. It is one of the challenges to increase the number of deaths reported, and also to report it accurately.
The key to decreasing the morbidity and mortality associated with T2DM is to maintain good control over the blood glucose levels. This can be achieved using a diet management plan, exercise and, if needed, the use of appropriate medication.
Drugs, which can be administered, include sulphonylureas, which promote insulin secretion after a rise in glucose levels. Meglitinides, which are insulin secretagogues. Biguanides such as Metformin, decrease the rate of gluconeogenesis and thus lower blood glucose. Insulin can also be used as a last resort in T2DM to maintain good glucose control.
A study has highlighted the poor blood-glucose control for patients with T2DM in SSA. These were patients who were on various different treatment regimens ranging from sulphonylureas to insulin. This maybe due to lack of availability of drugs, high cost of drugs/lack of funds, lack of adherence, lack of patient education and late presentation. One paper showed that a few health care settings in Tanzania only had a couple of sulphonylureas and insulin in their drug stores.
Major challenges and solutions
To understand why there is poor care of patients with T2DM in SSA, one has to identify the problems that are faced in order to create a solution. The economy of these countries is already stretched and so have low healthcare budgets. This means that there is not enough money to purchase drugs and provide optimal healthcare to T2DM patients who require chronic care. This problem is exacerbated due to the fact that communicable diseases such as HIV take up more of the budget, leaving a decreasing amount of money to be spent on non-communicable chronic conditions.
There is also a lack of qualified healthcare providers and so insufficient manpower. This maybe due to the lack of training and courses in order to create these qualified healthcare providers. There are also poor healthcare referral systems. This inevitably shows the lack of organisation within the healthcare systems in SSA. This needs to be tackled by reorganising the healthcare infrastructure and create/improve training programmes for the staff. Greater drug supply is also essential. One study showed that there was a lack of insulin in some SSA countries such as Mali. There also needs to be improved access to care, as many patients can’t reach the required level of care in order to manage their T2DM well.
There is also poor patient education in SSA, and so this leads to poor adherence of treatments as well as poor glycaemic control. T2DM is a chronic disease and so patient education is key in good management of the disease in order to decrease complications arising. Greater primary and secondary prevention strategies need to be established, as this will be economically beneficial. Interventions need to be cost effective as there are limited resources and funds.
A lot of the data collected regarding T2DM care is inaccurate or just simply not collected. In order to assess the characteristics of the disease in SSA, better data collection methods need to be initiated. Poor record keeping is detrimental to the care of the T2DM patient, where glucose monitoring ensures stable control.
An example to follow is the National Diabetes and Hypertension Program in Cameroon. This initiative saw the coming together of health-care providers, policy-makers and people from the community in order to tackle the growing epidemic of T2DM in SSA. Strategies are shown in figure 2. This program ensured greater monitoring, documentation as well as better interventions which all lead to better care for T2DM patients.
With the rapid urbanisation and greater prosperity seen in sub-Saharan Africa, T2DM is becoming an underestimated epidemic. With the focus on communicable diseases, the care of T2DM is not improving, as seen by the multitude of problems faced in SSA. Strained healthcare budgets mean that it is necessary, more than ever, to produce cost-effective initiatives. Governments need to understand the dangers of communicable diseases as well as non-communicable diseases. Better primary and secondary prevention strategies need to be created to target issues such as the rising levels of obesity. Governments need to issue better guidelines, training and promote policymaking. Initiatives such as National Diabetes and Hypertension Program in Cameroon have had very positive feedback and have set the standard for other governments within SSA.
If this problem is not addressed, there will be a negative impact on T2DM morbidity and mortality. This will inevitably reduce the socioeconomic growth in SSA countries, which is vital for the prosperity of the country.
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