Analysis of Type II Diabetes

Diabetes is a disease that affects insulin production and use. When your body turns the food you eat into energy (also called sugar or glucose), insulin is released to help transport this energy to the cells. Type 2 Diabetes is the most common and accounts for about 95% of overall diabetes cases. Type 2 diabetes is more common in adults but now increasingly affects children as childhood obesity increases. There's no cure for type 2 diabetes, but it may be possible to manage the condition through a proper diet, nutritional choices, exercise, and maintaining a healthy weight.

According to the International Diabetic Federation (IDF), an estimated 15.5 million adults aged 20-79 years were living with diabetes in the IDF Africa Region in 2017, representing a regional prevalence of 3.3%. The highest prevalence of diabetes in the region is found in adults aged 55 to 64. The region has the highest proportion of undiagnosed diabetes, with over two-thirds (69.2%) of adults currently living with diabetes unaware of their condition. More than half (55.3%) of adults living with diabetes in the Africa Region live in urban areas. The IDF African Region (AFR) includes 49 diverse sub-Saharan countries and territories and currently represents 34 diabetes organizations in 29 countries (International Diabetes Federation, 2017).

Type 2 diabetes mellitus (T2DM) increasingly contributes to the global burden of disease; the most dramatic epidemiological shift will take place in sub-Saharan Africa. The formal health systems, especially in low- and middle-income countries, may be overwhelmed by the magnitude of the T2DM burden. The importance of this rapid escalation of diabetes, especially in sub-Saharan Africa, cannot be overstated as it threatens to destabilize already fragile economies still reeling from infectious disease epidemics, including Ebola, human immunodeficiency virus (HIV), tuberculosis (TB), and malaria (Alleyne G. et al, 2013). The economic cost of managing diabetes is high, health care professionals often focus more on medical care rather than prevention, and the systems often suffer from weak health policies and guidelines, a lack of human resources and medicines, and inadequate coverage of service delivery. They are often poorly accessible, acceptable, available, affordable or adequate, resulting in poor prevention and management of T2DM (Karolinska Institutet DPH, 2018).

People living with Type 2 diabetes are found in every region of the world. Therefore, it is a major threat to public health. Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. Over the past decade, diabetes prevalence has risen faster in low- and middle-income countries than in high-income countries (WHO 2016). We estimate that in 2015, the overall cost of diabetes in sub-Saharan Africa was US$19.45 billion or 1.2% of cumulative gross domestic product (GDP). Around $10.81 billion (55.6%) of this cost arose from direct costs, which included expenditure on diabetes treatment (e.g., medication, hospital stays, and treatment of complications), with out-of-pocket expenditure likely to exceed 50% of the overall health expenditure in many countries (Atun R. et al, 2017). This rise can be traced to the lack of medical care in various parts and it being expensive where available. The global target of a 10% relative reduction in physical inactivity is, therefore, strongly associated with the global target of halting the risk in diabetes. Increasing physical activity can be achieved by incorporating physical education classes and programs into the educational system in the African continent; this helps reduce the incidence of diabetes especially in younger generations, ultimately reducing the need for healthcare.

The lack of global commitment is further complicated by the relatively limited in-country funding that sub-Saharan African countries dedicate to health compared with the rest of the world. In 2014, sub-Saharan African countries spent 5.5% of their gross domestic product (GDP) on health (private and public sector) compared with the 12.4% that the Organization for Economic Cooperation and Development countries spend annually on health (World Bank Group, 2015). Further examination of data from the World Bank in 2014 reveals that sub-Saharan African countries' funding for public sector health care is only 42.6% of the total health care spending or 2.3% of the total GDP. Average per capita spending is $98 (US, 2014), despite the heavy reliance that populations in sub-Saharan Africa have on public sector health care (World Bank Group, 2015). The organizational, state capacity, governance structures, and institutional strength of health systems vary across sub-Saharan Africa. In 2010, 42 countries in the WHO African region reported having a unit or department within their ministries of health with responsibility for NCDs, but just seven countries had a national operational policy, strategy, or plan for diabetes (Atun R. et al, 2017).

The physical or built environment plays an important role in facilitating physical activity for many people. Urban planning and active transport policies can ensure that walking, cycling and other forms of non-motorized actions address overweight and obesity, preventing type 2 diabetes (Skyler J S, 2015). The physical environment can also provide sports, recreation and leisure facilities, and ensure there are adequate safe spaces for active living for both children and adults. In 2012, 1.5 million deaths worldwide were directly caused by diabetes. It was the eighth leading cause of death among both sexes and the fifth leading cause of death in women (WHO, 2016). The poorest groups in society, especially women, may have less time and fewer resources to participate in leisure-time activity, making policy interventions that target active transport and incidental physical activity throughout the day even more important (Mozaffarian D, 2012). Socioeconomic positions have been linked to the development of type 2 diabetes.

Effective approaches are available to prevent type 2 diabetes and to prevent the complications and premature death that can result from all types of diabetes. The creation of supportive policy, social, and physical environments for healthy lifestyles is a key aspect of type 2 diabetes prevention. This number will increase by 162% by 2045, with Sub-Saharan Africa having a greater burden due to lack of access to healthcare. Sustaining lifestyle changes needed to reduce risk requires supportive family and social networks, as well as an enabling food system and physical environment (WHO, 2016). The starting point for living well with diabetes is an early diagnosis—the longer a person lives with undiagnosed and untreated diabetes, the worse their health outcomes are likely to be. More than 15.9 million people have diabetes.

Diabetes is no longer a disease predominantly observed in rich nations. The prevalence of diabetes is steadily increasing across the globe, most markedly in the world's middle-income countries (MICs). Unfortunately, in many settings, the lack of effective policies to create supportive environments for healthy lifestyles and the lack of access to quality health care means that the prevention and treatment of diabetes, particularly for people of modest means, are not being pursued (Margaret Chan, WHO, 2016). Interventions designed for Sub-Saharan Africa should be constructed in a self-supportive manner that continues to thrive long after the program ends.

SMART2D (Self-Management and Reciprocal learning for the prevention and management of Type-2-Diabetes) is a research project funded by the Horizon 2020 Framework Programme of the European Union. It includes six academic partners with Karolinska Institutet as the coordinating department.

The project aims to address the gaps in healthcare and management of type 2 diabetes mellitus (T2DM) by strengthening capacity for prevention and management through task-shifting, expanding care networks through community-based peer support groups, and targeting three populations in three different settings: 1) a rural community in a low-income country (Uganda), 2) an urban township in a middle-income country (South Africa), and 3) vulnerable areas in a high-income country (Sweden) (SMART2D stakeholder day, 2018).

Effective glycaemic control is essential for short-term wellbeing and long-term protection against complications. Current evidence suggests that many people with diabetes in sub-Saharan Africa do not achieve adequate glucose level control, although studies specifically addressing this issue have been small (Atum R. et al, 2017). Proper glycaemic control is most likely to be achieved when a patient has reliable access to clinical services, when the equipment to monitor control is good, when patients and health-care professionals have good knowledge about diabetes management, and when efficacious and affordable treatment is available and backed by adequately and effectively deployed measures of glucose control (Atun R. et al, 2017).

One innovative analytical approach to assess health system performance is the construction of a cascade of care with a tracer condition. Cascade-of-care analysis involves a detailed depiction of the step-wise care for the population affected by a disease of interest, including screening, diagnosis, and linkage to treatment programs, adherence to treatment, and finally achievement and maintenance of control. This analysis depicts the dynamics between demand and health system responses at each step of the care continuum and provides the opportunity to identify areas of unmet need and where attrition in care occurs (Manne-Goehler J, et al, 2017). The analyses of service delivery indicators suggest that, in the countries studied, there is low readiness across all levels of care and cadres of health professionals in management of diabetes in terms of correct diagnosis, adherence to guidelines, and provision of appropriate treatment (Atun R. et al, 2017). The clinical challenges of diabetes in sub-Saharan Africa are numerous, yet, despite differing levels of development and population structure, countries within the region face similar challenges concerning screening, diagnosis, and management. In this section we consider issues of clinical relevance, wherein common themes in the inability to provide quality care are scarcity of knowledge, inability to reliably access drugs, and poor access to treatments for complications. Lack of access to home blood glucose monitoring equipment greatly affects patient education and empowerment, which is important to diabetes management.

Furthermore, the first step of type 2 diabetes treatment in high income countries (HICs) is lifestyle advice, but few patients in sub-Saharan Africa receive such advice (Atun R. et al, 2017). While it is easy to highlight the lack of healthcare facility in sub-Saharan Africa, programs that aim at setting up advice and counselling sessions should be emphasized to close this gap.

In view of the huge costs involved in managing the complications of diabetes, and the increasing burden of diabetes, strategies to prevent complications are desperately needed in sub-Saharan Africa. Adequate management of hyperglycaemia, other risk factors, and regular assessment for early evidence of complications, are the mainstay of successful strategies to prevent microvascular and macrovascular complications. Diabetes registries have been highly successful platforms to drive improved outcomes in these regards in high income countries (HICs), but issues with availability of technology and other necessary infrastructure mean that such registries are largely absent in sub-Saharan Africa (Atun R. et al, 2017).

References

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