Diabetes in tropical Africa: a prospective study, 1981-7. II. Course and prognosis

Retention in care for type 2 diabetes management in Sub-Saharan Africa: A systematic review

OBJECTIVE

Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes.

METHODS

We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care.

RESULTS

From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings.

CONCLUSION

Rates of retention in care of people living with diabetes are poor in primary care research settings.

Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: The case study of the Changing Diabetes in Children program in Cameroon

INTRODUCTION

Type 1 diabetes in Africa has been associated with high mortality attributed mainly to poor insulin access. Free insulin provision programs for people with type 1 diabetes have been introduced across Africa recently. We aimed to determine the mortality rate and associated factors in a cohort of children and adolescents with type 1 diabetes who receive free insulin treatment in sub-Saharan Africa.

METHODS

We conducted a retrospective analysis using the Changing Diabetes in Children (CDiC) medical records in Cameroon between 2011 and 2015.

RESULTS

The overall mortality rate was 33.0 per 1000 person-years (95% CI 25.2-43.2). Most deaths (71.7%) occurred outside of the hospital setting, and the cause of death was known only in 13/53 (24.5%). Mortality was substantially higher in CDiC participants followed up in regional clinics compared to the main urban CDiC clinic in Yaounde; 41 per 1000 years (95% CI 30.8-56.0) versus 17.5 per 1000 years (95% CI 9.4-32.5), and in those with no formal education compared to those who had some level of education; 68.0 per 1000 years (95% CI 45.1-102.2) versus 23.6 per 1000 years (95% CI 16.5-33.8). In Cox proportional multivariable analysis, urban place of care (HR = 0.23, 95% CI 0.09-0.57; p = 0.002) and formal education (HR = 0.42, 95% CI 0.22-0.79; p = 0.007) were independently associated with mortality.

CONCLUSION

Despite free insulin provision, mortality remains high in children and adolescents with type 1 diabetes in Cameroon and is substantially higher in rural settings and those with no formal education.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

Diabetes Treatment as "Homework": Consequences for Household Knowledge and Health Practices in Rural Uganda

BACKGROUND

Health professionals assign diabetes patients "homework" in that they give them instructions on how to manage diabetes, recognizing that most diabetes care takes place in the home setting. We studied how homework is practiced and whether knowledge and behavioral practices related to diabetes self-management diffuse from patients to their housemates.

METHOD

This mixed-methods study combined quantitative data from a household survey including 90 rural Ugandan households (50% had a member with type 2 diabetes [T2D]) with qualitative data from health facilities and interviews with 10 patients with T2D. Focus for data collection was knowledge and practices related to diabetes homework. A generalized mixed model was used to analyze quantitative data, while content analysis was used for qualitative data analysis.

RESULTS

Patients with T2D generally understood the diabetes homework assignments given by health professionals and carried out their homework with support from housemates. Although adherence to recommended diet was variable, housemates were likely to eat a healthier diet than if no patient with T2D lived in the household. Knowledge related to diabetes homework diffused from the patients to housemates and beyond to neighbors and family living elsewhere. Knowledge about primary prevention of T2D was almost absent among health staff, patients, and relatives.

CONCLUSIONS

Homework practices related to T2D improve diabetes-related knowledge and may facilitate healthy eating in nondiabetic housemates. These findings suggest that having a chronic disease in the household provides an opportunity to improve health in the entire household and address the lack of knowledge about prevention of T2D.

Childhood diabetes in Africa

PURPOSE OF REVIEW

This review summarizes the current state of diabetes in African children.

RECENT FINDINGS

Type 1 diabetes is the most common form of pediatric diabetes in Africa. Significant improvements have been achieved over the last 6 years, including the training of more than 60 pediatric endocrinologists who are now practicing in 14 African nations, greater training of other healthcare providers, increased availability of insulin through the efforts of philanthropic organizations and industry, modestly better availability of testing supplies, and the introduction of patient education materials in native languages. However, there is still a long way to go before the standard-of-care available to children in resource-rich nations is available to children with diabetes in Africa.

SUMMARY

Here, we review the known epidemiology, pathophysiology, complications, and treatment of diabetes in children in Africa.

First Prospective Cohort Study of Diabetic Retinopathy from Sub-Saharan Africa: High Incidence and Progression of Retinopathy and Relationship to Human Immunodeficiency Virus Infection

PURPOSE

To describe the prevalence, incidence, and progression of retinopathy and to report associations with demographic, clinical, and biochemical variables in people with diabetes in Southern Malawi.

DESIGN

Prospective cohort study.

PARTICIPANTS

Subjects were systematically sampled from 2 primary care diabetes clinics.

METHODS

We performed the first prospective cohort study of diabetic retinopathy from Sub-Saharan Africa over 24 months. Visual acuity, glycemic control, blood pressure, human immunodeficiency virus (HIV) status, urine albumin-to-creatinine ratio, hemoglobin, and lipids were assessed. Retinopathy was graded at an accredited reading center using modified Wisconsin grading of 4-field mydriatic photographs.

MAIN OUTCOME MEASURES

Incidence of sight-threatening retinopathy and progression of retinopathy by 2 steps on the Liverpool Diabetic Eye Study Scale.

RESULTS

A total of 357 subjects were recruited to the 24-month cohort study. At baseline, 13.4% of subjects were HIV positive and 15.1% were anemic. The 2-year incidence of sight-threatening diabetic retinopathy (STDR) for subjects with level 10 (no retinopathy), level 20 (background), and level 30 (preproliferative) retinopathy at baseline was 2.7% (95% confidence interval [CI], 0.1-5.3), 27.3% (95% CI, 16.4-38.2), and 25.0% (95% CI, 0-67.4), respectively. In a multivariate logistic analysis, 2-step progression of diabetic retinopathy was associated with glycosylated hemoglobin (odds ratio [OR], 1.27; 95% CI, 1.12-1.45), baseline grade of retinopathy (OR, 1.39; 95% CI, 1.02-1.91), and HIV infection (OR, 0.16; 95% CI, 0.03-0.78). At 2 years, 17 subjects (5.8%) lost ≥15 letters.

CONCLUSIONS

Incidence of STDR was approximately 3 times that reported in recent European studies. The negative association of HIV infection with retinopathy progression is a new finding.

Accessing diabetes care in rural Uganda: Economic and social resources

Non-communicable diseases including type 2 diabetes (T2D) are increasing rapidly in most Sub-Saharan African (SSA) countries like Uganda. Little attention has been given to how patients with T2D try to achieve treatment when the availability of public health care for their disease is limited, as is the case in most SSA countries. In this paper we focus on the landscape of availability of care and the therapeutic journeys of patients within that landscape. Based on fieldwork in south-western Uganda including 10 case studies, we explore the diabetes treatment options in the area and what it takes to access the available treatment. We analyse the resources patients need to use the available treatment options, and demonstrate that the patients' journeys to access and maintain treatment are facilitated by the knowledge and support of their therapy management groups. Patients access treatment more effectively, if they and their family have money, useful social relations, and knowledge, together with the capacity to communicate with health staff. Patients coming from households with high socio-economic status (SES) are more likely to have all of these resources, while for patients with low or medium SES, lack of economic resources increases the importance of connections within the health system.

Diabetes in the young - a global view and worldwide estimates of numbers of children with type 1 diabetes

This paper describes the methodology, results and limitations of the 2013 International Diabetes Federation (IDF) Atlas (6th edition) estimates of the worldwide numbers of prevalent cases of type 1 diabetes in children (<15 years). The majority of relevant information in the published literature is in the form of incidence rates derived from registers of newly diagnosed cases. Studies were graded on quality criteria and, if no information was available in the published literature, extrapolation was used to assign a country the rate from an adjacent country with similar characteristics. Prevalence rates were then derived from these incidence rates and applied to United Nations 2012 Revision population estimates for 2013 for each country to obtain estimates of the number of prevalent cases. Data availability was highest for the countries in Europe (76%) and lowest for the countries in sub-Saharan Africa (8%). The prevalence estimates indicate that there are almost 500,000 children aged under 15 years with type 1 diabetes worldwide, the largest numbers being in Europe (129,000) and North America (108,700). Countries with the highest estimated numbers of new cases annually were the United States (13,000), India (10,900) and Brazil (5000). Compared with the prevalence estimates made in previous editions of the IDF Diabetes Atlas, the numbers have increased in most of the IDF Regions, often reflecting the incidence rate increases that have been well-documented in many countries. Monogenic diabetes is increasingly being recognised among those with clinical features of type 1 or type 2 diabetes as genetic studies become available, but population-based data on incidence and prevalence show wide variation due to lack of standardisation in the studies. Similarly, studies on type 2 diabetes in childhood suggest increased incidence and prevalence in many countries, especially in Indigenous peoples and ethnic minorities, but detailed population-based studies remain limited.

Diabetic ketoacidosis: an overlooked child killer in sub-Saharan Africa?

The true incidence of diabetic ketoacidosis (DKA) in sub-Saharan Africa is unknown but unlike in the Western countries, DKA is also uniquely frequent among type 2 diabetes patients of African origin. Increased hyperglycaemia and hepatic ketogenesis lead to osmotic diuresis, dehydration and tissue hypoxia. Acute complications of DKA include cerebral oedema, which may be compounded by malnutrition, parasitic and microbial infections with rampant tuberculosis and HIV. Overlapping symptoms of these conditions and misdiagnosis of DKA contribute to increased morbidity and mortality. Inability of the patients to afford insulin treatment leads to poor glycemic control as some patients seek alternative treatment from traditional healers or use herbal remedies further complicating the disease process. Standard treatment guidelines for DKA currently used may not be ideal as they are adapted from those of the developed world. Children presenting with suspected DKA should be screened for comorbidities which may complicate fluid and electrolyte replacement therapy protocol. Patient rehabilitation should take into account concurrent treatment for infectious conditions to avoid possible life-threatening drug interactions. We recommend that health systems in sub-Saharan Africa leverage the Expanded Immunization Programme or TB/HIV/AIDS programmes, which are fairly well entrenched to support diabetes services.

A systematic overview of prospective cohort studies of cardiovascular disease in sub-Saharan Africa

Background

Cardiovascular diseases (CVDs) are becoming increasingly significant in sub-Saharan Africa (SSA). Reliable measures of the contribution of major determinants are essential for informing health services and policy solutions.

Objective

To perform a systematic review of all longitudinal studies of CVDs and related risk factors that have been conducted in SSA.

Data source

We searched electronic databases from 1966 to October 2009. Published studies were retrieved from PubMed and Africa EBSCO. Reference lists of identified articles were scanned for additional publications.

Study selection

Any longitudinal study with data collection at baseline on major cardiovascular risk factors or CVD, including 30 or more participants, and with at least six months of follow up were included.

Data extraction

Data were extracted on the country of study, year of inception, baseline evaluation, primary focus of the study, outcomes, and number of participants at baseline and final evaluation.

Results

Eighty-one publications relating to 41 studies from 11 SSA countries with a wide range of participants were included. Twenty-two were historical/prospective hospital-based studies. These studies focused on risk factors, particularly diabetes mellitus and hypertension, or CVD including stroke, heart failure and rheumatic heart disease. The rate of participants followed through the whole duration of studies was 72% (64–80%), with a significant heterogeneity between studies (for heterogeneity, p < 0.001). Outcomes monitored during follow up included trajectories of risk markers and mortality.

Conclusions

Well-designed prospective cohort studies are needed to inform and update our knowledge regarding the epidemiology CVDs and their interactions with known risk factors in the context of common infectious diseases in this region.

Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review

Background

Diabetes prevalence is increasing globally, and Sub-Saharan Africa is no exception. With diverse health challenges, health authorities in Sub-Saharan Africa and international donors need robust data on the epidemiology and impact of diabetes in order to plan and prioritise their health programmes. This paper aims to provide a comprehensive and up-to-date review of the epidemiological trends and public health implications of diabetes in Sub-Saharan Africa.

Methods

We conducted a systematic literature review of papers published on diabetes in Sub-Saharan Africa 1999-March 2011, providing data on diabetes prevalence, outcomes (chronic complications, infections, and mortality), access to diagnosis and care and economic impact.

Results

Type 2 diabetes accounts for well over 90% of diabetes in Sub-Saharan Africa, and population prevalence proportions ranged from 1% in rural Uganda to 12% in urban Kenya. Reported type 1 diabetes prevalence was low and ranged from 4 per 100,000 in Mozambique to 12 per 100,000 in Zambia. Gestational diabetes prevalence varied from 0% in Tanzania to 9% in Ethiopia. Proportions of patients with diabetic complications ranged from 7-63% for retinopathy, 27-66% for neuropathy, and 10-83% for microalbuminuria. Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis. Meanwhile, antiviral treatment for HIV increases the risk of obesity and insulin resistance. Five-year mortality proportions of patients with diabetes varied from 4-57%. Screening studies identified high proportions (> 40%) with previously undiagnosed diabetes, and low levels of adequate glucose control among previously diagnosed diabetics. Barriers to accessing diagnosis and treatment included a lack of diagnostic tools and glucose monitoring equipment and high cost of diabetes treatment. The total annual cost of diabetes in the region was estimated at US$67.03 billion, or US$8836 per diabetic patient.

Conclusion

Diabetes exerts a significant burden in the region, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high mortality and prevalence of complications observed. The significant interactions between diabetes and important infectious diseases highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.

Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review

BACKGROUND

Diabetes prevalence is increasing globally, and Sub-Saharan Africa is no exception. With diverse health challenges, health authorities in Sub-Saharan Africa and international donors need robust data on the epidemiology and impact of diabetes in order to plan and prioritise their health programmes. This paper aims to provide a comprehensive and up-to-date review of the epidemiological trends and public health implications of diabetes in Sub-Saharan Africa.

METHODS

We conducted a systematic literature review of papers published on diabetes in Sub-Saharan Africa 1999-March 2011, providing data on diabetes prevalence, outcomes (chronic complications, infections, and mortality), access to diagnosis and care and economic impact.

RESULTS

Type 2 diabetes accounts for well over 90% of diabetes in Sub-Saharan Africa, and population prevalence proportions ranged from 1% in rural Uganda to 12% in urban Kenya. Reported type 1 diabetes prevalence was low and ranged from 4 per 100,000 in Mozambique to 12 per 100,000 in Zambia. Gestational diabetes prevalence varied from 0% in Tanzania to 9% in Ethiopia. Proportions of patients with diabetic complications ranged from 7-63% for retinopathy, 27-66% for neuropathy, and 10-83% for microalbuminuria. Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis. Meanwhile, antiviral treatment for HIV increases the risk of obesity and insulin resistance. Five-year mortality proportions of patients with diabetes varied from 4-57%. Screening studies identified high proportions (> 40%) with previously undiagnosed diabetes, and low levels of adequate glucose control among previously diagnosed diabetics. Barriers to accessing diagnosis and treatment included a lack of diagnostic tools and glucose monitoring equipment and high cost of diabetes treatment. The total annual cost of diabetes in the region was estimated at US$67.03 billion, or US$8836 per diabetic patient.

CONCLUSION

Diabetes exerts a significant burden in the region, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high mortality and prevalence of complications observed. The significant interactions between diabetes and important infectious diseases highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.

Diabetes in sub-saharan Africa: kenya, mali, mozambique, Nigeria, South Africa and zambia

Until a few years ago, a limited number of epidemiologists or public health experts mentioned the words “diabetes.” As new lifestyles, imported dietary practices, and globalization take roots in the developing world, as Africa is, today, diabetes and its complications are considered an epidemic in Africa, compelling African governments to start paying more attention to its impact as thousands of Africans run the risk of dying young. The potential severity of diabetes is such that some epidemiologists predict that its economic impact and death toll will surpass the ravages of HIV and AIDS in the near future. On the African sub-continent, present literature and the work of the World Diabetes Foundation have highlighted three countries, namely, Mali, Mozambique, and Zambia. However, the conditions in South Africa, Kenya, and Nigeria, some of the most developed areas of the continent, provide a clue to how people are coping and how governments are responding to diabetes and its full impact. This study is, therefore, a meta-summary of the incidence and prevalence of today's emerging silent killer or diabetes in Sub-Saharan Africa. The theme is that time is running out for Africa and that, as was for HIV/AIDS, by the time the governments wake up and stop denying the catastrophic potential of the epidemic, diabetes will simply overwhelm the continent's resources, and the world will witness the death of millions of Africans. The last section is a call for action against diabetes in terms of advocacy, promotion of awareness, and public health policies that empower people to diabetes self-management.

Prevalence of diabetes mellitus and impaired glucose tolerance in a rural community of Angola

BACKGROUND

To determine the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in a rural community (Bengo) of Angola.

METHODS

A random sample of 421 subjects aged 30 to 69 years (30% men and 70% women) was selected from three villages of Bengo province. This cross-sectional home survey was conducted using a sampling design of stage conglomerates. First, clinical and anthropometric data were obtained and fasting capillary glucose level was determined. Subjects who screened positive (fasting capillary glucose ≥ 100 mg/dl and < 200 mg/dl) and each sixth consecutive subject who screened negative (fasting capillary glucose < 100 mg/dl) were submitted to the second phase of survey, consisting of the 75-g oral glucose tolerance test. Data was analyzed by the use of SAS statistical software.

RESULTS

The prevalence rates of diabetes mellitus and IGT were 2.8% and 8.1%, respectively. The age group with the highest prevalence of diabetes was 60 to 69 years (42%). Impaired glucose tolerance prevalence was 38% in the 40 to 49 year age group and it increased with age, considering that the 50 to 59 and 60 to 69 year age groups as a whole represent 50% of all subjects with impaired glucose tolerance. The prevalence of diabetes mellitus did not differ significantly between men (3.2%) and women (2.7%) (p = 0.47). On the other hand, the prevalence of impaired glucose tolerance among women showed almost twice that found in men (9.1% vs. 5.6%, respectively). Overweight was present in 66.7% of the individuals with diabetes mellitus and 26.5% of individuals with impaired glucose tolerance showed overweight or obesity.

CONCLUSIONS

Although the prevalence of diabetes mellitus was low, the prevalence of impaired glucose tolerance is considered to be within an intermediary range, suggesting a future increase in the frequency of diabetes in this population.

Type 2 diabetes mellitus and obesity in sub-Saharan Africa

While communicable diseases such as human immunodeficiency virus/acquired immune deficiency syndrome, malaria, and tuberculosis have continued to pose greater threats to the public health system in sub-Saharan Africa (SSA), it is now apparent that non-communicable diseases such as diabetes mellitus are undoubtedly adding to the multiple burdens the peoples in this region suffer. Type 2 diabetes mellitus (T2DM) is the most common form of diabetes (90-95%), exhibiting an alarming prevalence among peoples of this region. Its main risk factors include obesity, rapid urbanization, physical inactivity, ageing, nutrition transitions, and socioeconomic changes. Patients in sub-Saharan Africa also show manifestations of beta-cell dysfunction and insulin resistance. However, because of strained economic resources and a poor health care system, most of the patients are diagnosed only after they have overt symptoms and complications. Microvascular complications are the most prevalent, but metabolic disorders and acute infections cause significant mortality. The high cost of treatment of T2DM and its comorbidities, the increasing prevalence of its risk factors, and the gaps in health care system necessitate that solutions be planned and implemented urgently. Aggressive actions and positive responses from well-informed governments appear to be needed for the conducive interplay of all forces required to curb the threat of T2DM in sub-Saharan Africa. Despite the varied ethnic and transitional factors and the limited population data on T2DM in sub-Saharan Africa, this review provides an extensive discussion of the literature on the epidemiology, risk factors, pathogenesis, complications, treatment, and care challenges of T2DM in this region.

Mortality of young patients with diabetes in Kinshasa, DR Congo

AIMS

As data on mortality of young patients with diabetes is not available in the Democratic Republic of Congo (DRC), we studied mortality rates, the influence of some determinants and causes of death.

METHODS

A retrospective review of standardized medical records of all patients with diabetes aged<or=30 years at diagnosis who were enrolled between 1994 and 2004 in a large, integrated healthcare network in Kinshasa, DRC. Diabetes was diagnosed clinically. As resources for classification according to type of diabetes were not available, the study sample was a mixed-type cohort. Death was established by review of medical records and by community interview. Mortality was recorded until 2007. Overall mortality rates and 95% confidence intervals (CI) were calculated. Kaplan-Meier survival and Cox regression analyses were performed to study the influence of determinants.

RESULTS

Of the patients, 17.4% (159/915) died, mostly during the first 5 years of follow-up. Mean yearly mortality was 3.62/100 patient-years (95% CI 3.1-4.2). Independent predictors were male gender [hazard ratio (HR) 0.66 (95% CI 0.5-0.9) for females vs. males] and age at diagnosis (HR 0.97 (95% CI 0.94-0.99) per increase of 1 year]. Major causes of death were ketoacidosis (38%) and infection (12%). Cause of death was unknown in 31% of cases.

CONCLUSIONS

One out of six patients died, most within 5 years after diagnosis. Death occurred more frequently at home, in male patients and in subjects aged<or=20 years. The major cause of death was ketoacidosis.

Type 2 diabetes management in nurse-led primary healthcare settings in urban and rural Cameroon

AIMS

To implement a protocol-driven primary nurse-led care for type 2 diabetes in rural and urban Cameroon.

METHODS

We set-up three primary healthcare clinics in Yaounde (Capital city) and two in the Bafut rural health district. Participants were 225 (17% rural) patients with known or newly diagnosed type 2 diabetes, not requiring insulin, referred either from a baseline survey (38 patients, 17%), or secondarily attracted to the clinics. Protocol-driven glucose and blood pressure control were delivered by trained nurses. The main outcomes were trajectories of fasting capillary glucose and blood pressure indices, and differences in the mean levels between baseline and final visits.

RESULTS

The total duration of follow-up was 1110 patient-months. During follow-up, there was a significant downward trend in fasting capillary glucose overall (p<0.001) and in most subgroups of participants. Between baseline and final visits, mean fasting capillary glucose dropped by 1.6 mmol/L (95% CI: 0.8-2.3; p< or =0.001). Among those with hypertension, blood pressure also decreased significantly for systolic and marginally for diastolic blood pressure. No major significant change was noticed for body weight.

CONCLUSIONS

Nurses may be potential alternatives to improve access to diabetes care in settings where physicians are not available.

Treating 4,000 diabetic patients in Cambodia, a high-prevalence but resource-limited setting: a 5-year study

BACKGROUND

Despite the worldwide increasing burden of diabetes, there has been no corresponding scale-up of treatment in developing countries and limited evidence of program effectiveness. In 2002, in collaboration with the Ministry of Health of Cambodia, Médecins Sans Frontières initiated an outpatient program of subsidized diabetic care in two hospital-based chronic disease clinics in rural settings. We aimed to describe the outcomes of newly and previously diagnosed diabetic patients enrolled from 2002 to 2008.

METHODS

We calculated the mean and proportion of patients who met the recommended treatment targets, and the drop from baseline values for random blood glucose (RBG), hemoglobin A1c (HbA1c), blood pressure (BP), and body mass index (BMI) at regular intervals. Analysis was restricted to patients not lost to follow-up. We used the t test to compare baseline and subsequent paired values.

RESULTS

Of 4404 patients enrolled, 2,872 (65%) were still in care at the time of the study, 24 (0.5%) had died, and 1,508 (34%) were lost to follow-up. Median age was 53 years, 2,905 (66%) were female and 4,350 (99%) had type 2 diabetes. Median (interquartile range (IQR)) follow-up was 20 months (5 to 39.5 months). A total of 24% (51/210) of patients had a HbA1c concentration of <7% and 35% (709/1,995) had a RBG <145 mg/dl within 1 year. There was a significant drop of 109 mg/dl (95% confidence interval (CI) 103.1 to 114.3) in mean RBG (P < 0.001) and a drop of 2.7% (95% CI 2.3 to 3.0) in mean HbA1c (P < 0.001) between baseline and month 6. In all, 45% (327/723) and 62% (373/605) of patients with systolic or diastolic hypertension at baseline, respectively, reached = 130/80 mm Hg within 1 year. There was a drop of 13.5 mm Hg (95% CI 12.1 to 14.9) in mean systolic blood pressure (SBP) (P < 0.001), and a drop of 11.7 mm Hg (95% CI 10.8 to 12.6) in mean diastolic blood pressure (DBP) (P < 0.001) between baseline and month 6. Only 22% (90/401) patients with obesity at baseline lowered their BMI <27.5 kg/m2 after 1 year. Factors associated with loss to follow-up were male sex, age >60 years, living outside the province, normal BMI on admission, high RBG on last visit, and coming late for the last consultation.

CONCLUSION

Significant and clinically important improvements in glycemia and BP were observed, but a relatively low proportion of diabetic patients reached treatment targets. These results and the high loss to follow-up rate highlight the challenges of delivering diabetic care in rural, resource-limited settings.

Improving glycaemic control in African diabetic patients on insulin: a resource-free approach

In the resource-poor areas of the tropics, diabetic patients requiring insulin are often treated with once-daily injections of intermediate-acting insulin. Glycaemic control on this regime is usually poor. We trialled a simple change to twice-daily insulin (same total daily dose, two-thirds given in morning, and one-third in evening) in a group of 20 Ethiopian diabetic patients treated in this way. Nurse support and contact, and self-glucose monitoring were not available. After three months, the haemoglobin Alc (HbAlc) had improved from 10.5 ± 1.8 to 8.0 ± 1.5% (P < 0.001). No improvement occurred in the 20 control patients who remained on once-daily insulin. Among the twice-daily insulin group there was a small increase in weight and mild hypoglycaemic episodes. However, all patients were very satisfied and wished to continue the new system. We conclude that a simple change from once- to twice-daily insulin, without monitoring or support, can lead to a significant improvement in the overall glycaemic control, and is suitable for resource-limited tropical countries.

A sub-Saharan African perspective of diabetes

Diabetes mellitus is an important and increasing cause of morbidity and mortality in sub-Saharan Africa. Accurate epidemiological studies are often logistically and financially difficult, but processes of rural-urban migration and epidemiological transition are certainly increasing the prevalence of type 2 diabetes. Type 1 disease is relatively rare, although this may be related to high mortality. This diabetic subgroup appears to present at a later age (by about a decade) than in Western countries. Variant forms of diabetes are also described in the continent; notably 'atypical, ketosis-prone' diabetes, and malnutrition-related diabetes mellitus. These types sometimes make the distinction between type 1 and type 2 diabetes difficult. Interestingly, this is also a current experience in the developed world. As more detailed and reliable complication studies emerge, it is increasingly apparent that African diabetes is associated with a high complication burden, which is both difficult to treat and prevent. More optimistically, a number of intervention studies and twinning projects are showing real benefits in varying locations. Future improvements depend on practical and sustainable support, coupled with local acceptance of diabetes as a major threat to the future health and quality of life of sub-Saharan Africans.

Diet, nutrition and the prevention of type 2 diabetes

Objectives:

The overall objective of this study was to evaluate and provide evidence and recommendations on current published literature about diet and lifestyle in the prevention of type 2 diabetes.

Design:

Epidemiological and experimental studies, focusing on nutritional intervention in the prevention of type 2 diabetes are used to make disease-specific recommendations. Long-term cohort studies are given the most weight as to strength of evidence available.

Setting and subjects:

Numerous clinical trials and cohort studies in low, middle and high income countries are evaluated regarding recommendations for dietary prevention of type 2 diabetes. These include, among others, the Finnish Diabetes Prevention Study, US Diabetes Prevention Program, Da Qing Study; Pima Indian Study; Iowa Women's Health Study; and the study of the US Male Physicians.

Results:

There is convincing evidence for a decreased risk of diabetes in adults who are physically active and maintain a normal body mass index (BMI) throughout adulthood, and in overweight adults with impaired glucose tolerance who lose weight voluntarily. An increased risk for developing type 2 diabetes is associated with overweight and obesity; abdominal obesity; physical inactivity; and maternal diabetes. It is probable that a high intake of saturated fats and intrauterine growth retardation also contribute to an increased risk, while non-starch polysaccharides are likely to be associated with a decreased risk. From existing evidence it is also possible that omega-3 fatty acids, low glycaemic index foods and exclusive breastfeeding may play a protective role, and that total fat intake andtransfatty acids may contribute to the risk. However, insufficient evidence is currently available to provide convincing proof.

Conclusions:

Based on the strength of available evidence regarding diet and lifestyle in the prevention of type 2 diabetes, it is recommended that a normal weight status in the lower BMI range (BMI 21–23) and regular physical activity be maintained throughout adulthood; abdominal obesity be prevented; and saturated fat intake be less than 7% of the total energy intake.

Long-term (20 years) outcome and mortality of Type 1 diabetic patients in Soweto, South Africa

AIMS

To assess the long-term (20 years) mortality, with causes of death, in a cohort of Type 1 diabetic patients resident in Soweto, South Africa.

METHODS

A cohort of Type 1 diabetic patients attending the Diabetic Clinic of Baragwanath Hospital, Soweto were studied in 1982. They were followed over the subsequent 20 years, the final investigation being in 2002. Numbers dying during the period were recorded, as well as year of death and cause. The complication status of survivors was also assessed.

RESULTS

Of the original cohort of 88 Type 1 patients, 21 died during the follow-up period. There were 39 lost to follow-up, giving a crude 20 years' mortality of 43%. Kaplan-Meier analysis showed mortality hazard of 33%. Of those dying, most (9/21) were as a result of renal failure. Other causes were hypoglycaemia (6), ketoacidosis (2), infection (2) and undetermined (2). Of the survivors, comparing data at 0 and 20 years' follow-up, there was a significant increase in rates of retinopathy (P<0.02) and hypertension (P<0.005), but not of other complications.

CONCLUSIONS

This is the first long-term outcome study of Type 1 diabetes in sub-Saharan Africa. Although the mortality was substantial, it is similar to equivalent studies of United States (US) Afro-Americans with Type 1 diabetes. The major cause of death was renal failure related to diabetic nephropathy, and reflects lack of adequate facilities for renal replacement therapy. Despite the deprivation, poverty, political upheaval and recent AIDS epidemic in Soweto, Type 1 diabetes carries a reasonable long-term prognosis, and survivors are generally free of debilitating complications.

The burden of mortality attributable to diabetes: realistic estimates for the year 2000

OBJECTIVE

To estimate the global number of excess deaths due to diabetes in the year 2000.

RESEARCH DESIGN AND METHODS

We used a computerized generic formal disease model (DisMod II), used by the World Health Organization to assess disease burden through modeling the relationships between incidence, prevalence, and disease-specific mortality. Baseline input data included population structure, age- and sex-specific estimates of diabetes prevalence, and available published estimates of relative risk of death for people with diabetes compared with people without diabetes. The results were validated with population-based observations and independent estimates of relative risk of death.

RESULTS

The excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths. Excess mortality attributable to diabetes accounted for 2-3% of deaths in poorest countries and over 8% in the U.S., Canada, and the Middle East. In people 35-64 years old, 6-27% of deaths were attributable to diabetes.

CONCLUSIONS

These are the first global estimates of mortality attributable to diabetes. Globally, diabetes is likely to be the fifth leading cause of death.

Morbidity and mortality among diabetic patients admitted to Mulago Hospital, Uganda

OBJECTIVES

To document the causes of admission, clinical presentation and outcome of patients admitted with diabetes mellitus to our medical wards.

SETTING

Medical wards of Mulago Hospital, teaching hospital and national referral for the government of Uganda.

STUDY DESIGN

Cross-sectional descriptive non-interventional study of diabetic medical admissions.

RESULTS

During the study period 129 (4.2%) patients with diabetes mellitus out of 3103 total medical admissions were admitted. The commonest cause of admission was uncontrolled diabetes (48.3%) but infections were present in 27.7% of all the study patients. The commonest infections were pneumonia (15%) and urinary tract infections (11.8%). Diabetic ketoacidosis (DKA) was a cause of admission in 9.2% of all the study subjects. Glycaemic control was satisfactory among 50.6% (HbA1c less than 7) despite 84.5% of the study subjects being hyperglycaemic at admission (mean random blood sugar 20±9.0 mmol/L). Fifty-point seven of the subjects had long term complications of diabetes at admission with hypertension (53.8%) and peripheral neuropathy (38.3%) being the commonest. There were 13 deaths (10.8%) and 61.5% of the deaths were among patients admitted with infections. The average length of hospitalisation was 9.5±4 days.

CONCLUSION

The results show that the commonest causes of admission were uncontrolled diabetes and infections. The mortality rate was 10.8%.

Diabetes trends in Africa

Diabetes is an important cause of morbidity and mortality in Africa. Although a dramatic increase in disease burden is projected, it remains to be seen what effect the ongoing devastation of HIV disease will have on the epidemiology of such chronic diseases as diabetes. Recent data on type 2 diabetes prevalence indicate low rates in some rural populations, moderate rates similar to those in developed areas in some countries, and alarmingly high rates in others. The frequent observation of moderate to high prevalence of impaired glucose tolerance, particularly in populations with a low prevalence of diabetes, may indicate the early stage of a diabetes epidemic. Risk factors include urbanization, age, and family history of disease, as well as such modifiable risk factors as adiposity and physical inactivity. For type 1 diabetes, limited data indicate that the prevalence is low in sub-Saharan Africa and that onset occurs later in life there than in other parts of the world. Mortality associated with diabetes is unacceptably high and is disproportionately due to preventable acute metabolic and infective causes. With long duration of disease, there is a high frequency of hypertension and microvascular complications. The apparent low frequency of chronic macrovascular complications needs fuller documentation - as does the apparent high frequency of hypertension even in the non-diabetic population. Efforts to prevent this disease and its complications in Africa are impeded by inadequate health care infrastructure, inadequate supply of medications, absence of educational programs, and lack of available health care facilities and providers.

Excess mortality associated with blindness in the onchocerciasis focus of the Mbam Valley, Cameroon

The association between blindness, mortality and nutritional status was investigated in a retrospective cohort study in villages of central Cameroon where onchocerciasis is hyper-endemic. Overall, 101 blind subjects and 101 non-blind controls matched with the blind for age, sex and (generally) village of residence were followed for 10 years. Blindness gave rise to a significant increase in mortality (relative risk = 2.3; P = 0.012), the life expectancy of the blind adults being reduced by 4 years compared with that of their controls. For a given age, excess mortality was found to be associated with a late onset of blindness. The causes of death were similar for the blind and the controls but blind subjects had relatively low body mass indices, which may lead to relatively early fatal disease outcomes. These results are similar to those obtained in other parts of Africa and emphasise, once more, the demographic impact of blindness in developing countries.

Assessment of glycaemic control in stable type 2 black South African diabetics attending a peri-urban clinic

Glycaemic control was assessed in type 2 black diabetics attending the diabetic clinic at a peri-urban hospital. Baseline glycosylated haemoglobin levels were measured and a subsequent estimation was carried out in those patients who attended a follow-up consultation to see whether current recommended targets for glycosylated haemoglobin levels were being attained. Out of 708 patients, mean age 56.3 years, 14.7% were insulin treated and 85.3% were non-insulin-treated. Target values of HbA1c < 7% were achieved in only 20.1% (142) of patients. Although mean glycosylated haemoglobin levels were significantly higher in females (p = 0.03), the proportion of poorly controlled diabetics was similar in the two sexes. Patients whose HbA1c levels fell within the target values had diabetes of significantly shorter duration than those exhibiting poor control (5.0 + 0.2 vs 7.03 + 0.5 years). Obesity was present in 562 patients (79.4%). Target values were only achieved in 16.4% of non-obese and 21% of obese diabetics, with mean glycosylated haemoglobin levels being significantly higher (p < 0.05) in the former group (10.3 + 0.4% vs 9.5 + 0.2%). Similar results were observed with respect to type of treatment, with only 14.4% of insulin-treated and 21% of non-insulin-treated diabetics achieving target values. The follow-up HbA1c estimation did not show any difference in the glycaemic control status of patients, with only 19.9% of them achieving the target values. Dietary advice (though minimal) seemed to have no impact on the metabolic control of our patients. These results suggest that glycaemic control was poor irrespective of sex, duration, BMI, educational status, dietary advice and type of treatment with recommended target values not being achieved in the majority of patients. Behavioural changes through health educational programmes need to be instituted with both patient and medical personnel being motivated to take this process forward.

Clinical classification of diabetes in tropical west Africa

The objective of this work was to classify and describe the different types of diabetic patients detected in West Africa. In four health centres (three in Ivory Coast, one in Niger) 310 new cases were detected and followed up over 1 year. Classification was based on age at diagnosis, BMI, ketonuria, basal and stimulated C-peptide levels at inclusion, and response to antidiabetic therapy. In this population, males were predominant (sex ratio = 2.40), and random blood glucose levels very high at screening (mean +/- SE, 18.6 +/- 0.4 mmol/l). Only one case of fibrocalculous pancreatic diabetes and one possible case of diabetes mellitus related to malnutrition were detected. IDDM was diagnosed in 11.3% of the patients, half of them above 35 years. Leanness was observed in 59% of the patients with NIDDM. A dramatic decrease of fasting blood glucose was observed in all groups after 2 months of treatment, especially in NIDDM. As IDDM and non-obese NIDDM presented great similarities before treatment, even for C-peptide levels, a point score system is proposed to classify these two groups at baseline. In conclusion, it is confirmed that the form of diabetes previously defined as related to malnutrition is a very rare entity in black African populations. In contrast, African diabetes is characterised by the high proportion of NIDDM patients with low BMI, and reduced beta-cell function, rarely associated to ketonuria. This form of diabetes seems to be adequately controlled with oral hypoglycaemic drugs and/or diet in the year following diagnosis.

Monitoring diabetic control in developing countries: a review of glycated haemoglobin and fructosamine assays

Measurement of glycated proteins, especially haemoglobins, is now a routine procedure for monitoring previous glycaemic control in diabetic patients in the developed world. Until recently, however, the assays were sophisticated and costly and, therefore, were only rarely used in developing countries. With easier and cheaper tests now available, the measurement of glycaemic control could be also introduced into regional hospitals in developing countries. This paper reviews feasible methods for clinical laboratories with limited resources. Recent experiences from African countries are included.

Noncommunicable disease management in resource-poor settings: a primary care model from rural South Africa

Noncommunicable diseases (NCDs) such as hypertension, asthma, diabetes and epilepsy are placing an increasing burden on clinical services in developing countries and innovative strategies are therefore needed to optimize existing services. This article describes the design and implementation of a nurse-led NCD service based on clinical protocols in a resource-poor area of South Africa. Diagnostic and treatment protocols were designed and introduced at all primary care clinics in the district, using only essential drugs and appropriate technology; the convenience of management for the patient was highlighted. The protocols enabled the nurses to control the clinical condition of 68% of patients with hypertension, 82% of those with non-insulin-dependent diabetes, and 84% of those with asthma. The management of NCDs of 79% of patients who came from areas served by village or mobile clinics was transferred from the district hospital to such clinics. Patient-reported adherence to treatment increased from 79% to 87% (P = 0.03) over the 2 years that the service was operating. The use of simple protocols and treatment strategies that were responsive to the local situation enabled the majority of patients to receive convenient and appropriate management of their NCD at their local primary care facility.

Glycaemic control and its determinants in diabetic patients in Ethiopia

A cross-sectional study was undertaken in which concentrations of glycated haemoglobins were measured in 102 diabetics seen at the outpatient clinic in Gondar, Ethiopia, between 26 January and 7 March, 1995. Mean HbA1, levels (standard deviations) were 5.35% (1.1) in non-diabetic controls, 12.0% (1.5) in 59 insulin-dependent diabetics, and 11.0% (2.0) in 43 non-insulin dependent outpatients. The majority of insulin-dependent mellitus (IDDM) (78%) and non-insulin-dependent mellitus (NIDDM) patients (77%) were poorly controlled (HbA1 > 10.8% in IDDM, and > 9.7% in NIDDM, respectively). Multiple linear regression analyses revealed that HbA1 levels were significantly positively associated with lower body mass index, duration of diabetes, a recent history of polydipsia, hypertension, and low income in NIDDM individuals. Whereas in IDDM patients lower age (or alternatively lower age at onset) was the only significant predictor. Whilst 49% of the model variance was explained by the predictors in NIDDM diabetics, only 9% were so in IDDM patients. Current fasting blood glucose level was marginally significant in NIDDM patients (r = 0.29; P = 0.058), but insignificant in IDDM individuals. This points towards the fluctuations in blood glucose levels experienced by IDDM patients in a setting where insulin supply is unreliable. It also confirms the doubts about the usefulness of fasting blood glucose values as a tool for assessing metabolic control.

High mortality from renal disease and infection in Aboriginal central Australians with diabetes

Few studies have examined the consequences of the high prevalence of diabetes in Aboriginal communities. We aimed to determine the rates and causes of mortality in all Aboriginal central Australians with diagnosed diabetes, identified by a previous study (n =374). Cohort members were followed from 1 January 1984, or the date of diagnosis (to 31 December 1986), to 31 December 1991 or death. Death certificates, medical notes and autopsy reports were examined for cause of death. There were 130 deaths in 2280.7 person-years of follow-up. Standardised mortality ratios for Aboriginal people with diabetes, compared to the Northern Territory Aboriginal population, were 209 (95 per cent confidence interval (CI) 158 to 273) for men and 169 (CI 129 to 218) for women. The difference in ratios for men and women was not statistically significant when adjusted for age (P = 0.2). The eight-year survival rates for men and women diagnosed between 1984 and 1986 were 55.8 per cent (CI 32.6 to 73.7) for men and 80.3 per cent (CI 64.8 to 89.5) for women. Renal disease was the direct cause of death in 22.3 per cent. Infection accounted for 20.8 per cent of deaths and ischaemic heart disease for 13.8 per cent. Forty-four per cent of death certificates made no mention of diabetes. Diabetes confers an additional risk of death on a population whose mortality is already markedly worse than that of other Australians. Unlike Western diabetic populations, infections and renal disease were more common causes of death than macrovascular disease. Diabetes amplifies the effect of the community prevalence of infection and renal disease.

Mortality and outcome of insulin-dependent diabetes in Soweto, South Africa

Sixty-four insulin-dependent (Type 1) diabetic patients (IDDM) in Soweto, South Africa were followed over a 10-year period. Patients were assessed in 1982 and again in 1992. There were 10 deaths (16%), half of which were due to renal failure. Ketoacidosis, hypoglycaemia, and sepsis accounted for the rest. At the 10-year follow-up mean age (+/- SD) was 32.4 +/- 5.0 years and diabetes duration 13.6 +/- 2.6 years. Retinopathy affected 52%, peripheral neuropathy 42%, and nephropathy 28% (all significantly increased from the 1982 assessment). Microalbuminuria and autonomic neuropathy were also common. Serum cholesterol was over 6.5 mmol l-1 in 19%, hypertension affected 22%, and 28% were cigarette smokers; though no patient had evidence of macroangiopathy. We conclude that IDDM in South Africa is associated with excess mortality, a significant proportion of which is related to nephropathy. Diabetes of long duration is now not uncommon in South Africa, and although diabetic complications frequently occur, most patients have good life quality and freedom from large vessel disease.

Hypoglycaemic admissions among diabetic patients in Soweto, South Africa

An audit of hypoglycaemic admissions among diabetic patients to Baragwanath Hospital, Soweto, South Africa was carried out prospectively during a recent 5-month period. A total of 51 episodes of biochemically confirmed hypoglycaemia (blood glucose < 2.2 mmol l-1 with coma or pre-coma, and requiring intravenous glucose) were observed in 43 patients. There was a wide range of ages (22-88 years) and an excess of males (27 M:16 F). Fourteen (33%) cases were associated with sulphonylurea (gliclazide) treatment. Doses of insulin or sulphonylureas were not excessive. The major cause precipitating the event was a missed meal (36%), though alcohol (22%), gastrointestinal upset (20%), and inappropriate treatment (18%) were also important contributory factors. Following recovery from the event, doses of drugs or insulin were frequently reduced, and three patients were successfully taken off insulin, and six off gliclazide. There was no mortality in this series, and no obvious long-term morbidity. We conclude that severe hypoglycaemia is a frequent and important acute diabetic complication in Soweto. Patient education and care in prescribing for Type 2 diabetic patients may help reduce its occurrence and severity.

Clinical pattern of childhood type 1 (insulin-dependent) diabetes mellitus in the Sudan

During a 10-year period, 101 children with Type 1 (insulin-dependent) diabetes mellitus were admitted to the Department of Paediatrics of the University Hospital in Khartoum, Sudan. The age distribution of the patients showed a steady increase from age one to ten years followed by a sharper increase around puberty. A higher number of cases were diagnosed during the cooler compared to the warmer months of the year (p less than 0.05). Family history of Type 1 diabetes was reported in 14.9% of patients. Diabetic ketoacidosis was a presenting symptom in 82 patients (81.2%) and 93 patients (92.1%) have had at least two documented episodes of ketoacidosis during the follow-up period. Almost all patients were treated with bovine insulin given as a single dose per day. An initial remission period was not observed in any of the patients. Four years after diagnosis, the average daily dose of insulin used by the patients was greater than 2.0 U/kg body weight and the mean HbA1C was 13.4% (reference value 5.3-6.7%). Seventeen patients (16.8%) were known to have died during 399 person-years of observation resulting in a mortality rate of 42.6 per 1000 person-years of follow-up. Another 29 patients (28.7%) for no apparent reason did not attend a follow-up examination after discharge from hospital. Some of these patients might have died in other hospitals or at home. The study emphasizes the need for urgent measures to increase public awareness of diabetes and to improve methods of case-finding and management of diabetic patients.

Childhood diabetes, insulin, and Africa. DERI (Diabetes Epidemiology Research International) Study Group

Mortality associated with Type 1 (insulin-dependent) diabetes has perceptually declined with the identification and widespread use of insulin. In the pre-insulin era, over 80% of all individuals developing diabetes died each year, now less than one in two hundred die. Sadly, this remarkable achievement has not reached the children who develop diabetes in sub-Saharan Africa where the onset of childhood diabetes is the equivalent of a death sentence. Two major issues of importance related to Type 1 diabetes in African and other developing countries are missed diagnosis and unavailability of insulin, issues which cannot be ignored.

Diabetes mellitus in The Gambia, west Africa

A register of diabetic patients attending the Royal Victoria Hospital, Banjul, The Gambia, was kept and data on hospital admissions recorded over a 1-year period. Two hundred and sixty-nine patients (110 men, 159 women) were registered of whom 66 (25%) were receiving insulin. Seventy-five patients (28%: 40 men, 35 women) were newly diagnosed. There were significant differences in age (p less than 0.001) and obesity (p less than 0.001) between men and women and between patients with different types of diabetes. There were 95 hospital admissions (5.2%) related to diabetes, as were a fifth of medical out-patient attendances. Ketoacidosis was the major cause of death while foot infections were more common (p less than 0.01) in women. Diabetes imposed a heavy burden on the health services of The Gambia, a small developing country in West Africa; more than 3.6% of the annual health budget was spent on the treatment of diabetic patients.

Must diabetes be a fatal disease in Africa? Study of costs of treatment

OBJECTIVE

To estimate the costs of diagnosis and treatment of diabetes in Tanzania.

DESIGN

Costs estimated from the reported and recorded experience of patients with newly presenting diabetes in 1989-90 and of diabetic patients first seen in 1981-2.

SETTING

Muhimbili Medical Centre, Dar es Salaam.

SUBJECTS

464 patients (315 men and 149 women). 262 patients diagnosed during 1 September 1989-31 August 1990 (group 1) and 202 during 1 June 1981-31 August 1982 (group 2).

RESULTS

The average annual direct cost of diabetes care in 1989-90 was $287 for a patient requiring insulin and $103 for a patient not requiring insulin. Purchase of insulin accounted for 68.2% ($156) of the average annual outpatient costs for patients requiring insulin. For patients not requiring insulin the cost of oral hypoglycaemic drugs and treatment of chronic complications and infections accounted for 42.5% ($29.3) and 48.8% ($33.7) of costs respectively. Cost of outpatient care of diabetic patients for the whole of Tanzania was estimated at $2.7m, *75,128 (32.2%) of which was for insulin. Doctors' and nurses' costs accounted for 0.2% of total costs of outpatient care. The annual direct inpatient care costs were estimated at $1.25m. Around 0.2% of the Tanzanian population aged 15 years and over used the equivalent of 8% of the total government health expenditure, which was $47,4088,382.

CONCLUSION

Diabetes places a severe strain on the limited resources of developing countries. If African patients with diabetes have to pay for their treatment most will be unable to do so and will die.

Treatment of diabetic ketoacidosis and non-ketotic hyperosmolar diabetic coma

Although mortality of diabetic ketoacidosis (KA) has decreased during the past 20 yr to 1-2%, hyperosmolar non-ketotic coma (HNC) is still lethal in 20-30% of cases due to severe underlying conditions or to complications. The most frequent causes of death are infections and thromboembolic disorders. The strategies of initial treatment of KA and HNC are similar; in KA, insulin, fluid and electrolyte replacement have first priority. In HNC, rehydration and electrolyte administration are of primary importance. It is now generally recognized that insulin therapy is best performed using low doses (4-8 units/h); after institution of insulin treatment and rehydration there are rapid changes of fluid and electrolytes from the extra- into the intravascular space. In this situation it is a major therapeutic challenge to avoid complications due to hypokalaemia, hypophosphataemia, hypomagnesaemia and hypovolaemia. These complications should be avoided by adequate replacement, and particularly by regular clinical and laboratory monitoring. When blood glucose concentrations decrease below 14 mmols/l, blood glucose concentrations should initially be maintained at this level because rapid lowering below this level may increase the risk of brain oedema. Too-vigorous fluid replacement with crystalline solutions also increases the risk that brain oedema or complications like the adult respiratory distress syndrome will develop. If hypovolaemia persists in spite of adequate crystalloid solutions, colloid-containing fluids such as albumin should be administered. It is not established whether replacements of phosphate and magnesium have clinical benefits. Nevertheless, it is probably justified to administer phosphate and magnesium when their serum concentrations are below the normal range, particularly if the clinical situation is critical. Mortality from diabetic coma in industrialized countries may only be decreased by prophylaxis, i.e. by education of all diabetic patients and physicians to detect metabolic decompensation early.

Clinical status of Ethiopian diabetic patients after 20 years of diabetes

By January 1990, over a period of 14 years, the Diabetic Clinic at Yekatit 12 Hospital, Addis Ababa had registered 1699 diabetic patients, of whom 204 were first diagnosed in or before 1969. Of these, 68 are known to have died after 11 to 36 years of diabetes (29% in renal failure), and 69 have been lost to follow-up for 3 or more years. Of the 121 who had been diabetic at least 20 years when last seen, 67 are attending, 18 are lost to follow-up, and 36 have died. Of these 121, 36.4% were known to have neuropathy, 29.8% nephropathy, and 45.5% retinopathy. Only 7 (5.8%) were Type 1 patients compared with 18.8% of the whole diabetic clinic, and most were obese Type 2 diabetic patients from Addis Ababa itself. Most of the 67 still attending after 20 to 34 years of diabetes are independent and fully employed, suggesting that the prognosis of diabetes may not be as dismal as has been generally reported from African countries. However, the survivors were mainly economically better-off Type 2 diabetic patients from the capital.

Diabetes mellitus in the sultanate of Oman

In February 1990 a World Health Organization consultancy was undertaken to assess the current impact of diabetes mellitus in Oman. Routine national health statistics suggested that diabetes was the principal diagnosis in approximately 1% of all hospital discharges in 1988. The number of 'new cases' of diabetes treated at hospitals during the same year was 4.8 per 1000 Omani population, representing almost 6000 diabetic patients. In 1989, at the Royal Hospital, Muscat, diabetes was recorded as the principal diagnosis for 2.6% of all discharges, and 6% of those in subjects aged 45 years and over. It is known that the frequency of diabetes is generally underestimated by routine health statistics. Limited ad hoc investigation during the consultancy suggested that approximately 9% of all adult hospital admissions and 12% of adult hospital bed occupancy were associated with diabetes. Thus, diabetes should be considered a priority in a national health strategy for Oman. It is recommended that emphasis be placed upon epidemiological research, education, and the provision of appropriate technology.