• You may be blind or down with stroke before knowing you have diabetes
By Chioma Obinna
An amputee narrated his ordeal with diabetes foot care. He was once a vibrant young man working in the entertainment industry and had everything going well for him. But life came to a stop when he sustained a leg injury which refused to heal.
He was unaware before then that he had diabetes – not even when he first reported at the health centre where the foot ulcer was managed for two weeks. He only got to know when he was referred to the General Hospital where the leg was eventually amputated. More than seven years after his amputation, he is yet to regain a normal life. He lost his job and his blood sugar level is ever rising because he cannot afford his medication and the devices he needs to monitor his sugar level. He is completely out of control of diabetes.
This is the story of a typical African living with diabetes. It’s a story that resonated throughout the one day Diabetic Summit organised by Sanofi Aventis in Lagos. The experts at the summit were unanimous in their submissions. Like a tsunami, diabetes mellitus is sweeping across Africa in a dangerous manner and people living with it are not receiving the type of care they need.
According to the International Diabetes Federation (IDF), an estimated 15.5 million adults, aged 20-79 years, were living with diabetes in Africa as of 2017. The continent is also reported to have the highest proportion of undiagnosed diabetes, with over two-thirds (69.2%) of adults currently living with diabetes unaware of their condition.
In Nigeria, no fewer than 3.9 million people are estimated to be living with diabetes currently while about 846,000 people have diabetes but are not aware they have it. Experts say most of them will likely get to know only when complications set in such as blindness, stroke, foot ulcer that could result in amputation, kidney failure, among several other conditions often linked with diabetes. This is because diabetes is a ‘silent’ disease which does not often present symptoms until it results in serious complications. The only way to get to know is through blood screening which most people will, ordinarily, not think about unless they have a health problem.
But the concern of the experts at the summit was about the care of those already living with diabetes. Held under the theme, ‘Personalizing Diabetes Care’, the consensus among the experts from Nigeria, USA, Egypt and Cameroon is that Nigerians living with diabetes, like other Africans, are not achieving treatment control in line with international standards. Complications such as foot amputation are reportedly on the increase in the country.
According to a professor of medicine and endocrinology, from the Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon, Jean Claude Mbanya, only a few people living with diabetes are achieving treatment clinical goals in Africa.
Citing data collected in 2016 from some African countries Algeria, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Kenya, Madagascar, Morocco, Nigeria, Senegal, South Africa and Tunisia in an International Diabetes Management Practice Study (IDMPS), tagged, ‘Wave 7 for Africa,’
Mbanya, in his presentation entitled, ‘Management of Mealtime Hyperglycaemia, disclosed that less than five percent of people with either Type 1 or Type 2 Diabetes Mellitus are achieving glycaemic target of HbA1c<7 percent – the blood test routinely performed in people with diabetes to measure their hemoglobin level and how well their diabetes is being managed over time – and blood sugar measurement of LDL-cs < 100mg/dL.
He listed three top reasons people with Type 2 diabetes are not achieving glycaemic goals as lack of diabetes education, lack of insulin titration (the right insulin dosage prescribed by the physician) and lack of experience in self-management while people with Type 1 diabetes are not also achieving control due to the fear of hypoglycaemia (low level of blood glucose), lack of insulin titration and lack of diabetes education.
Corroborating Mbanya’s views, Director and Team Lead, Public Health Advisory, Health Strategy and Delivery Foundation, HSDF, Dr Lilian Anomnachi, said universal health coverage is not possible without universal access. Thus, for a diabetes’ patient to achieve control, there must be the availability of quality diabetes care and treatment services within reasonable reach of those who need them, ability to pay for diabetes care and treatment services without financial hardship and willingness to seek diabetes care and treatment.
In Nigeria, she noted that these are not in place. For instance, current standing orders for nurses and other supportive health workers are not optimizing the limited workforce in diabetes care and treatment.
According to her, not only that diabetes care and treatment are poorly coordinated at the Primary Health Care level, also, the use of essential diagnostic tools such as Glucometers, HBA1C analyzers is not included in the current minimum service package for PHCs in the country.
“Most Nigerians in need of diabetes care and treatment are exposed to risks of catastrophic expenditure and financial hardship from treatment and complications,” she said.
Anomnachi further explained how poor awareness about diabetes prevention, care and treatment also contribute to the inability of Nigerians living with diabetes to achieve control while managing the disease. According to her, screening for diabetes is not integrated into basic and routine health services in Nigeria across all levels of care.
“Early diagnosis is very poor (about 51% of diabetes cases are undiagnosed) with patients presenting with debilitating complications; treatment at primary health care is very poor so patients have to travel long distances to seek care in secondary and tertiary health facilities; Diabetes education is not routinely provided after diagnosis. There are weak community support systems for self-care and management, lack of clinical guidelines and service protocols to guide quality improvement at all levels of care while the current essential medicines list (2016) has very few of these drug services,” she further revealed.
Lack of appropriate diet has also become a major reason for the failure of Nigerians living with diabetes to achieve control of the disease. Oftentimes, they are restricted to a diet of unripe plantain and beans as every other type of food is considered not appropriate for their condition. But Chima Patience, a dietician nutritionist, dispelled the myth, in her paper, titled, ‘The role of the patient and carer in diabetes care, said, “Until recently, people living with diabetes were prescribed a diet low in all types of carbohydrates and rich in proteins and fats. The use of whole grains, legumes, and fruits was discouraged because of their complex starch and sugar content which were transformed into glucose during digestion.
“There is no single ‘diabetic diet’”, she warned, adding: “Today’s dietary recommendation is low in fat, particularly saturated animal fat, low in sugar. This approach provides better results in controlling glycemia, preventing complications and improving longevity of diabetics.”
The experts, however, concluded that Nigerians living with diabetes need not go through much stress in the control of the disease. According to them, with the introduction of appropriate measures identified at the summit and a comprehensive coverage of diabetes by the National Health Insurance Health (NHIS), the threat of diabetes could be curtailed
The experts further recommended that the NHIS coverage should include diabetes screening, diagnosis, treatment and the management of complications often associated with the disease.
They also recommended an adequate provision of essential drugs for Nigerians living with the disease. While also calling for the provision of care on the healthcare plan for the indigent, disadvantaged and vulnerable people living with diabetes, the group noted that diabetes has assumed a pandemic proportion worldwide – in terms of prevalence, morbidity & mortality especially in developing countries like Nigeria with poor healthcare infrastructure and funding. “In a bid to check the attendant reduction in the quality and quantity of life of persons living with Diabetes (PLWD), now more than ever, there is a need for a call to action!” the communiqué issued at the end of the summit read.