Diabetes in developing countries Misra, Anoop; Gopalan, Hema; Jayawardena, Ranil ...
Journal of diabetes,
July 2019, 2019-Jul, 2019-07-00, 20190701, Volume:
11, Issue:
7
Journal Article
Peer reviewed
There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, ...South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro‐ and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost‐effective, but targeted high‐risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, “fatalistic attitudes”, high cost and non‐availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low‐cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non‐medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.
摘要
发展中国家的2型糖尿病(T2D)患病率迅速上升，在不同的农村与城市生活环境中以及在不同的城市化程度下，其患病率各不相同。与白种人相比，某些民族(如南亚人、其他亚洲人与非洲人)要早10年发生糖尿病，并且发病时的体重指数也较低，主要是腹型肥胖，并且糖尿病前期向糖尿病的转变也加速了。无论是大血管还是微血管并发症的负担都非常巨大，但也因人群而异。在许多发展中国家中经常见到糖尿病患者合并HIV或者肺结核，并且容易相互感染。在不同栖息地生活的大样本人群中筛查糖尿病可能并不划算，但是针对高风险人群进行筛查可能具有一定的意义。诊断测试的成本以及卫生人力资源的匮乏对于患者的诊断与监测来说都是一个巨大的障碍。在大多数发展中国家，预防工作仍处于初级阶段。护理质量大部分都很差；因此，有相当一部分患者都没有达到治疗目标。因为延误了寻求治疗的时间、“宿命态度”、药物与胰岛素的高成本并且不易获得，这种情况进一步在扩大。为了应对这些众多的挑战，迫切需要新的政治承诺和行政法规来促进健康与预防疾病。目前已经在试用一些低成本的创新方法并且取得了令人鼓舞的成果，包括培训与部署非医疗保健专业的辅助人员，使用手机与远程医疗提供简单的健康信息来预防与管理T2D。
Highlights
Diabetes in developing countries is increasing and often undiagnosed. In South Asians, diabetes and related metabolic abnormalities develop at a younger age and at a lower body mass index and waist circumference than in Whites.
Overall glycemic control and management of diabetes is suboptimal, driven by multiple factors (eg, unawareness, cost of drugs and insulin etc.), and the load of complications is high.
To stem this epidemic, strong actions for prevention and management are required using innovative and low‐cost approaches.
Background. Diabetes mellitus (DM) increases tuberculosis risk while tuberculosis, as an infectious disease, leads to hyperglycemia. We compared hyperglycemia screening strategies in controls and ...patients with tuberculosis in Dar es Salaam, Tanzania. Methods. Consecutive adults with tuberculosis and sex- and age-matched volunteers were included in a case-control study between July 2012 and June 2014. All underwent DM screening tests (fasting capillary glucose FCG level, 2-hour CG 2-hCG level, and glycated hemoglobin A1c HbA1c level) at enrollment, and cases were tested again after receipt of tuberculosis treatment. Association of tuberculosis and its outcome with hyperglycemia was assessed using logistic regression analysis adjusted for sex, age, body mass index, human immunodeficiency virus infection status, and socioeconomic status. Patients with tuberculosis and newly diagnosed DM were not treated for hyperglycemia. Results. At enrollment, DM prevalence was significantly higher among patients with tuberculosis (n = 539; FCG level > 7 mmol/L, 4.5% of patients, 2-hCG level > 11 mmol/L, 6.8%; and HbA1c level > 6.5%, 9.3%), compared with controls (n = 496; 1.2%, 3.1%, and 2.2%, respectively). The association between hyperglycemia and tuberculosis disappeared after tuberculosis treatment (adjusted odds ratio aOR for the FCG level: 9.6 95% confidence interval {CI}, 3.7–24.7 at enrollment vs 2.4 95% CI, .7–8.7 at follow-up; aOR for the 2-hCG level: 6.6 95% CI, 4.0–11.1 vs 1.6 95% CI, .8–2.9; and aOR for the HbA1c level, 4.2 95% CI, 2.9–6.0 vs 1.4 95% CI, .9–2.0). Hyperglycemia, based on the FCG level, at enrollment was associated with tuberculosis treatment failure or death (aOR, 3.3; 95% CI, 1.2–9.3). Conclusions. Transient hyperglycemia is frequent during tuberculosis, and DM needs confirmation after tuberculosis treatment. Performance of DM screening at tuberculosis diagnosis gives the opportunity to detect patients at risk of adverse outcome.
Universal screening for hyperglycemia during pregnancy may be in-practical in resource constrained countries. Therefore, the aim of this study was to develop a simple, non-invasive practical tool to ...predict undiagnosed Gestational diabetes mellitus (GDM) in Tanzania.
We used cross-sectional data of 609 pregnant women, without known diabetes, collected in six health facilities from Dar es Salaam city (urban). Women underwent screening for GDM during ante-natal clinics visit. Smoking habit, alcohol consumption, pre-existing hypertension, birth weight of the previous child, high parity, gravida, previous caesarean section, age, MUAC ≥ 28 cm, previous stillbirth, haemoglobin level, gestational age (weeks), family history of type 2 diabetes, intake of sweetened drinks (soda), physical activity, vegetables and fruits consumption were considered as important predictors for GDM. Multivariate logistic regression modelling was used to create the prediction model, using a cut-off value of 2.5 to minimise the number of undiagnosed GDM (false negatives).
Mid-upper arm circumference (MUAC) ≥ 28 cm, previous stillbirth, and family history of type 2 diabetes were identified as significant risk factors of GDM with a sensitivity, specificity, positive predictive value, and negative predictive value of 69%, 53%, 12% and 95%, respectively. Moreover, the inclusion of these three predictors resulted in an area under the curve (AUC) of 0.64 (0.56–0.72), indicating that the current tool correctly classifies 64% of high risk individuals.
The findings of this study indicate that MUAC, previous stillbirth, and family history of type 2 diabetes significantly predict GDM development in this Tanzanian population. However, the developed non-invasive practical tool to predict undiagnosed GDM only identified 6 out of 10 individuals at risk of developing GDM. Thus, further development of the tool is warranted, for instance by testing the impact of other known risk factors such as maternal age, pre-pregnancy BMI, hypertension during or before pregnancy and pregnancy weight gain.
Traditional jumping-dance rituals performed by Maasai men involve prolonged physical exertion that may contribute significantly to overall physical activity level. We aimed to objectively quantify ...the metabolic intensity of jumping-dance activity and assess associations with habitual physical activity and cardiorespiratory fitness (CRF).
Twenty Maasai men (18-37 years) from rural Tanzania volunteered to participate in the study. Habitual physical activity was monitored using combined heart rate (HR) and movement sensing over 3 days, and jumping-dance engagement was self-reported. A 1-h jumping-dance session resembling a traditional ritual was organized, during which participants' vertical acceleration and HR were monitored. An incremental, submaximal 8-min step test was performed to calibrate HR to physical activity energy expenditure (PAEE) and assess CRF.
Mean (range) habitual PAEE was 60 (37-116) kJ day
kg
, and CRF was 43 (32-54) mL O
min
kg
. The jumping-dance activity was performed at an absolute HR of 122 (83-169) beats·min
, and PAEE of 283 (84-484) J min
kg
or 42 (18-75)% when expressed relative to CRF. The total PAEE for the session was 17 (range 5-29) kJ kg
, ~28% of the daily total. Self-reported engagement in habitual jumping-dance frequency was 3.8 (1-7) sessions/week, with a total duration of 2.1 (0.5-6.0) h/session.
Intensity during traditional jumping-dance activity was moderate, but on average sevenfold higher than habitual physical activity. These rituals are common, and can make a substantial contribution to overall physical activity in Maasai men, and thus be promoted as a culture-specific activity to increase energy expenditure and maintain good health in this population.
Diabetes mellitus (DM) is a common comorbidity among people with tuberculosis (TB). Despite the availability of guidelines on how to integrate dual TB/DM in Tanzania, the practice of integration at ...various healthcare levels is unclear.
To explore the participants' experiences and perceptions on the pathway towards clinical management of dual TB/DM.
The research was carried out in Dar es Salaam, Iringa, and Kilimanjaro regions between January and February 2020. A qualitative, in-depth interview approach was used to collect participants' experiences and perspectives on the acquisition of dual TB/DM services at various levels of healthcare facilities. The information gathered were coded and classified thematically.
The participants' perception of TB services within the healthcare facilities was positive due to the support they received from the healthcare providers. On the other hand, participants reported difficulty receiving management in various health facilities for each condition in terms of access to dual TB/DM care and access to DM medication. This was viewed as a significant challenge for the participants with dual TB/DM.
The current disjunction and disruption in healthcare for people with dual TB/DM makes it difficult to access services at various levels of health facilities. For optimal clinical management for people with dual TB/DM, patient-centered strategies and integrated approaches are urgently needed.
Objective
Diabetes mellitus (DM) has been known to compromise tuberculosis (TB) treatment outcomes. Association data are limited for early hyperglycaemia detection and TB treatment outcomes. Thus, we ...assessed treatment outcomes including time to sputum conversion and death in TB participants with or without hyperglycaemia.
Methods
A prospective cohort study recruited TB participants receiving anti‐TB treatment at health facilities in Tanzania between October 2019 and September 2020. Hyperglycaemia was defined as having pre‐existing DM or pre‐treatment random blood glucose of ≥7.8 mmol/L, in combination categorised as impaired glucose regulation (IGR). Those with IGR were further screened for hyperglycaemia severity using glycated haemoglobin. In case of unknown status, participants were tested for HIV. Time to death was determined at 6 months of TB treatment.
Results
Of 1344 participants, 187 (13.9%) had IGR, of whom 44 (23.5%) were HIV co‐infected. Overall treatment success was 1206 (89.7%), and was similar among participants with or without IGR (p > 0.05). Time to death for participants with and without IGR was 18 versus 28 days (p = 0.870), respectively. Age ≥ 40 years (p = 0.038), bacteriological positive (p = 0.039), HIV (p = 0.009), or recurrent TB (p = 0.017) predicted death or treatment success during TB treatment in adjusted multivariable models.
Conclusion
IGR did not influence clinical outcomes in TB patients with or without IGR in a programme of early IGR diagnosis and integration TB, HIV and DM care. Early detection and co‐management of multi‐morbidities among people diagnosed with TB may reduce likelihood of poor treatment outcomes in a programmatic setting.
Abstract Aim The Diabcare Africa project was carried out across six sub-Saharan African countries to collect standardised and comparable information for the evaluation of diabetes control, management ...and late complications in diabetic populations at specialist clinics. Methods A cross-sectional, descriptive study of 2352 type-2 diabetes patients who were treated at specialist clinics for at least 12 months prior to the study. Results The mean age of patients was 53.0 ± 16.0 years and had 8.0 ± 6.0 years known duration of diabetes. 47% had their HbA1c assessed in the past year (mean 8.2 ± 2.4%) with 29% achieving a level <6.5%. 21% had BP within 130/80 mmHg and 65% were treated for hypertension. Fasting lipids were assessed in 45% of the patients with mean cholesterol level of 4.9 ± 1.2 mmol/L, HDL-cholesterol of 1.3 ± 0.7 mmol/L and triglycerides of 1.2 ± 0.7 mmol/L. 13% of the patients were treated for hyperlipidaemia, mostly with statins. Background retinopathy (18%) and cataract (14%) were the most common eye complications. Macrovascular disease was rare, and 48% had neuropathy. Conclusions Half of the patients benefitted from standard care, and a third had appropriate glycaemic control – attributed to access to, rather than quality of care. This study provided evidence to support appropriate interventions to diabetic populations of sub-Saharan origin.
The agro-pastoralist Maasai of East Africa are highly physically active, but their aerobic fitness has so far only been estimated using heart rate (HR) response to submaximal exercise and not ...directly measured. Thus, we aimed to measure aerobic fitness directly using respiratory gas analysis in a group of Maasai, and habitual physical activity energy expenditure (PAEE) as explanatory variable.
In total, 21 (10 rural, 11 semi-urban) of 30 volunteering Tanzanian Maasai men were eligible to participate. Respiratory gas exchange was measured during a graded exercise test until exhaustion on a stationary bicycle to determine aerobic fitness. Maximal effort criteria were at least two of the following (1) leveling off, (2) respiratory exchange ratio (RER) >1.10, and (3) maximum HR within 10 bpm of age-estimated maximum HR. Habitual PAEE was estimated using combined accelerometry and HR monitoring. Anthropometry, biochemistry, blood pressure, resting HR, and dietary intake information were collected for background information.
Mean age was 43.2 (range 26-60) years, and hemoglobin was higher in the rural versus semi-urban Maasai (16.9 vs. 15.4 g/dl, p = .02). Mean aerobic fitness (34.4 vs. 33.3 mlO
/min/kg, p = .79), and mean PAEE (58.5 vs. 52.9 kJ/day/kg, p = .64) were similar in rural and semi-urban Maasai, respectively.
Aerobic fitness was low to moderate in male rural and semi-urban Maasai. This may be explained by relatively low PAEE in comparison to previous objectively measured activity levels in Maasai, which indicates recent lifestyle changes.
Gestational Diabetes Mellitus (GDM) remains a neglected cause of maternal and foetal morbidity and mortality in developing countries exacerbated by limited screening and management strategies. This ...study aimed to understanding how the RCH health system works in Tanzania, so as to provide opportunity for improving GDM screening and management.
A questionnaire was administered to facility staff and physical performance observed in 30 randomly selected public RCH facilities.
Deficiencies identified included limited understaffing, late booking at ANC, and limited screening for GDM due to lack of equipment and supplies. Most women (96%) attending ANCs and postnatal care (87%) were managed at respective facilities with only 12% and 22% respectively being referred to higher levels of care. Facility staff were less trained or received fewer refresher courses in diabetes (0–5%), hypertension (4–6%), and other NCDs (0–16%) compared to training in PMCTC (39%), management of postpartum bleeding (31%) and HIV/AIDs (31%).
Diabetes during pregnancy is rarely sought in public health facilities and its management is suboptimal. Training and refresher courses of staff in diabetes and hypertension should be uplifted and health systems should be strengthened to improve capacity and capability of facilities for better quality of care.
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