The global burden of diabetes: a case study from Guatemala

Peter Rohloff, MD PhD Wuqu Kawoq | Maya Health Alliance Brigham and Womens Department of Global Health Equities

Thirst/fatigue

Friend runs a lab Unemployment/p eriodic financial crisis

Hyperglycemic

Fee-for-service clinic

Visual s/s, neuropathy

Health Post (glimepiride generic 1 wk rx)

Naturopath (I can cure you)

Fee-for-service (met/glyburide branded)

Pharmacy prn NPH injections 12/wk

Case finding/recruit ment 10 years!! WK | Maya Health

Global Perspective on NCDs

63% of global deaths due to NCDs 80% of global NCD deaths occur in LMICs NCD deaths will rise by 20% over next decade 80% of CVD/DM deaths occur in LMICs 90% of COPD deaths occur in LMICs Two-thirds of cancer deaths occur in LMICs

Global Perspective on NCDs

Even in AFR, NCD deaths will exceed maternal/child and communicable disease deaths by 2030 29% of NCD deaths occur in < 60 years in LMICs (13% on HICs)

Lancet 2011; 378: 3140

Diabetes in Guatemala
PAHO/CAMDI (2012): 8.4% among urban adults Lancet (2011): 8.9%11.5% men; 8%14% women

BMC Health Services Research 2012,

12:476

Knowledge of Diabetes
Symptoms of hyperglycemia Sequelae of end organ damage Knowledge of DM prior to diagnosis 87% (n = 20) 43% (n = 10) 39% (n = 9)

DM as a chronic condition
Need for glycemic control Glycosylated hemoglobin testing Effects of diet on glycemic control 0%

70% (n = 16)
96% (n = 22)

96% (n = 22)

Diabetes Causal Attributions (xe violencia, xe azcar) Strong emotional experience Susto Familial conflict or violence Heredity Poor diet Excessive work 43% (n = 10) 39% (n = 9) 22% (n = 5) 17% (n = 4) 13% (n = 3) 9% (n = 2)

Four Core Questions for Global-Rural DM Work

What should a rural DM program look like? How do you create behavior change? What is good control? Why do rural/indigenous people get DM?

Our DM Program a work in progress

Medication supply chain/formulary Free Nurses/CHWs (visits q 1-3 months) Home visits for family support, diet reinforcement, insulin training Protocols for medication titration without MD involvement (except insulin) Treatment of comorbidities (HTN, proteinuria)

Elements
Foot exam (not microfilament) Macroproteinuria (not microalbumin) (q 3-6 months) Fingerstick glucose A1C (q 3-6 months) Serum creatinine (q 6-12 months) Blood pressure BMI Diet counseling Insulin Teaching

What is good control? UKPDS newly diagnosed DM, mean age 53. Intensive (A1C
7.0) vs standard (A1C 7.9) 12% reduction in all-DM endpoint/10% in death mostly (but not all) due to microvascular outcomes; changes persisted in ~17 year f/u despite loss of tight glycemic control ADVANCE Mean duration dx ~ 8 years, mean age 66. Reduction in nephropathy with intensive (6.5) vs standard (7.3) treatment. No macrovascular benefit. Increased risk of death/severe endpoint in subset of intensively treated patients who were severely hypoglycemic.

What is good control?

VADT. Median duration of dx ~ 8 yrs, age 60. Intensive (A1C 6.9) vs. standard (8.4) therapy. No difference in micro or macrovascular outcomes. ACCORD. Median duration of dx ~ 10 yrs, age 62. Intensive (A1C 6.4) vs standard (7.5) therapy. Higher rate of CV mortality in intensive therapy (HR 1.22)

Why do indigenous/rural populations get DM? Invasion of processed foods

Changing lifestyles less farming, less manual labor Ruralurban migration But.

Why do indigenous/rural populations get DM? Stunted children develop central adiposity during puberty
(Brazil. Nutr. (2007) 23:640) Stunted children have impaired insulin production (Brit J Nutr (2006) 95:996). % body fat is higher in stunted children (Pak J Nutr.(2006) 4:418 ) Stunted children have lower BMRs (Eur J Clin Nutr (2005) 59:835)

Why do indigenous/rural populations get DM? Chronic undernutrition in childhood is associated with HTN
in adulthood (Mat Child Nutr (2005) 1:155) Stunting predicts adult overweight (East Mediterr Health J (2009) 15:549 Short adults have higher serum lipid levels and lower rates of fat oxidation (Am J Hum Biol (2009) 21:664 Short maternal stature predicts maternal obesity, HTN, abdominal obesity (Brit J Nutr (2009)101:1239

Damned if you do, damned if you dont: endemic undernutrition and the nutrition transition

www.abc.com

Thanks Matyx chiwe

Janet Jokela Malcolm Hill Jane Striegel Tyrone Melvin Melinda Dabrowski Claire Melvin Miranda Greiner Instituto de Nutricion de Centroamerica y Panama UIUC COM/MSP All of our yawai patients!

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peter@mayahealth.org www.mayahealth.org/diabetes www.mayahealth.org/donate