In this interview, Jean-Marie Dangou from the WHO Regional Office for Africa discusses diabetes in the African region, including lack of access to treatment and ongoing action to solve this
About 422 million people worldwide have diabetes, particularly in low-and middle-income countries. Did you know that diabetes is one of the leading causes of death in the world? Simply put, there are two types of diabetes: Type 1 diabetes (lack of insulin) and Type 2 diabetes (ineffective use of insulin).
We find out more about diabetes in the African region in a conversation with Pr. Jean-Marie Dangou, Coordinator, Noncommunicable Diseases Primary Prevention (NPP), Noncommunicable Diseases Cluster at WHO Regional Office for Africa.
In this interview, we find out what diabetes is and why it has become a new priority and what surveys tell us about the extent of diabetes in the African region. Amongst the numerous insights offered here, we also learn about the lack of access to proper treatment and diabetic medications, especially insulin, resulting in avoidable complications and what is being done to address this.
While infectious diseases, HIV/AIDS and poverty have traditionally dominated the African region. To what extent has diabetes now become a new priority?
Over the past three decades, the occurrence of diabetes mellitus has risen dramatically in all countries of all income levels. The prevalence of diabetes in sub-Saharan Africa, similar to trends being seen worldwide, is rapidly rising. The sub-Saharan African region is expected to see the largest percentage increase in the incidence of diabetes in any region in the world. In 2015, the International Diabetes Federation (IDF) estimated that there were 14.2 million people with diabetes in sub-Saharan Africa.
Prevalence is highly varied between countries, with prevalence ranging from a low of 0.6% in Benin to a high of 18.2% in Réunion. There is also great variability in rural versus urban prevalence with urban areas facing the brunt of the burden. The wide variation in diabetes prevalence can be explained partly due to regional differences in lifestyle and body mass index. If we do not act now, this figure will increase by 162% by 2045. Africa is the region with the highest percentage of undiagnosed people – 70% of people with diabetes do not know they have it. Diabetes caused about 312,000 deaths in 2017 and 3 out of 4 (73%) deaths due to diabetes were people under the age of 60.
This rise is due to ageing populations and lifestyle changes – including unhealthy diets and lack of physical activity. Overweight and obesity are the strongest risk factors for Type 2 diabetes, cardiovascular disease and other noncommunicable diseases.
2. What is diabetes and what are the main symptoms?
Diabetes mellitus is a serious, persistent disease in which blood sugar is elevated. Over a period of time raised blood glucose may lead to serious damage to nerves and blood vessels. The disease may go undiagnosed for years until complications have arisen. Symptoms include excessive urination and thirst, constant hunger, weight loss, vision changes and fatigue. Some people may suffer from signs and symptoms of heart attack or limb gangrene. If not well-controlled, diabetes may cause blindness, kidney failure, lower-limb amputations, heart attacks, strokes and other complications.
3. How would you summarise the three different types of diabetes?
There are three main forms of diabetes – Type 1 diabetes; Type 2 diabetes and gestational diabetes. Type 1 diabetes, previously known as insulin-dependent, juvenile-onset or childhood-onset diabetes, is characterised by deficient insulin production by the pancreas. People with Type 1 diabetes require daily administration of insulin to utilise the glucose in their blood. Without insulin, they cannot survive. The cause of Type 1 diabetes is not known and it is currently not preventable. Type 2 diabetes formerly called non-insulin-dependent or adult-onset diabetes occurs when the body can no longer effectively use insulin. A vast majority of people with diabetes (over 90%) have this form of the disease.
Some risk factors for Type 2 diabetes – such as genetics, ethnicity and age – are not modifiable. Others, such as being overweight or obese, unhealthy diet, insufficient physical activity, alcohol consumption and smoking are modifiable through behavioural and environmental changes. Type 2 diabetes was once seen only in adults, but it has begun to occur in children in recent years. Gestational diabetes is a temporary condition that occurs in pregnancy and carries long- term risk of Type 2 diabetes.
Approximately one in seven births are affected by gestational diabetes, a severe and neglected threat to maternal and child health. Many women with gestational diabetes experience pregnancy-related complications including high blood pressure, large birth weight babies and obstructed labour.
4. What have surveys shown about the extent of diabetes in the African Region?
In 2017, the top five countries for the number of people with diabetes (18-99 years) were Ethiopia, South Africa, Democratic Republic of Congo, Nigeria and Tanzania. Currently, the prevalence of diabetes in the African region is estimated to be 7.1 % compared to 3.1% in 1980. Early diagnosis, detection and the management of Type 2 diabetes reduce the development of complications such as visual impairment and blindness. Management of Type 2 diabetes involves the control of blood glucose through a combination of dietary, physical activity, counselling and appropriate medicines if necessary.
The risk of developing Type 2 diabetes and its complications could be significantly reduced by maintaining a healthy body weight, engaging in sufficient physical activity, eating a well-balanced diet low in sugar and fat but supplemented with fresh fruits and vegetables on a daily basis, as well as avoiding tobacco and harmful use of alcohol throughout a person’s life. A lot needs to be done in the African region to stem the tide of rising noncommunicable diseases including diabetes.
5. What are the issues around a lack of access to proper treatment and diabetic medications, especially insulin, resulting in avoidable complications? What is being done to address this?
Unfortunately, in many African settings, half the people living with Type 2 diabetes are unaware of their disease and therefore not receiving treatment. Early diagnosis and treatment are important for preventing complications of diabetes. Since diabetes can potentially strike any family, awareness of the signs, symptoms and risk factors is important to help detect it early. Diabetes treatment usually requires daily doses of insulin.
This can lead to catastrophic expenditure for people with diabetes and their families when they have to pay out of their own pockets for their treatment. Diabetes can push families into poverty if breadwinners with diabetes become disabled or lose their life prematurely. Diabetes is also a huge burden on the health care system and the national economy. I would like to call upon governments to accelerate the prevention and control of diabetes and other non-communicable diseases by adopting policies, legislation and programmes that promote a healthy diet, physical activity and reduce exposure to tobacco and harmful use of alcohol.
6. Tell us where you see diabetes in the region heading by 2030?
The number of diabetic patients is expected to increase to 34.2 million patients by 2040. Although the immediate needs of the population already facing diabetes are dire, there exists an equally important need to introduce policy designed to encourage the creation of nutritious food environments and avoid emerging food environments that are being flooded with obesogenic/diabetogenic foods (sugar-sweetened beverages, highly processed foods, etc.).
This nutrition transition is fuelling the dramatic rise in diabetes prevalence in urban areas that are shifting toward a more western, sedentary style of life. Although this nutrition and lifestyle transition does not seem to have reached many rural sub-Saharan African settings yet, the extension of this trend is inevitable as the economic growth of sub-Saharan Africa continues to increase. In addition to a nutritious food environment, education about healthy eating and physical activity needs to be implemented at all levels, targeting children and adults as well as urban and rural markets.
To identify the unique prevention strategies needed for rural areas, contextualised, culturally adapted research needs to be supported to investigate the dietary patterns that may be increasing the risk for diabetes. Estimation of the costs associated with diabetes is crucial to make progress towards meeting the targets laid out in Sustainable Development Goal 3 set for 2030. The studies included in this review show that the presence of diabetes leads to elevated costs of treatment which further increase in the presence of complications. The cost of drugs generally contributed the most to the total direct costs of treatment.
7. Thank you. Is there anything you would like to add?
This region faces unique challenges in combating diabetes – lack of funding, lack of availability of studies and guidelines specific to the population, lack of availability of medications, differences in urban and rural patients and inequity between public and private sector health care. Because of these challenges, diabetes has a greater impact on morbidity and mortality related to the disease in sub-Saharan Africa than any other region in the world. In order to address these unacceptably poor trends, contextualised strategies for the prevention, identification, management and financing of diabetes care within this population must be developed.
Combatting diabetes and other NCDs is the business of all – individual; communities; national authorities; development partners; NGOs and INGOs; civil society. Diabetes can be prevented by maintaining normal body weight, engaging in regular physical activity, eating healthy diets that include sufficient consumption of fruits and vegetables and avoiding alcohol consumption and the use of tobacco. We should institute policies and practices across populations and within specific settings (school, home and workplace) that contribute to good health for everyone, regardless of whether they have diabetes.