The Global Burden of Diabetes: Case Studies from Guatemala

7/28/2019 The Global Burden of Diabetes: Case Studies from Guatemala

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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


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Thirst/fatigue Friend runs a

lab

Hyperglycemic

Fee-for-serviceclinic

Visual s/s,

neuropathy

Pharmacy prn

NPH injections 1-

2/wk

Naturopath

(I can cure you)

Fee-for-service

(met/glyburide

branded)

Health Post

(glimepiride

generic 1 wk rx)

Case

finding/recruit

ment

WK | Maya

Health

Unemployment/periodic financial

crisis

10 years!!


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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


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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)


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Lancet 2011; 378: 3140


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Diabetes in Guatemala

PAHO/CAMDI (2012): 8.4% among urban adults

Lancet (2011): 8.9%11.5% men; 8%14% women


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BMC Health

Services

Research

2012,

12:476


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Knowledge of Diabetes

Symptoms of hyperglycemia 87% (n = 20)

Sequelae of end organ damage 43% (n = 10)

Knowledge of DM prior to diagnosis 39% (n = 9)

DM as a chronic condition 70% (n = 16)Need for glycemic control 96% (n = 22)

Glycosylated hemoglobin testing 0%

Effects of diet on glycemic control 96% (n = 22)


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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?


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Our DM Programa 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 MDinvolvement (except insulin)

Treatment of comorbidities (HTN, proteinuria)


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Elements

Foot exam (not microfilament)Macroproteinuria (not microalbumin) (q 3-6months)

Fingerstick glucose

A1C (q 3-6 months)Serum creatinine (q 6-12 months)

Blood pressure

BMI

Diet counselingInsulin Teaching


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UKPDS newly diagnosed DM, mean age 53. Intensive (A1C7.0) 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 patientswho were severely hypoglycemic.


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VADT. Median duration of dx ~ 8 yrs, age 60. Intensive (A1C6.9) 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 mortalityin intensive therapy (HR 1.22)


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Why do indigenous/rural populations get

DM?

Invasion of processed foods

Changing lifestyles less farming, less manual labor

Ruralurban migration

But.


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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)


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DM?

Chronic undernutrition in childhood is associated with HTNin 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


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www.abc.com

Damned if you do, damned if you dont: endemic

undernutrition and the nutrition transition


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The Global Burden of Diabetes: Case Studies from Guatemala

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