Diabetes in French Guiana, adapting national standards of therapeutic education and care to the amazonian challenge

Giving a voice to "the silent killer": a knowledge, attitude and practice study of diabetes among French Guiana's Parikweneh people

BACKGROUND

The prevalence of type 2 diabetes (T2D) in the French overseas department of French Guiana, South America, nearly doubles that in its European counterpart, Metropolitan France. This region is demographically diverse and includes several populations of Indigenous Peoples. Although such populations are at particular risk of developing T2D across the Americas, very little is known about their health status in French Guiana, and accurate numbers of diabetic patients do not exist.

METHODS

In light of a potential public health crisis, an ethnomedicinal study of diabetes experienced by Indigenous Parikweneh was conducted to provide better insight into the knowledge, attitudes and practices (KAP) related to this quickly emerging disease in French Guiana. Altogether, 75 interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikweneh population of Macouria and Saint-Georges de l'Oyapock.

RESULTS

Interviews suggest a high incidence of T2D in this population, with cases that have risen quickly since the mid-twentieth century. Parikweneh participants linked the development of the illness to dietary changes, notably through the introduction of new and sweet foods. Recognizing the complexity of diabetes and its symptoms, diabetic patients highlighted the importance of biomedical treatments and follow-ups, though they frequently alternated or used them concomitantly with Parikweneh medicines. With the help of biomedical tools (i.e. glucometer), local medicinal practices mirrored biomedical approaches through dietary adaptation and the use of medicinal animals and plants for glycaemic control and the treatment of complications from the disease.

CONCLUSION

Parikweneh are appropriating T2D into their knowledge system and adapting their health system in response to this relatively new health concern. A greater understanding of local practices and perceptions relating to T2D among medical staff may therefore be beneficial for meeting patients' needs, providing greater autonomy in their health path, and improving treatment outcomes.

Factors associated with chronic kidney disease in patients with diabetes in French Guiana

Introduction

With over half of the population living under the poverty threshold, the social and health context in French Guiana is more difficult than in mainland France. The prevalence of diabetes is twice as great and end-stage renal failure is 45% higher than in mainland France.

Objective

Our objective was to describe the profile of diabetic patients with chronic kidney disease in French Guiana and search for possible risk factors.

Method

We conducted a multicenter cross-sectional observational study based on the CODIAM cohort (Cohort of Diabetes in French Amazonia). We analyzed 1,287 patients followed up between May 2019 and June 2021 at Cayenne Hospital, Saint Laurent Hospital, and delocalized health centers.

Results

In our cohort, chronic kidney disease was present after an average of 12 years of diabetes. Compared with the French population, 41% of diabetic patients had chronic kidney disease (i.e., 12% more), and had an average age of 56 years (i.e., 10 years younger). Forty-eight per cent of these patients were obese (i.e., 7% more). Seventy-four per cent of patients were precarious and 45% were foreigners but neither was associated with chronic kidney disease, contrary to countries where the health system is not universal.

Conclusion

Screening of patients with chronic kidney disease among diabetics in French Guiana remains a real challenge. Patients were younger and more obese than in other French territories. In this cohort, precariousness and immigration were not associated with the presence of chronic kidney disease. However, particular attention should be paid to hypertensive patients and those over 65 years of age, which are, with diabetes itself, the two most obvious risk factors for developing chronic kidney disease among diabetic patients in our territory.

Adaptations in the transformation of cassava (Manihot esculenta Crantz; Euphorbiaceae) for consumption in the dietary management of diabetes: the case of Palikur, or Parikwene People, from French Guiana

Introduction

In the French overseas department of French Guiana, in South America, nutrition therapy for the management of diabetes is based on French guidelines. However, this region is demographically diverse and includes several populations of Indigenous Peoples, Parikwene among others, also called Palikur. Due to socio-economical, cultural, and geographical differences, along with distinctions in the local food system, dietary recommendations, which many consider in the context of post-colonial power dynamics, are not well suited to local populations. In the absence of suitable recommendations, it is hypothesized that local populations will adapt their dietary practices considering diabetes as an emerging health problem.

Methods

Seventy-five interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikwene population of Macouria and Saint-Georges de l'Oyapock communes. Data regarding the representation of cassava (Manihot esculenta Crantz) consumption and diabetes were collected via semi-structured interviews and participant observation (i.e., observation and participation in community activities), namely via participating in activities related to the transformation of cassava tubers at swidden and fallow fields.

Results and Discussion

Parikwene have adapted the transformation of cassava tubers for their consumption in the management of diabetes.The importance of cassava tubers as a staple and core food to the Parikwene food system was established by identifying it as a cultural keystone species. Narratives illustrated conflicting perceptions regarding the implication of cassava consumption in the development of diabetes. Adaptations to the operational sequence involved in the transformation of cassava tubers led to the production of distinct cassava roasted semolina (i.e., couac), based on organoleptic properties (i.e., sweet, and acidic couac). Preferences for the consumption of acidic couac were grounded in the Parikwene knowledge system, as well as attention to diabetes related symptoms and glucometer readings.

Conclusion

These results provide important insights related to knowledge, attitudes, and practices in developing locally and culturally adapted approaches to providing dietary recommendations in the treatment of diabetes.

[Overview of infectious and non-infectious diseases in French Guiana in 2022]

Source of many myths, French Guiana represents an exceptional territory due to the richness of its biodiversity and the variety of its communities. The only European territory in Amazonia, surrounded by the Brazilian giant and the little-known Suriname, Ariane 6 rockets are launched from Kourou while 50% of the population lives below the poverty line. This paradoxical situation is a source of health problems specific to this territory, whether they be infectious diseases with unknown germs, intoxications or chronic pathologies.Some infectious diseases such as Q fever, toxoplasmosis, cryptococcosis or HIV infection are in common with temperate countries, but present specificities leading to sometimes different management and medical reasoning. In addition to these pathologies, many tropical diseases are present in an endemic and / or epidemic mode such as malaria, leishmaniasis, Chagas disease, histoplasmosis or dengue. Besides, Amazonian dermatology is extremely varied, ranging from rare but serious pathologies (Buruli ulcer, leprosy) to others which are frequent and benign such as agouti lice (mites of the family Trombiculidae) or papillonitis. Envenomations by wild fauna are not rare, and deserve an appropriate management of the incriminated taxon. Obstetrical, cardiovascular and metabolic cosmopolitan pathologies sometimes take on a particular dimension in French Guiana that must be taken into account in the management of patients. Finally, different types of intoxication are to be known by practitioners, especially due to heavy metals.European-level resources offer diagnostic and therapeutic possibilities that do not exist in the surrounding countries and regions, thus allowing the management of diseases that are not well known elsewhere.Thanks to these same European-level resources, research in Guyana occupies a key place within the Amazon region, despite a smaller population than in the surrounding countries. Thus, certain pathologies such as histoplasmosis of the immunocompromised patient, Amazonian toxoplasmosis or Q fever are hardly described in neighboring countries, probably due to under-diagnosis linked to more limited resources. French Guiana plays a leading role in the study of these diseases.The objective of this overview is to guide health care providers coming to or practicing in French Guiana in their daily practice, but also practitioners taking care of people returning from French Guiana.

Cardiovascular Risk Assessment among Farmers in French Guiana in 2018-A Screening Program

CONTEXT

There is a general health decline among farmers and the leading cause of death in this population remains cardiovascular (CV) diseases. The situation is similar in the Guianese general population, with a preoccupying increase in CV diseases. However, there are no data on farmers' health.

METHODS

A cross-sectional study analyzed data from the "Novembre Vert" action conducted in 2018 in French Guiana. Beneficiaries and farmers affiliated to the Mutualité Sociale Agricole who completed the survey were included. The objective was to assess their CV risk.

RESULTS

603 farmers were included. The sex-ratio was 1.6 and the median age was 52. Over 70% of the participants had a Body Mass Index ≥ 25, with a greater risk of obesity in the female population. High blood pressure (HBP) affected 53.1% of farmers and 80.1% were diagnosed during screening. About 13.5% had diabetes. Overall, 27% of participants were at high or very high CV risk. CV risk was 3 times greater in men.

CONCLUSION

HBP (53.1%), obesity (30.3%) and diabetes (13.5%) prevalence are particularly worrying and underline the importance of policies to reduce cardiovascular morbimortality among farmers.

Impact of Lipoprotein(a) on Macrovascular Complications of Diabetes in a Multiethnic Population in the French Amazon

BACKGROUND AND AIMS

In French Guiana, the prevalence of diabetes is around 10%, and cardio and neurovascular pathologies are the first medical cause of early mortality. Lipoprotein(a) (Lp(a)) is described in the literature as a risk factor independent of other cardiovascular risk factors, but there are important interindividual differences, especially according to ethnicity. The objective of this study was to investigate the association of Lp(a) and macrovascular complications in a multiethnic population of patients with diabetes in the French Amazon.

MATERIALS AND METHODS

Since May 2019, 1243 patients were screened 806 of whom had Lp(a) determination. We compared the prevalence of macrovascular complications in three groups according to Lp(a) concentration: between 0 and 75 mg/mL, between 76 and 300 mg/mL, and >300 mg/mL.

RESULTS

712 patients in the study had type 2 diabetes (88.34% of the sample). A history of hypertension was significantly associated with greater Lp(a) levels. Lp(a) concentration was greater among Creole ethnic groups. No association was found between Lp(a) levels and macrovascular complications in the Lp(a) > 300 mg/mL group.

CONCLUSIONS

These results do not replicate findings in mostly Caucasian populations suggesting that the Lp(a) threshold for, or the link with, cardiovascular risk may be different given the predominantly African origin of the French Guianese population. Further studies should study genetic polymorphisms in our population.

Nutritional and Socioeconomic Determinants of Overweight and Obesity in the French Amazon: The Health Barometer Study

OBJECTIVES

French Guiana is a multicultural overseas territory where obesity is a major public health problem. This study aimed to highlight the nutritional and socioeconomic determinants of overweight and obesity in different populations in French Guiana.

METHODS

A two-stage random sample of 1390 individuals aged 15 to 75 years was surveyed by telephone, and the participants were initially screened for diabetes. Logistic regression was fitted on the sample to adjust for potential confounding factors.

RESULTS

Overweight and obesity were found in 54.7% of the respondents, a higher proportion than in mainland France. There was a significant body image discrepancy in our population, with a higher risk of obesity among single women, often immigrants from the non-French Caribbean and South America, unemployed or low education.

CONCLUSIONS

The main factors associated with obesity were being a precariousness immigrant; there was often a mismatch between body image and overweight/obesity, which is a major obstacle to the improvement of dietary behaviors and lifestyle. This information provides operational clues as to where to act and the necessary adaptations to attempt to modify behaviors in a culturally-adapted manner.

Vitamin D Deficiency in Patients with Diabetes in French Guiana: Epidemiology and Relation with Microvascular and Macrovascular Complications

Vitamin D (VD) insufficiency is common among patients with diabetes in French Guiana. The study aimed to evaluate the prevalence of VD deficiency in the different type of diabetes encountered and to analyze the relationship between VD deficiency and diabetes complications. Methods: An observational study was conducted between May 2019 and May 2020 in French Guiana, based on data from the CODIAM study (Diabetes Cohort in French Amazonia), describing the characteristics of patients with diabetes mellitus. Among 600 patients enrolled with diabetes, 361 had an available VD assay. Results: The mean 25(OH)VD (hydroxycalciferol) level was 27.9 ng/mL. The level of VD was inversely proportional to the HbA1c (glycated hemoglobin) level. Patients with angina pectoris had a greater proportion of deficiencies VD < 20 ng/mL than those without angina. By contrast, patients with retinopathy had higher vitamin D concentrations than those without retinopathy. There was no association between vitamin D and arteriopathy, stroke, nephropathy and polyneuropathy. VD deficiency was more frequent in women, and in patients with a high school education. Conclusion: The prevalence of VD deficiency was high in patients with diabetes in French Guiana, emphasizing the importance of VD supplementation.

Diabetes Care in French Guiana: The Gap Between National Guidelines and Reality

INTRODUCTION

French Guiana is a multicultural overseas territory in the Amazon, where precariousness and difficulties in access to care are widespread. The prevalence of diabetes is double that of other French departments, and cardiovascular morbidity and mortality is high. The objective of the study was to analyze the biological, clinical and therapeutic follow-up of patients with diabetes mellitus using exhaustive data and to correlate it with national and European recommendations.

MATERIAL AND METHODS

Using the national health insurance data, 9079 and 10075 patients with diabetes mellitus were analyzed in 2018 and 2019, respectively. We analyzed antidiabetic treatments, medical, dental, and podiatric consultations, examinations prescribed as part of the annual follow-up, and home nursing care.

RESULTS

There was a significant increase over one year in the number of patients (+10%) with diabetes, mainly women (60%), and 31% were under 54 years of age, with a disparity depending on the area of the territory, the most isolated having less access to screening. Less than 56% of patients had HbA1c measurements twice a year, less than 43% had an annual renal check-up, only 19% had an ophthalmic check-up at least every two years, less than 25% had an annual dental check-up, and less than 4% had an annual follow-up with the podiatrist.

CONCLUSIONS

Substandard diabetes monitoring is a major problem likely to increase morbidity and mortality. Adapting health care to the specificities of the territory is crucial, notably by formalizing the delegation of care to advanced practice nurse and non-healthcare professionals in precarious or geographically isolated areas.