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P97 Management of type 2 diabetes in clinical practices in sub-Saharan Africa: Results of the AMAR-AFO study in Senegal and Ivory Cost
Abstract
Introduction: Lack of specialists is one of the major problems in the management of diabetes mellitus in sub-Saharan Africa. Our objective was to evaluate the practice of trained general practitioners (GPs) on diabetes.Material and methods: A multicenter study was conducted in Senegal and Côte-d'Ivoire from August 2008 to August 2009. Untreated type 2 diabetics (T2D) were enrolled when the GP decide to initiate an oral antidiabetic therapy (OAD). All aspects of the follow up were recorded in a standardized notebook during 3 months. Data were analyzed using Epi Info® version 6.Results: 1052 T2D patients were included by 81 GPs, mean age was 53.2 ± 9.6 years, sex ratio (M/F) 0.78; hypertension and overweight or obesity were associated to T2D in 47% and 48% respectively; mean capillary blood glucose was 2.47 g/L and mean HbA1c 8.9%; screening of complications was performed in 20% of the patients only. OAD treatment was a monotherapy in 82.5% and a combination therapy (including metformin in all cases) in 17.5%. Hypertension was treated in 33.8%. Number of visits during the study was 3 in average; fasting blood glucose normalized (≤ 1.26 g/L) in 47.9% T2D with a mean lowering of 1.01 ± 0.82 g/L: this result was associated with male gender (pCombining double low line0.012) and the value of blood glucose at baseline (pCombining double low line0.0001).Conclusion: In sub-Saharan Africa, T2D management by GPs has to be included in the strategies against non communicable diseases. This must be based on adapted therapeutic recommendations taking into account the associated cardiovascular risk factors.
... The profile of our patients is similar to data from Sub-Saharan African [2] [9] [10]. It was diabetes subject in mean age between 40 and 50 years old, mean duration of diabetes mellitus in way of 7 year and most often poor glycemic control. ...
... Type 2 diabetes mellitus is specially known to be purveyor of chronic complications or associated with cardiovascular risk factors [12]. However, evaluating practice diabetes in Africa, particularly with General practitioner, often reported a non-exhaustive screening of these parameters [2] [10]. This is in part explained by inadequate health coverage and access to care in most of these countries. ...
... However, our study reported a low rate of 40% of patients on insulin in the light of the 64.8% of patients with HbA1c > 9% at inclusion. Therapeutic inertia is the explanation and remains a reality in diabetes mellitus, especially in sub-SaharianAfrica [2] [3] [9][10]. After 12 month of follow-up, the evolving profile of antidiabetic pharmacology seems like the finding reported in DiabCare Africa[2].The only difference lies in the fact that more than 60% of our patients had reached the target of HbA1c < 7%. ...
... In most case these patients present themselves with one of the complications of the diabetes already set up as shown in Senegal [3], where there is less than 10 specialists in diabetology for 14 million inhabitants. So, the general practitioners are the major actors in the global strategy for caring diabetic patients [4]. The aim of this survey was to evaluate knowledge, attitudes and practices of the general doctors on management of type 2 diabetes with specific focus on managing hyperglycemia, other cardiovascular risk factors and degenerative complications prevention. ...
... Epidemiological studies made in our African areas emphasize on the significant role of the GPs in the global strategy of managing type 2 diabetic patients because of lake of medical doctors in general, and diabetologist in particular [4]. ...
... Our study gathered 142 patients aged on average over 55 years with a female predominance. This female predominance in this diabetic population has been already reported in our context [5]. More of our patients were type 2 diabetic. ...
... Resting electrocardiogram is commonly used among the range of complementary examinations for cardiovascular risk evaluation. It allows to highlight a number of abnormalities regardless of the existence of cardiovascular risk factors but also and especially ischaemic heart disease often in silent clinical expression [3]. The ECG poses in our regions a problem of availability and achievement due to lack of means. ...
Introduction :
Seul ou associé à d’autres facteurs de risque vasculaire, le diabète est responsable d’une lourde morbi-mortalité partout dans le monde. Son expansion prend des allures de pandémie, mais elle reste encore peu documentée en Afrique sub-saharienne. Ce travail fournit quelques aspects épidémiologiques du diabète parmi les autres facteurs de risque vasculaire en milieu urbain à Saint-Louis, au Sénégal.
Patients et méthodes :
Il s’agit d’une étude observationnelle, transversale, descriptive, qui s’est déroulée du 3 au 30 mai 2010. Les unités de sondage étaient constituées par les Sénégalais habitant la ville de Saint-Louis, âgés de 15 ans au moins. L’échantillonnage utilisé était un sondage aléatoire, stratifié en grappes, utilisant comme base de sondage les données du recensement général de l’habitat de Saint-Louis.
Résultats :
L’enquête a concerné 1 424 individus. Le sex-ratio femmes/hommes était de 2,23. L’âge moyen de la population était de 43,4 ± 17,8 ans. La prévalence du diabète était de 10,4 %, incluant 7,8 % de cas connus et 2,6 % de cas nouvellement diagnostiqués. Ce diabète était dit « contrôlé » dans 33,3 % des cas selon les critères de la Fédération internationale du diabète (IDF) et 39,6 % selon ceux de l’Association américaine du diabète (ADA). Le traitement était médicamenteux dans 74,3 % des cas et par tradithérapie dans 54,3 % des cas.
Les autres facteurs de risque vasculaire étaient :
–la dyslipidémie (64,6 %), connue dans 2,4 % des cas et dépistée dans 62,2 % des cas. Seuls 20 % des patients étaient traités par hypolipémiants et 12 % étaient à l’objectif ;–la sédentarité (64,0 %), plus fréquente chez les femmes que chez les hommes (p < 0,001) ;–l’hypertension artérielle (HTA, 46,0 %), connue de l’individu dans 23,0 % des cas et ignorée chez les 23,0 % restants ; 31,0 % des hypertendus n’étaient pas traités et 30,5 % l’étaient par tradithérapie ;–l’obésité (23,0 %), à prédominance féminine ;–le tabac (5,8 %) et l’alcool étaient moins fréquents.
Le diabète était associé à l’HTA ou à la dyslipidémie dans 87,8 % des cas ; 62,8 % des sujets avaient au moins trois facteurs de risque associés.
Sur le plan des complications, 16,6 % des sujets présentaient une insuffisance rénale, 17,0 % une artériopathie des membres inférieurs (indice de pression systolique [IPS] abaissé) et 3,2 % avaient présenté un accident vasculaire cérébral.
Conclusion :
Cette enquête révèle des chiffres alarmants sur la prévalence du diabète, ainsi que celle de la dyslipidémie, de l’HTA et même de l’insuffisance rénale dans la population autochtone de la ville de Saint-Louis. Ces facteurs de risque vasculaire sont probablement sous-estimés dans la population générale. Il est nécessaire de conduire des enquêtes de prévalence à l’échelle nationale afin de mettre en place des politiques de prévention efficaces et pérennes.
Aim:
The DiabCare-Senegal project aimed to describe diabetes control and management, as well as the stage of late complications observed in diabetic patients who are under follow-up and treatment.
Methods:
A descriptive study has been conducted in five centers specialized in diabetes management over a period of 3 months, including all patients being followed up in these centers for more than 12 months. Data were collected from the patient’s medical records and HbA1c was the only test performed for the purpose of the study.
Results:
There were 387 patients. Diabetes was type 2 mainly (92.5%), with a mean age of 52.2 ± 12.4 years. Mean age of type 1 diabetics was 25 years. Mean duration of diabetes was 7 ± 6 years. Mean levels of HbA1c, fasting and postprandial plasma glucose showed moderate diabetes control (7.6 ± 2.4%, 8.4 ± 4 mmol/L and 10.5 ± 5.5 mmol/ L, respectively) but the majority of patients failed to achieve glycemic targets as defined by ADA or IDF. Main complications were neuropathy (26.3%), eye complications (20.5%), and diabetic foot (5.1%). More than one third of type 2 diabetic patients were not receiving any antidiabetic pharmacological agent. Among treated patients, most (36.9%) were receiving an oral antidiabetic drug (OAD) monotherapy while 10.1% were treated with insulin alone and 5.2% with a combination of OAD and insulin. Despite the frequent association of central obesity, high blood pressure and/or dyslipidemia, very few patients were treated for those comorbidities.
Conclusion:
Glycemic control in Senegalese diabetic patients is suboptimal. Pharmacological management should be implemented earlier and be more aggressive, including treatment of both hyperglycemia and associated cardiovascular risk factors.
During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of microvascular complications than did those receiving conventional dietary therapy. We conducted post-trial monitoring to determine whether this improved glucose control persisted and whether such therapy had a long-term effect on macrovascular outcomes.
Of 5102 patients with newly diagnosed type 2 diabetes, 4209 were randomly assigned to receive either conventional therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin or, in overweight patients, metformin) for glucose control. In post-trial monitoring, 3277 patients were asked to attend annual UKPDS clinics for 5 years, but no attempts were made to maintain their previously assigned therapies. Annual questionnaires were used to follow patients who were unable to attend the clinics, and all patients in years 6 to 10 were assessed through questionnaires. We examined seven prespecified aggregate clinical outcomes from the UKPDS on an intention-to-treat basis, according to previous randomization categories.
Between-group differences in glycated hemoglobin levels were lost after the first year. In the sulfonylurea-insulin group, relative reductions in risk persisted at 10 years for any diabetes-related end point (9%, P=0.04) and microvascular disease (24%, P=0.001), and risk reductions for myocardial infarction (15%, P=0.01) and death from any cause (13%, P=0.007) emerged over time, as more events occurred. In the metformin group, significant risk reductions persisted for any diabetes-related end point (21%, P=0.01), myocardial infarction (33%, P=0.005), and death from any cause (27%, P=0.002).
Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837.)
To determine the relation between systolic blood pressure over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes.
Prospective observational study. Setting: 23 hospital based clinics in England, Scotland, and Northern Ireland.
4801 white, Asian Indian, and Afro-Caribbean UKPDS patients, whether randomised or not to treatment, were included in analyses of incidence; of these, 3642 were included in analyses of relative risk.
Primary predefined aggregate clinical outcomes: any complications or deaths related to diabetes and all cause mortality. Secondary aggregate outcomes: myocardial infarction, stroke, lower extremity amputation (including death from peripheral vascular disease), and microvascular disease (predominantly retinal photocoagulation). Single end points: non-fatal heart failure and cataract extraction. Risk reduction associated with a 10 mm Hg decrease in updated mean systolic blood pressure adjusted for specific confounders.
The incidence of clinical complications was significantly associated with systolic blood pressure, except for cataract extraction. Each 10 mm Hg decrease in updated mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes (95% confidence interval 10% to 14%, P<0.0001), 15% for deaths related to diabetes (12% to 18%, P<0.0001), 11% for myocardial infarction (7% to 14%, P<0.0001), and 13% for microvascular complications (10% to 16%, P<0.0001). No threshold of risk was observed for any end point.
In patients with type 2 diabetes the risk of diabetic complications was strongly associated with raised blood pressure. Any reduction in blood pressure is likely to reduce the risk of complications, with the lowest risk being in those with systolic blood pressure less than 120 mm Hg.
The A1C assay, expressed as the percent of hemoglobin that is glycated, measures chronic glycemia and is widely used to judge the adequacy of diabetes treatment and adjust therapy. Day-to-day management is guided by self-monitoring of capillary glucose concentrations (milligrams per deciliter or millimoles per liter). We sought to define the mathematical relationship between A1C and average glucose (AG) levels and determine whether A1C could be expressed and reported as AG in the same units as used in self-monitoring.
A total of 507 subjects, including 268 patients with type 1 diabetes, 159 with type 2 diabetes, and 80 nondiabetic subjects from 10 international centers, was included in the analyses. A1C levels obtained at the end of 3 months and measured in a central laboratory were compared with the AG levels during the previous 3 months. AG was calculated by combining weighted results from at least 2 days of continuous glucose monitoring performed four times, with seven-point daily self-monitoring of capillary (fingerstick) glucose performed at least 3 days per week.
Approximately 2,700 glucose values were obtained by each subject during 3 months. Linear regression analysis between the A1C and AG values provided the tightest correlations (AG(mg/dl) = 28.7 x A1C - 46.7, R(2) = 0.84, P < 0.0001), allowing calculation of an estimated average glucose (eAG) for A1C values. The linear regression equations did not differ significantly across subgroups based on age, sex, diabetes type, race/ethnicity, or smoking status.
A1C levels can be expressed as eAG for most patients with type 1 and type 2 diabetes.
Data for trends in glycaemia and diabetes prevalence are needed to understand the effects of diet and lifestyle within populations, assess the performance of interventions, and plan health services. No consistent and comparable global analysis of trends has been done. We estimated trends and their uncertainties in mean fasting plasma glucose (FPG) and diabetes prevalence for adults aged 25 years and older in 199 countries and territories.
We obtained data from health examination surveys and epidemiological studies (370 country-years and 2·7 million participants). We converted systematically between different glycaemic metrics. For each sex, we used a Bayesian hierarchical model to estimate mean FPG and its uncertainty by age, country, and year, accounting for whether a study was nationally, subnationally, or community representative.
In 2008, global age-standardised mean FPG was 5·50 mmol/L (95% uncertainty interval 5·37-5·63) for men and 5·42 mmol/L (5·29-5·54) for women, having risen by 0·07 mmol/L and 0·09 mmol/L per decade, respectively. Age-standardised adult diabetes prevalence was 9·8% (8·6-11·2) in men and 9·2% (8·0-10·5) in women in 2008, up from 8·3% (6·5-10·4) and 7·5% (5·8-9·6) in 1980. The number of people with diabetes increased from 153 (127-182) million in 1980, to 347 (314-382) million in 2008. We recorded almost no change in mean FPG in east and southeast Asia and central and eastern Europe. Oceania had the largest rise, and the highest mean FPG (6·09 mmol/L, 5·73-6·49 for men; 6·08 mmol/L, 5·72-6·46 for women) and diabetes prevalence (15·5%, 11·6-20·1 for men; and 15·9%, 12·1-20·5 for women) in 2008. Mean FPG and diabetes prevalence in 2008 were also high in south Asia, Latin America and the Caribbean, and central Asia, north Africa, and the Middle East. Mean FPG in 2008 was lowest in sub-Saharan Africa, east and southeast Asia, and high-income Asia-Pacific. In high-income subregions, western Europe had the smallest rise, 0·07 mmol/L per decade for men and 0·03 mmol/L per decade for women; North America had the largest rise, 0·18 mmol/L per decade for men and 0·14 mmol/L per decade for women.
Glycaemia and diabetes are rising globally, driven both by population growth and ageing and by increasing age-specific prevalences. Effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequelae.
Bill & Melinda Gates Foundation and WHO.
In the 108 patients with diabetes (75 men and 33 women between the ages of 15 and 86 years) hospitalized in the Internal Medicine Department of the Libreville Hospital Center between January 1, 1989 and December 31, 1991, 53 were easily classified, 12 being due to alcohol-induced chronic calcific pancreatitis, two to insulin-dependent diabetes, and 39 to non-insulin-dependent diabetes. Fifty-five patients treated with insulin were not immediately classifiable including 11 who were obese and probably should not have required insulin. In the remaining 44 patients who were not overweight, the youngest often presented features comparable to those observed in patients with chronic calcific pancreatitis except with regard to calcification. Most of the older patients were women in whom diagnosis was coincidental. These findings indicate that authentic insulin-dependent diabetes is uncommon, that non-insulin-dependent diabetes are frequent, and that the endocrine pancreas is particularly susceptible to alcohol abuse.
Cardiovascular disease (CVD) is rising in low-income countries. However, the impact of modifiable CVD risk factors on myocardial infarction (MI) has not been studied in sub-Saharan Africa (SSA). Therefore, we conducted a case-control study among patients with acute MI (AMI) in SSA to explore its association with known CVD risk factors.
First-time AMI patients (n=578) were matched to 785 controls by age and sex in 9 SSA countries, with South Africa contributing approximately 80% of the participants. The relationships between risk factors and AMI were investigated in the African population and in 3 ethnic subgroups (black, colored, and European/other Africans) and compared with those found in the overall INTERHEART study. Relationships between common CVD risk factors and AMI were found to be similar to those in the overall INTERHEART study. Modeling of 5 risk factors (smoking history, diabetes history, hypertension history, abdominal obesity, and ratio of apolipoprotein B to apolipoprotein A-1) provided a population attributable risk of 89.2% for AMI. The risk for AMI increased with higher income and education in the black African group in contrast to findings in the other African groups. A history of hypertension revealed higher MI risk in the black African group than in the overall INTERHEART group.
Known CVD risk factors account for approximately 90% of MI observed in African populations, which is consistent with the overall INTERHEART study. Contrasting gradients found in socioeconomic class, risk factor patterns, and AMI risk in the ethnic groups suggest that they are at different stages of the epidemiological transition.
Within less than a quarter century diabetes has become a health problem in developing countries. In Africa this metabolic disorder is found in a wide variety of sometimes atypical forms. The purpose of this study was to highlight the special epidemiological features of medically diagnosed diabetes in Ivory Coast. Data from the files of 10320 African patients who presented at a major national outpatient care centre between January 1, 1991 and December 31, 2000 were compiled and analyzed. Findings showed that morbidity gradually increased from 30 to 49 years then stabilized from 50 to 69 years with a higher rate in males between 30 and 49 years. One of the five national ethnic groups appeared to be most affected and two appeared to be relatively unaffected. On the basis of several criteria, 5968 patients were classified as type 1 in 11.8% of cases, type 2 without excess body weight in 48.7% and type 2 with excess body weight in 39.5%. The second of these identified groups was characterized by intermediate-discovered glycaemia and older age at diagnosis. Epidemiological features included age of occurrence and higher morbidity in young male patients, probable higher premature mortality, likely links with socio-cultural environmental factors and existence of two type 2 subgroups. This profile underlines the challenges of screening, management and prevention of diabetes in Ivory Coast.
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