The global burden of diabetes: a case study from Guatemala

Peter Rohloff, MD PhD Wuqu’ Kawoq | Maya Health Alliance Brigham and Women’s 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: 31–40

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’ azúcar”) 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 • Ruralurban 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 don’t: endemic undernutrition and the nutrition transition

www.abc.com

Thanks – Matyöx 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 yawa’i’ – patients!

Get Involved!
peter@mayahealth.org www.mayahealth.org/diabetes www.mayahealth.org/donate

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