By Dr. Manal Ghazzzawi
FREETOWN – Diabetes mellitus (DM) is a global health catastrophe that affects how the body processes sugar due to either lack of the hormone insulin or issues that makes the body resistant to the action of insulin. Insulin is the hormone in our body that stores excess glucose to glycogen and helps the cells of our body absorb glucose for energy. DM leads to devastating complications like stroke, heart issues, amputation, blindness etc, if left untreated or unattended to. People with diabetes that lead a normal life, have a full-time job to ensure their sugar level remains stable. In as much as affected persons with diabetes try endlessly to prevent sugar levels from escalating, patients must also work so hard to prevent sugar levels not to go too low to prevent complications like coma.
People in Africa, face lots of difficulties in terms of accessibility to diabetes care they need, marginalised communities are unaware of DM and its consequences, and must pay out of pocket for their drugs and continuity of care. In a country like Sierra Leone, most tertiary and secondary facilities are clustered in the city, leaving villagers accessing health care at community health centres, which lack the necessary expertise to manage and prevent DM. Unfortunately, many Africans are diagnosed late after complications have already set in.
There are about 4 types of DM, type 1 which is insulin dependent DM, type 2 is non-insulin dependent DM, type 3 is DM affecting women during pregnancy, type 4 is DM due to drugs and other diseases affecting the pancreas.
Burden of DM in the African region
According to the International Diabetes Federation (IDF), the African region represents the highest proportion with undiagnosed DM, with 60% of its adults have DM and are unaware of their condition. Below is a concise representation of type 1 & 2 diabetes in Africa and projections of prevalence of diagnosed and undiagnosed diabetes by 2030/2045, and projected government health expenditure by 2030/2045. In summary, it is estimated in 2019 that 19 million people are living with diabetes in Sub-Saharan Africa (SSA) and this figure is expected to skyrocket to 47 million by 2045. Among those with undiagnosed DM, 12 million people have diabetes unknowing to them and 366,200 people in Africa die because of DM. The eighth edition of the Diabetes Atlas report estimates that 77% of all diabetes related deaths worldwide occur in SSA in people under 60 years of age (IDF atlas 2017). This information is quite a bit alarming, but the good news is diabetes is a preventable disease when we adopt healthy lifestyle behaviours. In a systematic analysis on prevalence and sub-regional distribution of undiagnosed diabetes mellitus among adults in African countries, reveal that West Africa has the highest burden of undiagnosed DM. Nigeria represents the top five countries in Africa with high prevalence of DM. In Sierra Leone, adequate data is unavailable to ascertain, national prevalence of DM.
It is inevitable that uncontrolled endemic and epidemic diseases affecting a nation, can extremely place health expenditure burden on government, especially with our fragile health system in Africa. According to IDF 2019, government expenditure on health due to diabetes is 10 billion USD and is projected to increase up to 17 billion by 2045.
What could be the cause for the time ticking diabetes bomb that awaits us?
DM characterizes one of the leading non-communicable diseases (NCDs) in Africa, DM itself leads to increased risk of leading causes of communicable diseases like Human Immunodeficiency Virus (HIV), tuberculosis (TB), viral hepatitis, pneumonia and Covid-19 infections (Davies K et al., 2020). Plausible reasons for the increasing prevalence of DM in Africa, is due to common chronic communicable diseases in Africa, that cause inflammatory state leading to organ dysfunction and damage. Even some drugs used to treat for instance, HIV and TB could also lead to DM (Davies K et al., 2020).
In addition, obesity appears to be a major issue among urban women aged 15–49 years, as demonstrated from the results of demographic and health survey from 24 African countries (Neupane S et.al, 2016). These women have high risk of developing gestational diabetes in the future, which in turn predisposes their poor babies to diabetes at adulthood or even childhood.
A study was conducted by me in 2017, to assess the risk of developing DM among adults in Freetown. A population size of 1013 was randomly selected, and the prevalence of participants to be at high risk of developing type 2 DM (T2DM) was 17.8%. Though more rigorous and extensive research is needed to ascertain this, the study highlighted that age, gender, occupation, high waist circumference, hypertension and family history are associated risk factors that yielded statistical significance. Body Mass Index (BMI) categorization by gender shows that more females (77%) had higher BMI compared to males (53%). Also, more females (19.2%) compared to males (8.1%) were found to have a high waist circumference (WC) which denotes central obesity. This study conforms to a systemic review and metanalysis conducted by Davies A et.al, in Nigeria, which demonstrated that there were 21 million and 12 million overweight and obese persons respectively, in the Nigerian population aged 15 years or more in 2020, and more females were over-weight and in the obese category compared to males.
Previous studies have established that West African Lineage is associated with greater BMI and total body fat. Many studies have shown distinct evidence to confirm that obesity is a major risk factor for T2DM. Obesity is on the increase in Africa, due to adoption of westernized culture, urbanization, growth in economy, sedentary lifestyle, and introduction of processed foods (Searcey & Richtel 2017). It is indeed poignant, that improved standards of living is driving us to make poor health life choices. In Sierra Leone or in some regions in Africa, obesity is a sign of affluence, dignity, and respect (Janzon E et al., 2015). Despite this fact, let us not forget that diabetes respects no socioeconomic status or boundaries in general. In a country like Sierra Leone, which probably other countries in the region can relate, people can hardly afford to buy fruits and vegetables. Healthy foods are not produced abundantly in our country, and the poor will continue to be deprived from eating healthy foods that could prevent the occurrence of diabetes. We are highly dependent on importation of most of our food items, even salt and sugar. It has reached to a point where imported foods can be cheaper that home gowned foods. Poverty, which is our biggest killer, forces the us to eat unhealthy foods to fill our stomach. Adoption of the Mediterranean diet which mainly consists of fruits, vegetables, nuts, wholegrains, and fish have been shown to prevent diabetes.
Regular physical activity is an undeniably relevant in the prevention and management of diabetes. The American Diabetes Association recommends 150 minutes of regular physical activity per week to prevent and manage DM. Our road networks in Africa could be a turn off for citizens to be engaged in walking and jogging. That needs to be changed, citizens of African countries have every right to be able to exercise conveniently whenever and wherever they find themselves. People living in the rural setting walk miles to reach their farm or place of work, while as in the urban setting we just rely on transportation. The latter provides such a convenience to people in the urban setting combined with the chair we sit on the whole day at work, highly encouraging us not to be active.
Among other factors that is causing high disease burden and undiagnosed cases in Africa, are lack of motivation needed for health workers to provide service; shortage of health work force, brain drain, lack of organized structure for chronic disease care, fewer tertiary care hospitals, lack of awareness of prevalent diseases among the population and inappropriate health care information systems
Strategies to mitigate the epidemic in Africa
Without leadership, governance, financing, health workforce, health information systems, supply chains, and service delivery, we will continue to suffer from diabetes and many chronic diseases. Integrating diabetes care through a diagonal health systems strengthening approach is a promising solution to the inefficient and poor quality of service delivery that is the current reality in SSA (figure 2).
Because diabetes is a lifelong disease and is associated with acute and chronic complications that could cause multiple organ damage, it requires several multi-faceted approaches to reduce the burden of the disease from a public health point of view. Horizontal and vertical approach to providing diabetes care is associated with its disadvantages. The diagonal approach tends to avoid the disadvantages of the horizontal and vertical approach of service delivery and embraces the advantages of the horizontal and vertical health system strengthening approach. Since we continue to depend on donor funds in Africa, vertical programs are often unsustainable, on the other hand, horizonal approach which could be impactful are usually dampened by the countless challenges associated with it.
Figure 2 WHO health system building blocks as a framework for functional diabetes care system
South Africa is one country in Africa that has already started implementing taxations on sugary foods and beverages to fight against diabetes and obesity. Other interventions to target obesity include nutrition labelling; marketing restrictions of unhealthy foods and beverages to kids; fruit and vegetable subsidies; physical activity policies and social marketing campaigns. WHO member states around the world, including South Africa, have committed to halt the rise of obesity and diabetes, reduce premature deaths from NCDs by 25% by 2025 and one-third by 2030, the latter target in line with the Sustainable Development Goals. How many countries is Africa are really committed to keep that ambitious promise? Many countries in Africa will be hesitant to execute laws that would prevent DM due to political reasons. In Sierra Leone, selling of alcohol occurs in the streets that can even be sold to kids. There are foreign companies that manufacture high percentage of alcohol beverages with no one to hold them accountable. Alcohol overuse and substance abuse is a rising pandemic that also needs to be addressed. Chronic alcohol use is an associated risk factor for the development of diabetes. Studies have shown a genetic predisposition to increased risk of DM among heavy alcohol users (Jang et al 2019).
As we know, diabetes was known as the disease of the rich. Though it is still affecting people living in developed countries, many strategies are being put in place to help protect their citizens. The political will is there. In Africa, some of our presidents themselves are obese, they are diabetic or are at high risk of developing T2DM. Politicians of African countries including the health ministers themselves, will rather fly to the most sophisticated countries to seek medical care. They themselves do not trust their health system which they are supposed to fix, leaving their own citizens vulnerable and deprived of the basic health care they need.
Our health system in Africa is so fragile except for other few countries. In Sierra Leone, for e.g., we keep on putting blame of our poor health system, due to war, due to Ebola and now due to the Covid-19 pandemic. If we do not finance our health system, to achieve universal health coverage, life expectancy of Africans will remain low, and economic growth continues to reduce. Many people are pushed to extreme poverty when they must pay out of pocket for diseases other than TB, HIV.
A multipronged urgent control measure is needed to diagnose people at risk of developing diabetes to prevent subsequent complications of the disease that is affecting quality of life of people globally. This is the time like to other to take actions towards strengthening our health system in Africa. We need to create a donor-independent health system. Emerging and remerging infectious diseases will continue to claim our lives further exposing our fragile health system, sadly a reality which we cannot ignore. Diversion of resources towards communicable diseases, away from non-communicable diseases and provision of essential health services further leads to more morbidity and mortality. Africa needs to wake up!
Manal Ghazzzawi is a Doctor of Pharmacy, a public health specialist and a consultant clinical pharmacist. She is a health entrepreneur, CEO of Citiglobe Pharmacies Ltd, and a laureate for women in Africa Entrepreneurs 2020 and has won many awards as the most outstanding pharmacist in Sierra Leone.
References
Davies Adeloye, Janet O. Ige-Elegbede, Martinsixtus Ezejimofor, Eyitayo O. Owolabi, Nnenna Ezeigwe, Chiamaka Omoyele, Rex G. Mpazanje, Mary T. Dewan, Emmanuel Agogo, Muktar A. Gadanya, Wondimagegnehu Alemu, Michael O. Harhay, Asa Auta & Akindele O. Adebiyi (2021) Estimating the prevalence of overweight and obesity in Nigeria in 2020: a systematic review and meta-analysis, Annals of Medicine, 53:1, 495-507, DOI: 10.1080/07853890.2021.1897665
IDF Diabetes Atlas, eighth edition 2017. International Diabetes Federation; [cited 2021 Mar 6]. Available from: https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html.
Janzon E, Namusaazi S, Bolmsjö I. Increasing Obesity in Ugandan Women due to Transition from Rural to Urban Living Conditions? a Qualitative Study on Traditional Body Image, Changed Lifestyles and Unawareness of Risk for Heart Disease. J Res Obes, IBIMA publishing. 2015:1–13.
Jang, H.B., Go, M.J., Park, S.I. et al. Chronic heavy alcohol consumption influences the association between genetic variants of GCK or INSR and the development of diabetes in men: A 12-year follow-up study. Sci Rep 9, 20029 (2019). https://doi.org/10.1038/s41598-019-56011-y.
Kibirige, D., Lumu, W., Jones, A.G. et al. Understanding the manifestation of diabetes in sub–Saharan Africa to inform therapeutic approaches and preventive strategies: a narrative review. Clin Diabetes Endocrinol 5, 2 (2019). https://doi.org/10.1186/s40842-019-0077-8
Neupane S, K CP, Doku DT. Overweight and obesity among women: analysis of demographic and health survey data from 32 Sub-Saharan African Countries. BMC Public Health. 2016;16(1):30. [Crossref], [PubMed], [Google Scholar]
Searcey D, Richtel M. Obesity was rising as Ghana embraced fast food, then came KFC. New York Times. 2017 Oct 2.
