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

Routine health data describe adherence and persistence patterns for oral diabetes medication for a virtual cohort in the Khayelitsha sub-district of Cape Town, South Africa

Type 2 diabetes mellitus (T2DM) is managed with combined lifestyle modifications and antidiabetic drugs, but people on treatment often fail to reach glycaemic control. Adherence is important for achieving optimal glycaemic control, and management of diabetes with drugs is a lifelong process, so understanding adherence through analysis of longitudinal medications data is important. Using retrospective routine health data and metformin dispensing records as a proxy for medication use, we describe longitudinal persistence and adherence to oral diabetes medication in a virtual cohort of 10541 people with diabetes (PLWD) in Khayelitsha subdistrict, Cape Town. Adherence was measured in 120-day sliding windows over two years and used to estimate metformin adherence trajectories. Multinomial logistic regression identified factors influencing these trajectories. Analysis of pharmacy dispensing records showed varying medication refill patterns: while some PLWD refilled prescriptions consistently, others had treatment gaps with periods of non-persistence and multiple treatment episodes-from one to five per individual across two years. There was a general trend of decreasing adherence over time across all sliding windows in the two-year period, with only 25% of the study population achieved medication adherence (> = 80% adherence) after two years. Four adherence trajectories; 'low adherence gradual decline (A), 'high adherence rapid decline' (B), 'low adherence gradual increase (C) and 'adherent' (D) were identified. Only trajectory D represented participants who were adherent at treatment start and remained adherent after two years. Taking HIV antiretroviral treatment before or concurrently with diabetes treatment and taking metformin in combination with sulphonylurea and/or insulin were associated with the long-term adherence (trajectory D). Routine data shows real life medication implementation patterns which might not be seen under controlled study conditions. This study illustrates the utility of these data in describing longitudinal adherence patterns at both an individual and population level.

Self-Management of Diabetes and Associated Factors among Patients Seeking Chronic Care in Tshwane, South Africa: A Facility-Based Study

The burden of diabetes continues to increase in South Africa and a significant number of diabetes patients present at public primary healthcare facilities with uncontrolled glucose. We conducted a facility-based cross-sectional study to determine the diabetes self-management practices and associated factors among out-patients in Tshwane, South Africa. An adapted validated questionnaire was used to collect data on sociodemography, diabetes knowledge, and summaries of diabetes self-management activities measured in the previous seven days, and over the last eight weeks. Data were analysed using STATA 17. A final sample of 402 diabetes out-patients was obtained (mean age: 43 ± 12 years) and over half of them were living in poor households. The mean total diabetes self-management of score was 41.5 ± 8.2, with a range of 21 to 71. Almost two thirds of patients had average self-management of diabetes, and 55% had average diabetes knowledge. Twenty-two percent of patients had uncontrolled glucose, hypertension (24%) was the common comorbidity, and diabetic neuropathy (22%) was the most common complication. Sex [male: AOR = 0.55, 95% CI: 0.34-0.90], race [Coloured: AOR = 2.84, 95% CI: 1.69-4.77 and White: AOR = 3.84, 95% CI: 1.46-10.1], marital status [divorced: AOR = 3.41, 95% CI: 1.13-10.29], social support [average: AOR = 2.51, 95% CI: 1.05-6.00 and good: AOR = 4.49, 95% CI: 1.61-7.57], body mass index [obesity: AOR = 0.31, 95% CI: 0.10-0.95], diabetes knowledge [average: AOR = 0.58, 95% CI: 0.33-0.10 and good: AOR = 1.86, 95% CI: 0.71-4.91], and uncontrolled glucose [AOR = 2.97, 95% CI: 1.47-5.98] were factors independently predictive of diabetes self-management. This study emphasizes that the self-management of diabetes was mostly on average among patients and was associated with the aforementioned factors. Innovative approaches are perhaps needed to make diabetes education more effective. Face-to-face sessions delivered generally during clinic visits should be better tailored to the individual circumstances of diabetes patients. Considerations should be given to the options of leveraging information technology to ensure the continuity of diabetes education beyond clinic visits. Additional effort is also needed to meet the self-care needs of all patients.

Diabetes in a TB and HIV-endemic South African population: Analysis of a virtual cohort using routine health data

BACKGROUND

It is widely accepted that people living with diabetes (PLWD) are at increased risk of infectious disease, yet there is a paucity of epidemiology studies on the relationship between diabetes and infectious disease in SSA. In a region with a high burden of infectious disease, this has serious consequences for PLWD.

METHODS AND FINDINGS

Using routinely collected longitudinal health data, we describe the epidemiology of diabetes in a large virtual cohort of PLWD who have a high burden of HIV and TB, from the Khayelitsha subdistrict in the Western Cape Province in South Africa. We described the relationship between previous TB, newly diagnosed TB disease and HIV infection on diabetes using HbA1c results as an outcome measure. The study population was predominately female (67%), 13% had a history of active TB disease and 18% were HIV positive. The HIV positive group had diabetes ascertained at a significantly younger age (46 years c.f. 53 years respectively, p<0.001) and in general had increased HbA1c values over time after their HIV diagnosis, when compared to the HIV-negative group. There was no evidence of TB disease influencing the trajectory of glycaemic control in the long term, but diabetes patients who developed active TB had higher mortality than those without TB (12.4% vs 6.7% p-value < 0.001). HIV and diabetes are both chronic diseases whose long-term management includes drug therapy, however, only 52.8% of the study population with an HIV-diabetes comorbidity had a record of diabetes treatment. In addition, the data suggest overall poor glycaemic control in the study population with only 24.5% of the participants having an HbA1c <7% at baseline despite 85% of the study population being on diabetes treatment.

CONCLUSION

The epidemiologic findings in this exploratory study highlight the need for further research into diabetes outcomes in a high TB and HIV burden setting and demonstrate that routine health data are a valuable resource for understanding disease epidemiology in the general population.

Suboptimal control for patients with type 2 diabetes in the Central Chronic Medicine Dispensing programme in South Africa

BACKGROUND

In South Africa, the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme allows stable patients with non-communicable diseases, including type 2 diabetes mellitus (T2DM), to collect their medication from a pick-up location near their home, thus avoiding long waiting times and travel expenses. The CCMDD programme aims at improving patient retention and adherence through better access to medicines, resulting in better health outcomes.

AIM

We assessed whether patients with T2DM enrolled in CCMDD achieved the recommended targets for glycaemic, blood pressure (BP) and lipid control.

SETTING

City of Tshwane, South Africa.

METHODS

We reviewed the records of 198 T2DM patients enrolled in CCMDD and assessed their control of haemoglobin A1c (HbA1c), BP and lipids.

RESULTS

Most of the records reviewed belonged to women (64.7%), African (89.9%), hypertensive (82.7%) and to patients exclusively on oral antidiabetic agents (98.5%). Patients were, on average, 57.7 (s.d. = 12.1) years old and had participated in the CCMDD programme for, on average, 2 years. The mean HbA1c was 8% (s.d. = 2). Glycaemic control was achieved by only 29.2% of patients, and 49% of patients had HbA1c between 7% and 9%. Ninety-three patients (66%) had achieved the total cholesterol target, 57.4% achieved BP targets and 6.9% had achieved the low-density lipoprotein cholesterol target.

CONCLUSION

A small group of patients achieved the targets for glycaemic, BP and lipid control. Despite improved accessibility to medication, the CCMDD is not synonymous of improved clinical outcomes. Future research should ascertain the factors associated with suboptimal control for these patients.

Inequalities and factors associated with adherence to diabetes self-care practices amongst patients at two public hospitals in Gauteng, South Africa

BACKGROUND

Self- management is vital to the control of diabetes. This study aims to assess the diabetes self-care behaviours of patients attending two tertiary hospitals in Gauteng, South Africa. The study also seeks to estimate the inequalities in adherence to diabetes self-care practices and associated factors.

METHODS

A unique health-facilities based cross-sectional survey was conducted amongst diabetes patients in 2017. Our study sample included 396 people living with diabetes. Face-to-face interviews were conducted using a structured questionnaire. Diabetes self-management practices considered in this study are dietary diversity, medication adherence, physical activity, self-monitoring of blood-glucose, avoiding smoking and limited alcohol consumption. Concentration indices (CIs) were used to estimate inequalities in adherence to diabetes self-care practices. Multiple logistic regressions were fitted to determine factors associated with diabetes self-care practices.

RESULTS

Approximately 99% of the sample did not consume alcohol or consumed alcohol moderately, 92% adhered to self-monitoring of blood-glucose, 85% did not smoke tobacco, 67% adhered to their medication, 62% had a diverse diet and 9% adhered to physical activity. Self-care practices of dietary diversity (CI = 0.1512) and exercise (CI = 0.1067) were all concentrated amongst patients with higher socio-economic status as indicated by the positive CIs, whilst not smoking (CI = - 0.0994) was concentrated amongst those of lower socio-economic status as indicated by the negative CI. Dietary diversity was associated with being female, being retired and higher wealth index. Medication adherence was found to be associated with older age groups. Physical activity was found to be associated with tertiary education, being a student and those within higher wealth index. Self-monitoring of blood glucose was associated with being married. Not smoking was associated with being female and being retired.

CONCLUSION

Adherence to exercising, dietary diversity and medication was found to be sub-optimal. Dietary diversity and exercise were more prevalent among patients with higher socio-economic status. Our findings suggest that efforts to improve self- management should focus on addressing socio-economic inequalities. It is critical to develop strategies that help those within low-socio-economic groups to adopt healthier diabetes self-care practices.

Glycaemic, blood pressure and low-density lipoprotein-cholesterol control among patients with diabetes mellitus in a specialised clinic in Botswana: a cross-sectional study

OBJECTIVE

Control of glycaemic, hypertension and low-density lipoprotein-cholesterol (LDL-C) among patients with type 2 diabetes mellitus (T2DM) is vital for the prevention of cardiovascular diseases. The current study was an audit of glycaemic, hypertension and LDL-C control among ambulant patients with T2DM in Botswana. Also, the study aimed at assessing factors associated with attaining optimal glycaemic, hypertension and LDL-C therapeutic goals.

DESIGN

A cross-sectional study.

SETTING

A specialised public diabetes clinic in Gaborone, Botswana.

PARTICIPANTS

Patients with T2DM who had attended the clinic for ≥3 months between August 2017 and February 2018.

PRIMARY OUTCOME MEASURE

The proportion of patients with optimal glycaemic (HbA1c<7%), hypertension (blood pressure <140/90 mm Hg) and LDL-C (<1.8 mmol/L) control.

RESULTS

The proportions of patients meeting optimal targets were 32.3% for glycaemic, 54.2% for hypertension and 20.4% for LDL-C. Age≥ 50 years was positively associated with optimal glycaemic control (adjusted OR [AOR] 5.79; 95% CI 1.08 to 31.14). On the other hand, an increase in diabetes duration was inversely associated with optimal glycemic control (AOR 0.91; 95% CI 0.85 to 0.98). Being on an ACE inhibitor was inversely associated with optimal hypertension control (AOR 0.35; 95% CI 0.14 to 0.85). Being female was inversely associated with optimal LDL-C control (AOR 0.24; 95% CI (0.09 - 0.59).

CONCLUSION

Patients with T2DM in Gaborone, Botswana, presented with suboptimal control of recommended glycaemic, hypertension and LDL-C targets. These findings call for urgent individual and health systems interventions to address key determinants of the recommended therapeutic targets among patients with diabetes in this setting.

Cross-sectional study of patients with type 2 diabetes in OR Tambo district, South Africa

OBJECTIVES

South Africa has pledged to the sustainable development goal of promoting good health and well-being to all residents. While this is laudable, paucity of reliable epidemiological data for different regions on diabetes and treatment outcomes may further widen the inequalities of access and quality of healthcare services across the country. This study examines the sociodemographic and clinical determinants of uncontrolled type 2 diabetes mellitus (T2DM) in individuals attending primary healthcare in OR Tambo district, South Africa.

DESIGN

A cross-sectional analytical study.

SETTING

Primary healthcare setting in OR Tambo district, South Africa.

PARTICIPANTS

Patients treated for T2DM for 1 or more years (n=327).

PRIMARY OUTCOME MEASURE

Prevalence of uncontrolled T2DM.

SECONDARY OUTCOME MEASURE

Determinants of uncontrolled T2DM (glycosylated haemoglobin (HbA1c) ≥7%).

RESULTS

Out of the 327 participants, 274 had HbA1c≥7% (83.8%). Female sex (95% CI 1.3 to 4.2), overweight/obesity (95% CI 1.9 to 261.2), elevated low-density lipoprotein cholesterol (95% CI 4.4 to 23.8), sedentary habits (95% CI 7.2 to 61.3), lower monthly income (95% CI 1.3 to 6.5), longer duration of T2DM (95% CI 4.4 to 294.2) and diabetes information from non-health workers (95% CI 1.4 to 7.0) were the significant determinants of uncontrolled T2DM. There was a significant positive correlation of uncontrolled T2DM with increasing duration of T2DM, estimated glomerular filtration rate and body mass index. However, a significant negative correlation exists between monthly income and increasing HbA1c.

CONCLUSIONS

We found a significantly high prevalence (83.8%) of uncontrolled T2DM among the patients, possibly attributable to overweight/obesity, sedentary living, lower income and lack of information on diabetes. Addressing these determinants will require re-engineering of primary healthcare in the district.

Glycaemic Control and Associated Self-Management Behaviours in Diabetic Outpatients: A Hospital Based Observation Study in Lusaka, Zambia

BACKGROUND

The control of diabetes mellitus depends on several factors that also include individual lifestyles. We assessed glycaemic control status and self-management behaviours that may influence glycaemic control among diabetic outpatients.

METHODS

This cross-sectional study among 198 consenting randomly selected patients was conducted at the University Teaching Hospital diabetic clinic between September and December 2013 in Lusaka, Zambia. A structured interview schedule was used to collect data on demographic characteristics, self-management behaviours, and laboratory measurements. Binary logistic regression analysis using IBM SPSS for Windows version 20.0 was carried out to predict behaviours that were associated with glycaemic control status.

RESULTS

The proportion of patients that had good glycaemic control status (HbA1c≤ 48 mmol/mol) was 38.7% compared to 61.3% that had poor glycaemic control status (HbA1c≥ 49 mmol/mol). Adherence to antidiabetic treatment and fasting plasma glucose predicted glycaemic control status of the patients. However, self-blood glucose monitoring, self-blood glucose monitoring means and exercise did not predict glycaemic control status of the patients.

CONCLUSION

We find evidence of poor glycaemic control status among most diabetic patients suggesting that health promotion messages need to take into account both individual and community factors to promote behaviours likely to reduce nonadherence.

Knowledge, attitude and practice regarding lifestyle modification in type 2 diabetic patients

Background

The number of persons suffering from type 2 diabetes mellitus continues to rise worldwide and causes significant morbidity and mortality, especially in the developing world. Behaviour change and adoption of healthy lifestyle habits help to prevent or slow down the complications of type 2 diabetes mellitus. However, the knowledge and practice of healthy lifestyles in many diabetic patients have been inadequate.

Aim

This study sought to establish the knowledge, attitude and practice regarding lifestyle modification amongst type 2 diabetic patients.

Setting

The diabetic clinic of Mamelodi hospital, Pretoria, Gauteng Province, South Africa.

Methods

A cross-sectional study was done using a structured questionnaire amongst 217 type 2 diabetic patients seen at the diabetic clinic of Mamelodi hospital. Baseline characteristics of the participants were obtained and their knowledge, attitude and practice regarding lifestyle modification were assessed.

Results

Of the 217 participants, 154 (71%) were obese and 15 (7%) were morbidly obese. The majority of respondents (92.2%) had poor knowledge of the benefits of exercise, weight loss and a healthy diet. What is interesting is that the majority (97.7%) demonstrated bad practices in relation to lifestyle modifications, although over four-fifths (84.3%) had a positive attitude toward healthy lifestyle modifications.

Conclusion

Despite the positive attitudes of respondents toward healthy lifestyle modifications, the knowledge and practice regarding lifestyle modifications amongst type 2 diabetes mellitus participants seen at Mamelodi hospital were generally poor.

Effective intervention of self-care on glycaemia control in patients with type 2 diabetes

BACKGROUND

Diabetes is one of the most common diseases, which requires lifelong self-care to improve the quality of life.

OBJECTIVES

The current study aimed to determine the impact of self-care education programs on reducing HbA1c in patients with type 2 diabetes.

PATIENTS AND METHODS

The current experimental study was conducted on 138 female patients with type 2 diabetes in Zahedan city, Iran. The data were collected by a self-administered questionnaire which included items on demographics, awareness, beliefs, Self-care behaviors. Before the educational intervention, the (HbA1c) test check list was completed for the patients in both groups. Then the training was applied for the intervention group in five 60-minute educational sessions within one month. Three months following the training, the data collection based on the check list was repeated for both groups. Data were analyzed using SPSS software.

RESULTS

The mean scores of awareness, beliefs, Self-care behaviors of the educational group, were 46.6 ± 8.57, 46.5 ± 0.86 and 29.06 ± 10.02, respectively; and it was found that after the education, knowledge, attitude, and self-care scores increased significantly (P < 0.001 Before the training, the scores of self-care, beliefs, and awareness were less than average in the intervention and control groups. In addition, the levels of HbA1c in the patients were higher than the normal levels. Following the intervention, the mean of self-care and HbA1c of the intervention group significantly reduced as compared with those of the control group (P < 0.001).

CONCLUSIONS

Self-care training instructions led to improve knowledge, attitude, and performance of the subjects under study and also the average HbA1c. Therefore, the nurses and health care staff should be educated accordingly.

Obesity and type 2 diabetes in Sub-Sahara Africa

There is a mounting body of evidence regarding the challenge posed by diabetes and obesity on the health systems of many Sub-Sahara African countries. This trend has been linked to the changing demographic profile together with rapid urbanization and changing lifestyles in both rural and urban settings in Africa. Africa is expected to witness the greatest increase in the number of people with diabetes from 19.8 million in 2013 to 41.4 million in 2035 if current trends persist. Excess weight alone currently accounts for at least 2.8 million deaths globally each year through increased risk for type 2 diabetes and cardiovascular complications. This review highlights recent literature on the problem of obesity and type 2 diabetes in Sub-Sahara Africa. It exposes the need for concrete interventions based on the now available wealth of evidence.

Achieving HbA1c targets in clinical trials and in the real world: a systematic review and meta-analysis

PURPOSE

To review the proportion of diabetic patients reaching recommended therapeutic goals, as reported in intervention trials and observational studies, and to analyse the factors associated with success or failure in achieving these targets.

METHODS

A systematic review and meta-analysis through a Medline and Embase search for "diabetes" and "HbA1c" has been performed between 1 January 1995 and 1 March 2012 on randomised clinical trials and observational studies on type 1 (T1DM) or type 2 diabetes (T2DM) enrolling at least 200 patient*year.

RESULTS

Out of 169 patient groups in RCTs with results available for analysis, the overall proportion of patients reaching HbA1c ≤ 7 % was 36.6 (34.1-39.1) %. Of these, 8 groups included T1DM subjects [proportion at target (PAT) 27.2 (22.7-32.3) %] and 161 T2DM patients [PAT 37.1 (34.5-39.7) %]. In patients with T2DM on oral agents, at multivariate analysis, higher success rate was associated with higher age and body mass index (BMI), lower duration of diabetes, lower proportion of Caucasians and more recent publication year. Among the insulin treated, only duration of diabetes retained a significant association with success rate. Among 41 groups from cross-sectional studies, 6 and 22 were composed of patients with T1DM and T2DM, respectively, and the remaining 13 included both types. Patients at target for HbA1c were 19.8 (12.4-30.1), 36.1 (31.5-41.0), and 39.0 (32.9-45.3) %, respectively. Higher age, lower BMI, shorter duration of diabetes and a higher proportion of males and Caucasians were associated with a higher success rate.

CONCLUSIONS

Available data show that a wide distance remains between recommended targets and actual achievements in routine clinical practice.

Medication adherence in diabetes mellitus and self management practices among type-2 diabetics in Ethiopia

BACKGROUND

Type-2 diabetes mellitus and its complication are becoming more prevalent in Ethiopia. Evidence abound that the most important predictor of reduction of morbidity and mortality due to diabetes complication is the level of glycemic control achieved.

AIMS

The aim is to assess adherence to anti diabetic drug therapy and self management practice among type-2 diabetic patient in Ethiopia.

PATIENTS AND METHOD

The study consists of two phases. A cross-sectional review of randomly selected 384 case notes of type-2 diabetic patient that attend diabetes mellitus clinic over 3 month and cross-sectional interview, with pre tested adherence and self management and monitoring tool questioner of 347 consecutive patients that attend in Jimma university specialized hospital diabetic clinic.

RESULT

Oral hypoglycemic agent were prescribed for 351(91.4) of the patient while insulin and oral hypoglycemic agent was prescribed in 33(8.6%). About 312 (88.9%) patients on oral hypoglycemic agent were on mono therapy, the most frequently prescribed oral hypoglycemic agent was glibenclamide 232(74.3%) and metformine 80(25.7%). Only 41.8% of the patient had adequate glycemic control. The main external factors for non adherence were lack of finance (37.1%) followed by perceived side effect of drug 29.2%. Only 6.5% patient who missed their medications disclosed to physician during consultation. The knowledge and practice of critical component of diabetes self management behavior were generally low among the patient studied.

CONCLUSION

Majority of the patient with type 2 diabetes in Ethiopia are managed by OHA monotherapy mainly glybenclamide and metformine. While the current prescribing strategy do not achieve glycemic control on majority of the patient. This is due to poor adherence with the prescribed drug regimen and poor knowledge and practice of successful self management.

Perceptions of Caribbean type 2 diabetes patients on self-monitoring of blood glucose

CONTEXT

The views of type 2 diabetes (T2DM) patients have not been considered in the debate on the role of self-monitoring of blood glucose (SMBG) in the management of T2DM.

OBJECTIVE

To assess the views of T2DM patients on SMBG.

METHODS

Two previously trained research assistants used a structured pre-tested questionnaire to interview 416 T2DM patients practising SMBG in out-patient clinics in the privacy of the patients after they have consented to be interviewed.

RESULTS

79% of patients were unemployed with mean duration of diabetes of 11.8 ± 0.5 year. 94% of patients did not have health insurance policies while 86% did not belong to any diabetes support group. Although 70% of the patients identified SMBG as expensive, 94% believed it assists glycaemic control, while 89% thought it was worth the expense.

CONCLUSION

Caribbean T2DM patients believe SMBG was beneficial for the management of their diabetes and empowering them may reduce diabetes complications.

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.

In vivo Studies on Antidiabetic Plants Used in South African Herbal Medicine

Diabetes is one of the most common metabolic disorders worldwide. It is a major health problem with its frequency increasing every day in most countries. The disease is generally believed to be incurable; and the few orthodox drugs available to manage the disease are not readily affordable to the poor. Based on the historical success of natural products as antidiabetic agents and the ever increasing need for new antidiabetics, a number of South African medicinal plants have been evaluated for their antidiabetic properties. In this article, we review the major studies conducted based on ethnobotanical surveys carried out between 2005 and 2008 in South Africa on plants that are traditionally used for the treatment of diabetes. Overall, the results of the studies conducted confirmed the potential of South African medicinal plants in antidiabetic drug discovery and identified a number of promising taxa for further in vivo investigation as plant-based antidiabetic agents.

The relationship between patient education and glycaemic control in a South African township

OBJECTIVE

To investigate if there is a relationship between patients' perceived diabetes education and their glycaemic control.

METHODS

Two hundred and forty-seven diabetic (both DM 1 and DM 2) patients who were treated for diabetes in a primary nurse led health care clinic in South Africa were analyzed. Patients were interviewed, and information was retrieved from the patients' medical record.

RESULTS

Fasting blood glucose levels were <7.0 mmol/l in 17.6% of the patients, 79.3% of the patients had a BMI>2788.2% of the patients received information about diabetes, the majority received information from the nurse. Patients with a higher educational level and patients who received education tended to have a better glycaemic control. (n.s.) Significantly more patients who received information had a good or acceptable FBG level (p=0.03). The recorded prevalence of chronic complications was low.

CONCLUSIONS

Glycaemic control was suboptimal in the big majority of patients. Education had a positive effect on glycaemic control, albeit not impressive. Also in South Africa poor health literacy should be taken into account in diabetes education.

Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services

OBJECTIVE

To determine the dietary intake, practices, knowledge and barriers to dietary compliance of black South African type 2 diabetic patients attending primary health-care services in urban and rural areas.

DESIGN

A cross-sectional survey. Dietary intake was assessed by three 24-hour recalls, and knowledge and practices by means of a structured questionnaire (n = 133 men, 155 women). In-depth interviews were then conducted with 25 of the patients to explore their underlying beliefs and feelings with respect to their disease. Trained interviewers measured weight, height and blood pressure. A fasting venous blood sample was collected from each participant in order to evaluate glycaemic control.

SETTING

An urban area (Sheshego) and rural areas near Pietersburg in the Northern Province of South Africa.

SUBJECTS

The sample comprised 59 men and 75 women from urban areas and 74 men and 80 women from rural areas. All were over 40 years of age, diagnosed with type 2 diabetes for at least one year, and attended primary health-care services in the study area over a 3-month period in 1998.

RESULTS

Reported dietary results indicate that mean energy intakes were low (< 70% of Recommended Dietary Allowance), 8086-8450 kJ day(-1) and 6967-7382 kJ day(-1) in men and women, respectively. Urban subjects had higher (P < 0.05) intakes of animal protein and lower ratios of polyunsaturated fat to saturated fat than rural subjects. The energy distribution of macronutrients was in line with the recommendations for a prudent diet, with fat intake less than 30%, saturated fat less than 10% and carbohydrate intake greater than 55% of total energy intake. In most respects, nutrient intakes resembled a traditional African diet, although fibre intake was low in terms of the recommended 3-6 g/1000 kJ. More than 90% of patients ate three meals a day, yet only 32-47% had a morning snack and 19-27% had a late evening snack. The majority of patients indicated that they followed a special diet, which had been given to them by a doctor or a nurse. Only 3.4-6.1% were treated by diet alone. Poor glycaemic control was found in both urban and rural participants, with more than half of subjects having fasting plasma glucose above 8 mmol l(-1) and more than 35% having plasma glycosylated haemoglobin level above 8.6%. High triglyceride levels were found in 24 to 25% of men and in 17 to 18% of women. Obesity (body mass index > or = 30 kg m(-2)) was prevalent in 15 to 16% of men compared with 35 to 47% of women; elevated blood pressure (> or = 160/95 mmHg) was least prevalent in rural women (25.9%) and most prevalent in urban men (42.4%).

CONCLUSIONS

The majority of black, type 2 diabetic patients studied showed poor glycaemic control. Additionally, many had dyslipidaemia, were obese and/or had an elevated blood pressure. Quantitative and qualitative findings indicated that these patients frequently received incorrect and inappropriate dietary advice from health educators.