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Diabetes in Sub-Saharan Africa—Overview of a Looming Health Challenge
not accompanied by any marked improvements in infections or
Figure 3: Estimated Number of Adults with Diabetes in
undernutrition; many studies have reported high rates of co-existence Sub-Saharan Africa and in Developed Countries by Age
of obesity and undernutrition in the same communities and even in the
Group and Year
same households.
22
This means that diabetes has to compete for scarce
financial and healthcare resources with infections and undernutrition.
Sub-Saharan Africa
9
Of course, this does not sound like a recipe for success. Prevalent
2000 2030
8
undiagnosed diabetes is very high—about 80% in data from
Cameroon.
23
Even in known patients with diabetes, control is often very
7
poor. Only about one in four known patients with diabetes in a
6
population survey in Cameroon had optimal fasting blood glucose
5
levels.
23
In a study in Ethiopia of 105 patients with diabetes seen by one
4
physician, despite a low body mass index (BMI)—median BMI was
3
20.6kg/m
2
—mean glycated hemoglobin (HbA
1c
) was 11.3±2.8% and 68%
of patients had an HbA
2
1c
over 10%.
24
1
Published data on acute complications of diabetes in SSA are scarce, 0
but nonetheless point to the fact that these are more common than
20–44 45–64 65+
Estimated number of people with diabetes (millions)
in developed countries and mostly carry a worse outcome. Case
Age (years)
fatality rates for diabetic coma of 10–20% have been reported in Developed countries
50
studies in specialized hospitals.
25,26
Evidently, the outcome of such 2000 2030
cases in more deprived areas with less specialized hospitals would be
45
much worse. These acute complications are usually made worse by
40
accompanying severe infections, which are usually the precipitating
35
factor. Toure et al.
27
reported three-fold higher tuberculosis-related
30
hospital mortality in patients with diabetes compared with non- 25
diabetes controls. 20
15
Chronic microvascular and neuropathic complications of diabetes
10
have been reported to be highly prevalent across different populations
5
in SSA. As summarized by Gill et al.,
28
the reported prevalence of the
0
different chronic complications varies enormously between studies. 20–44 45–64 65+
Estimated number of people with diabetes (millions)
Prevalence rates of retinopathy (15–55%), nephropathy (32–57%), and
Age (years)
neuropathy (10–42%), with a 49% prevalence of erectile dysfunction in
21
Source: Wild et al., 2004.
men, have been reported across studies in SSA.
29
These data have to
be interpreted cautiously as there are wide differences in study
Figure 4: Direct, Indirect, and Total Cost of Diabetes per
design, population characteristics, and other underlying risk factors. In
Person with Diabetes Compared with the Average Gross
many of these patients, complications are already present at the
National Income Per Capita in the WHO Africa Region
initial diagnosis of diabetes. Worse still, in some patients the initial
12
diagnosis of diabetes is made during consultation or hospital
admission for a diabetes-related complication in a hitherto unknown 10
diabetes subject. Retinopathy is reported to be present in 21–25% of
patients at diagnosis.
29
In a study from Nigeria, 25% of patients
8
admitted to hospital for diabetic foot were previously undiagnosed.
30
In
another hospital audit from Cameroon,
25
21% of patients admitted
6
in diabetic coma into the endocrinology unit of a main teaching
4
hospital were not previously known to have diabetes.
2
Macrovascular complications of diabetes including coronary heart
disease (CHD) and stroke appear to be less frequent in SSA than in other
Amount (thousands of international dollars)
0
Group 1 Group 2 Group 3
regions;
31
in fact, blacks are at lower risk for macrovascular disease
compared with other ethnic groups. Concerns about data quality and
Countries
absence of vital statistics may be involved in the information on these
Average GNI per capita Average indirect cost
per person with diabetes
diseases from many SSA countries. However, in a study from South
Average direct cost
Average total cost per person with diabetes
Africa in the same community and using the same methods, Kalk and
per person with diabetes
Joffe
32
found in a sample of adults with diabetes that CHD was present
GNI = gross national income. Countries are grouped according to average gross national income
in 4% of black Africans and in 23% of Caucasians.
33
per capita. Source: Kirigia et al.
US ENDOCRINOLOGY 17
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