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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What is good control?
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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What is good control?
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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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)
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Why do indigenous/rural populations get
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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