Preventing Diabetes mellitus in Nigeria: Policy issues

Navigation: Main page » Diabetics and Diabetes

 Print this page Submit articleComment article

Author: Inegbenebor, Ute

Introduction

Diabetes mellitus, a chronic debilitating disease, which results from derrangement of carbohydrate metabolism, is very commonly seen in Nigerian hospitals

1. Common etiological factors have been named as obesity (an emerging public health problem in Nigeria), physical inactivity, drugs and toxic agents

2 which may include food additives. Most of the diabetics present in modern health care facilities, when complications such as blurred vision

3, coma and gangrenous foot ulcers 4 have set in. Many of those who survive go back home with amputation of various proportions of one or more limbs. These patients increase the burden of the immediate or extended members of the family.

4 Late presentation to modern health facilities may be related to non-availablity of doctors in primary health centers, which are closer and more accessible to majority of Nigerians.

5 It is therefore necessary to develop appropriate policies that will prevent most people from developing diabetes mellitus, facilitate early diagnosis and treatment in order to reduce the pain, suffering and burden of patients and families. It is also cheaper in the long run to prevent diabetes mellitus from occuring, or being complicated than to spend money, time and energy in treating and rehabilitating disabled diabetics. Seventy percent (70%) of the population of Nigeria live in the rural and semiurban areas.

6 In Nigeria, there is at least one primary health centers in each of the 10-12 wards that make up a local government. There are 774 local government areas in Nigeria. Since primary health centers are by definition the first point of contact between the community and modern health care, they can serve as the health facility for screening for diabetes mellitus. In developped countries, glucometers are easily affordable by members of the community and so can be used for making diagnosis. In Nigeria, where many people live on less than one dollar (120 Naira) a day, the mode of screening depends on the availability and affordability of the screening material. Urine glucose testing is a readily available tool for screening. However, it must be established that it can detect diabetes mellitus at all times. In this study, urine glucose testing with test strips was compared with fasting blood sugar measured with a glucometer in order to determine sensitivity and specificity of urine glucose testing in detecting diabetes mellitus.

MATERIALS AND METHODS

The subjects were carefully selected using age, sex and weight as parameters for matching cases with control. The cases were 40 known diabetics being managed in the hospital and the controls were patients of the same hospital being managed for other ailments and not known to be diabetics. All subjects selected were between the age of 35 and 60 years. Preprandial samples of mid stream urine were collected for both cases and controls and analyzed with Medi-Test;Combi 9 urinalysis test strips.. Simultaneously, fresh capillary preprandial samples of blood were also collected from both cases and controls and tested for glucose with glucometer. Results of urine and blood glucose were compared and subjected to tests of significance using the Chi square test. Sensitivity and specificity of urine glucose testing were also calculated. P- value was calculated using Graph pad software written by John Pezzullo, Georgetown university medical center.

RESULTS

Out of 40 diabetics studied, 16 had a fasting blood sugar level of 8mmol/l and above. All 16 were also positive to urine glucose testing. Twenty-four had fasting blood sugar level of less than 8mmol/l. Twenty of these tested negative to urine glucose testing while the remaining four tested positive. Among the controls, only one had a fasting blood sugar above 8mmol/l and also tested positive to urine glucose testing. Thirty-nine had a fasting blood sugar below 8mmol/l. Thirty-five of these tested negative to urine glucose testing while four tested positive. Urine glucose testing was found to significantly distinguish between normoglycemia below 8mmol/l and hyperglycemia 8mmol/l and above (p-value < 0.0001) The sensitivity of urine glucose testing in detecting hyperglycemia 8mmol/l and above in Nigerian diabetics was 100% while the specificity was found to be 83 per cent. Predictive value of urine glucose testing was found to be 80 per cent Discussion Urinalysis is an easy, relatively inexpensive and readily available test in most health care facilities in Nigeria. It is socially and culturally acceptable to Christians and Muslims and it is non invasive. It is therefore widely applicable to large populations without attendant socioeconomic consequences. In Nigeria, where people do not present themselves in the hospital until severe complications have developed, it becomes a veritable tool to be applied to all patients, who come to the hospital for other ailments.

Urinalysis is highly sensitive though less specific as has been shown in this study , where sensitivity and specificity were 100% and 83% respectively. It is therefore a good screening test for diabetic mellitus. It is able to detect all patients who are diabetic. To this extent, it could be used in making diagnosis. However, patients, who are not diabetic but have renal glycosuria are also diagnosed as diabetics making it unreliable as a single diagnostic tool for diabetes mellitus. In this study, the false positive rate was 17%. Patients, who are diabetic but with high renal threshold, are diagnosed as non-diabetics with urine glucose testing. However, in this study, false negative rate was zero percent. Diabetes mellitus can be diagnosed using following criteria; a fasting blood glucose level of 8mmol/l or above, a random blood sugar level of 11mmol/l and above and an oral glucose tolerance test. . Fasting blood glucose level was used as the criteria for diagnosis in this study because it is the best predictor of mean glucose concentrations over the following 24 hours7 and glycosylated hemoglobin (HbAic) estimations correlate well with mean fasting blood glucose.8 There are borderline areas such as a fasting blood sugar between 6mmo/l and 8mmol/l, which may be described as chemical diabetics. This study does not concern itself with borderline cases. Rather, it tries to identify how readily urine glucose testing can detect changes in blood glucose levels in diabetics and non-diabetics with a view to determining, if it can be substituted for blood glucose testing as a screening and monitoring tool for diabetes mellitus in developing countries such as Nigeria.

Conclusion and Recommendations

Urine glucose testing can monitor blood glucose level within the limits of whether blood glucose level is high enough to produce renal glycosuria or not. When appropriately timed, for example, preprandial test, it can detect nearly all cases where fasting blood sugar level is 8mmol/l and above. It can therefore be used to select cases that could be tested further using blood glucose levels to establish diagnosis of diabetic mellitus. Urine glucose testing can also be used to monitor the effectiveness of medications in diabetic patients as a negative glycosuria implies the absence of glucose level 8mmol/l and above. Use of urine glucose testing or urinalysis will obviously reduce cost of diagnosis and treatment of diabetics in Nigeria.

Obesity is assuming public health importance in recent years due to its increasing incidence seconday to excessive patronage of fastfood restaurants by the youths and the affluent, the almost monotonous use of starchy, fermented cassava paste as the staple food by the rural and urban poor, the change from subsistence farming to more sedentry occupations and the more frequent use of motorbikes and cars for journeys that used to be done on foot. Even bicycles are getting out of use. Obesity plays a very important role in the development of type 2 (Non insulin dependent) diabetic mellitus as it wears out endogenously produced insulin and increases insulin tolerance. It has therefore become necessary that a national policy on nutrition should be enacted in order prevent obesity. The national health policy should shift emphasis from white elephant tertiary projects to functional comprehensive primary health care, where all members of the communities in the catchment area of the primary health centre could be screened for diabetes mellitus. Such functional health centers should have the basic components of a health facility, which include a reception, Nurses' bay, doctor's consulting room, laboratory and mini-pharmacy or drugstore. It is also expected that the manpower should include one doctor, one laboratory scientist/technician, pharmacist/pharmacy technician and four nurse/midwives to provide a 24 hour coverage. These functional primary health centers will enable most Nigerians to be screened regularly for diabetes mellitus. Those, who are diagnosed as diabetics can then have supervised treament, monitoring and control with the aim of preventing complications of diabetes mellitus.

References

1. Oyegbade OO, Abioye-Kuteyi EA, Kolawole BA, Ezeoma IT, Bello IS. Screening for diabetes mellitus in a Nigerian family practice population. In: SA Fam Pract 2007:49(8) 2. ADEGHATE, E. SCHATTNER, P . DUNN, E. An Update on the Etiology and Epidemiology of Diabetes Mellitus. In: Diabetes Mellitus and its Complications: Molecular Mechanisms, Epidemiology, and Clinical Medicine Ann. N.Y. Acad. Sci. 2006 1084: 1-29 3. .Nwosu, SNN. Low vision in Nigerians with diabetes mellitus. In: Documenta ophthamological. Spring Netherlands. 2000; 101(1): 51-57 4. Ogbera, AO,Adedokun A, Fasanmade OA, Ohworiole, AE, Ajani, M. The Foot at Risk in Nigerians with Diabetes Mellitus- The Nigerian Scenario. In : Int J Endocrinol Metab 2005; 4: 165-173 5. Inegbenebor, U. Conceptual model for the prevention of maternal mortality in Nigeria. Tropical Doctor. 2007: Apr.37(2) 104-106(3) 6. Ezekwem, U. Social practices harmful to women in Nigeria. Tropical journal of Obstetrics and Gynecology (Ibadan) 2002 : 19(1) 22-25 7. Paisey, RB, Bradshaw, B, Hartog, M. Home blood glucose concentration in maturity onset diabetics. Br Med J 1980: I: 596-598 8. Walters, D. Home blood glucose monitoring - a review. In: Practical Diabetes digest.1989; Launch issue: 8-12