Diabetes mellitus (DM) is a chronic disease characterized by glucose intolerance of varying degrees, resulting in high blood glucose levels. Uncontrolled diabetes causes progressive and chronic damage to blood vessels and multiple organs, leading to further complications and increasing morbidity and mortality. More than 3 million Nigerians have diabetes, but a significant number of affected persons are not aware, and are diagnosed incidentally or after presenting with complications from the disease (Jackson, Adibe, Okonta, & Ukwe, 2014).
Numerically, diabetes is defined as fasting blood glucose (8 hours without eating) > 126 mg/dl, or random blood glucose checked at anytime > 200 mg/dl. Some people have impaired glucose tolerance or pre-diabetes, which is signaled by fasting blood glucose of 100-125 mg/dl. This last group of individuals could be targeted for preventative intervention to avoid progression to diabetes mellitus (Oguoma et al., 2017). Diabetes presents with several symptoms including excessive thirst (Polydipsia), excessive hunger (polyphagia), excessive urination (polyuria), dry mouth, nausea and vomiting, abdominal pain, weight loss, weakness, blurred vision, and frequent infections of the urinary tract and skin. There are two major types of diabetes, namely Type 1 and Type 2, and there are other transient forms of diabetes, including Gestational (pregnancy) diabetes. These three will be discussed in this article.
Type 1 Diabetes Mellitus
Type 1 diabetes is usually seen in children and young adults, and is sometimes referred to as Juvenile diabetes. It is characterized by high blood glucose levels and inability to metabolize glucose because of absolute insulin deficiency. Insulin is produced by the beta cells of the pancreas, but in these people, the beta cells are destroyed by an autoimmune attack, causing them to become non-functional and unable to produce insulin. Insulin helps remove glucose from the blood and into cells for use. Therefore, persons with Type 1 diabetes lack the ability to utilize glucose, leading to several symptoms which may be reported at time of diagnosis (Katsarou et al., 2017). These symptoms include:
Diabetic ketoacidosis (DKA): This is a condition which results from inability of the body to utilize available glucose for metabolic processes, so it breaks down fat into fatty acids and causes the liver to release stored glucose in attempt to provide fuel for the body. However, the body cannot utilize the extra glucose released, acid and the byproduct of fat breakdown known as ketones build up in the body, leading to a condition known as ketoacidosis. Ketoacidosis usually presents with several symptoms including fruity breath smell, confusion, abdominal pain, as well as labored and rapid breathing as the body attempts to compensate for acidosis. This condition is life threatening and requires hospitalization and management in the intensive care unit (Katsarou et al., 2017).
Dehydration: High blood glucose levels results in increased urine output because the body excretes excess glucose by causing large amounts of urine to be produced. Over time, the person loses too much fluid, resulting in dehydration.
Weight Loss: Consistent inability to metabolize and utilize glucose, fat breakdown, and increased urine output all contribute to produce significant and unintentional weight loss in people with untreated Type 1 diabetes.
Initial Management of Type 1 Diabetes
Persons with Type 1 diabetes do not produce insulin, and require insulin administration and close monitoring of blood glucose levels upon diagnosis. Unfortunately, most of those affected are usually diagnosed upon hospitalization for life threatening symptoms such as DKA. Therefore, management involves addressing the key factors which includes insulin therapy, replacing loss fluids through intravenous hydration, treating any coexisting condition such as electrolyte abnormalities, and providing counseling for the patient and available family members.
Insulin Administration: Insulin is the mainstay of therapy for persons diagnosed with Type 1 diabetes. If admitted to the hospital in the setting of DKA, the patient must be placed on insulin drip and titrated to maintain acceptable blood glucose levels. Hourly blood glucose checks are recommended in the acute phase to ensure that the patient does not become hypoglycemic (low blood glucose). Once the patient improves and is stable, frequency of glucose monitoring can be decreased and insulin administration should be scheduled to coincide with timing of blood glucose checks and meals.
Fluid Administration: Uncontrolled hyperglycemia (high blood glucose) causes dehydration due to excessive urine output as the body attempts to get rid of glucose in the blood. Therefore, fluid administration is the second most important aspect of managing these patients in the acute phase. Hydration helps to replace loss fluid, improves perfusion of vital organs, helps reduce the solute load in the blood, and correct some electrolyte abnormalities usually present in the setting of DKA.
Counseling: Counseling is so important because Type 1 diabetes is a lifelong condition that requires frequent monitoring and daily management. Most of those affected are very young at time of initial diagnosis, and may not fully understand the magnitude of the disease process. The healthcare provider has to explain as much information that is age appropriate for the affected person, and also do extensive discussion and teaching on self-monitoring and management for available family members that will participate in caring for the patient upon discharge. Patient and family counseling can booster confidence in the ability to manage the disease, and reduce the incidence of complications. Teaching must address all aspects of the disease including daily insulin administration, blood glucose checks, symptoms of DKA and other complications, as well as storage of insulin, which is a big issue in areas with unstable power supply.
Type 2 Diabetes Mellitus
Type 2 diabetes is the most common form of diabetes in the world, and the number of new cases continues to increase. In Nigeria, it affects more than 3 million people, especially persons between the ages of 40-59 years, and most are unaware of their status. Unlike Type 1 diabetes which presents with dramatic deterioration because of absolute insulin deficiency, Type 2 diabetes can remain undetected for years because the body produces enough insulin to prevent rapid decompensation and acidosis. However, they still experience symptoms of hyperglycemia (high blood glucose) such as excess thirst, excess hunger, excess urine output, and frequent urinary tract and other infections.
Type 2 diabetes is characterized by reduced sensitivity to insulin or insulin resistance. It is caused by overweight, obesity, abdominal adiposity (belly fat), and decreased physical activity. The increase in the prevalence of Type 2 diabetes in Nigeria is attributed to rapid urbanization which has promoted a more sedentary lifestyle, as well as changes in dietary patterns with increased intake of processed and sugary foods. These lifestyle changes which are mostly seen in the expanding middle and upper-class has increased the risk of diabetes. Obesity particularly in the abdominal area causes the release of large amounts of inflammatory cytokines which promote resistance to insulin and dysfunction of insulin producing cells of the pancreas, resulting in dysregulation of glucose metabolism in the body (Oluyombo et al., 2016).
Initial Management of Type 2 Diabetes
Once a person is diagnosed with this form of diabetes or found to have a degree of glucose intolerance, initial management must include recommendation of lifestyle changes to promote weight loss. This will involve increased physical activity (up to 150 minutes of aerobic activity or 75 minutes of vigorous exercise a week), and dietary modification to decrease intake of processed foods, carbohydrates and simple sugars, with a move towards a more balanced diet by increasing fruits and vegetables in appropriate portions. A combination of these factors will reduce weight gain, promote weight loss and well-being, and improve insulin sensitivity.
For those who do not achieve adequate control with lifestyle modifications, medication therapy must be initiated to improve blood glucose levels and decrease the risk of complications from hyperglycemia. There are two forms of medication therapy available; these two include oral antidiabetic agents and insulin. Initiation of medication therapy for persons with Type 2 diabetes must always begin with oral agents. The most common oral antidiabetic medication used in Nigeria is Metformin (Olamoyegun, Ibraheem, Iwuala, Audu, & Kolawole, 2015).
Metformin works by reducing glucose production in the liver, reducing glucose absorption from the digestive system, and improving insulin sensitivity. The medication is highly effective and widely available in Nigeria. However, there is need for healthcare providers and pharmacist to reinforce the importance of understanding side-effects such as hypoglycemia (low blood glucose), which might exhibit as headache, weakness, confusion, shaking, sweating, hunger, irritability, and fast heart rate. Although rare, Metformin can also cause lactic acidosis (buildup of lactic acid in the blood), particularly in persons with renal dysfunction and other health conditions. Symptoms include muscle aches and pains, numbness of arms and legs, stomach pains, nausea, vomiting, tiredness, weakness, trouble breathing, dizziness or light headedness, slow irregular heart rate etc (Lee, et al., 2017). Metformin is not recommended for people with liver problems and kidney failure, as the medication can buildup in these situations and cause severe side-effects (Lalau, 2010). Pregnant women or those breastfeeding should talk to their doctors before use because the medication is not appropriate during pregnancy, and passes through breast milk which can possibly make the breastfed baby hypoglycemic.
Failure to achieve adequate blood glucose control with oral antidiabetic agents will require initiation of insulin therapy with a goal of improving glucose control, while continuing to make lifestyle changes. The goal blood glucose level for individuals on antidiabetic medication is <110 mg/dl, but this target is hard for many to achieve.
Gestation Diabetes
Gestational diabetes is high blood glucose first diagnosed during pregnancy. It causes multiple complications including large birthweight, immature lungs and subsequent respiratory distress for the newborn baby, low blood glucose in the newborn because their bodies produced more insulin to handle the high blood glucose while they were in the womb, and premature delivery. Risk factors include age > 25 years, Body Mass Index (BMI) > 25 kg/m2, previous history of gestational diabetes, family history of Type 2 diabetes, and history of poor obstetric outcomes (Bhavadharini, Uma, Saravana, & Mohan, 2016). Pregnant women should be tested for this condition between the 24-28th week of pregnancy, and this can be done with the Oral Glucose Tolerance Test (OGTT). The OGTT measures the body’s ability to handle glucose, and involves giving a person 75 grams of glucose to drink after an 8 hour fasting period (8 hours without eating). Blood samples are collected prior to glucose administration, and at 1 and 2 hours after the glucose challenge, to assess blood glucose levels (Ogbera & Ekpebegh, 2014). According to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) Criteria, the following values indicate the presence of abnormal glucose tolerance:
- Fasting blood glucose > 126 mg/dl indicates existence of diabetes before pregnancy
- Fasting blood glucose > 92 mg/dl indicates gestational diabetes
- 1 hour after 75 grams OGTT, blood glucose > 180 mg/dl indicates gestational diabetes
- 2 hour after 75 grams OGTT, blood glucose > 153 mg/dl indicates gestational diabetes (Bhavadharini et al., 2016).
Gestational diabetes can resolve completely after childbirth. However, the affected woman has a higher risk of developing Type 2 diabetes, and children born to mothers with gestational diabetes have a higher risk of becoming obese and developing Type 2 diabetes later in life (Fansamade & Dagogo-Jack, 2015).
Long-term Complications of Diabetes
Long-term complications of diabetes are divided into macrovascular and microvascular complications. Microvascular complications such as Nephropathy (damage of kidneys), Retinopathy (damage of the eyes), and Peripheral Neuropathy (damage of nerves) are the most common and debilitation effects of uncontrolled diabetes over a period of time. Each of these will be discussed below.
Diabetic Nephropathy: This describes a situation where high blood glucose causes damage to the tiny blood vessels (Nephrons) that filter blood in the kidneys. If this condition is not arrested, the kidneys loses their filtering capacity over time, resulting in kidney failure. Diabetic Nephropathy is the leading cause of End-Stage Renal Disease (ESRD) in the world, and leads to dependence on dialysis to filter waste products from the blood (Sharaf El Din, Salem, & Abdulazim, 2017). Some people with diabetes may not develop ESRD, but long-term high blood glucose will eventually lead to some degree of kidney dysfunction. Early detection is key to management, and it is recommended that individuals with diabetes follow-up with a doctor to assess their urine for excretion of excess protein (albumin), because excess protein in urine (Proteinuria) is an indication of decreased filtering capacity by the kidneys (Olamoyegun et al., 2015).
Diabetic Retinopathy: This is the most common microvascular complication of diabetes, and it is characterized by damage to the small blood vessels of the eyes as a result of high blood glucose. If left undetected and untreated, it could lead to blindness (Kizor-Akaraiwe, et al, 2016). Signs and symptoms include bleeding in the eyes, cotton wool spots or floaters, blurred vision, impaired color vision, dark or empty spots in field of visor etc. Early detection is essential to reducing the risk of progression to blindness. It is important for affected individuals to follow-up with an ophthalmologist (eye doctor) for management of this condition (Olamoyegun et al, 2010).
Diabetic Peripheral Neuropathy: This is characterized by damage to the nerves of the body, particularly the hands and legs, as a result of uncontrolled high blood glucose. It is one of the late complications of diabetes. Symptoms include numbness and decreased sensitivity to pain and temperature changes, pain, tingling, and burning etc. Peripheral neuropathy predisposes the affected person to falls due to decreased balance and coordination, and the development of foot ulcers (Olamoyegun et al., 2015). Affected persons must take time to check their legs daily, wear comfortable shoes, avoid walking barefooted as decreased sensation may make it difficult to be aware of the presence of injury. It is important to be aware that peripheral neuropathy and high blood glucose decrease the ability of wounds to heal, therefore wounds in the legs may take much longer to heal and lead to severe complications such as infection, gangrene, and subsequent amputation.
Limitations to Diabetes Care in Nigeria
The biggest challenge to effective diabetes care in Nigeria is lack of financial and medical resources, which limits the ability to manage the growing population of people living with diabetes.
Lack of Financial Resources: The current Nigerian healthcare system is one in which there is no universal healthcare coverage, necessitating that individuals with health problems pay for all healthcare expenses. This places an unusual burden on people with chronic health conditions such as diabetes, which requires follow-up with healthcare providers, self-monitoring devices, and daily medication therapy. The financial burden of purchasing antidiabetic drugs can be so much that some individuals choose to skip medications to prolong drug availability, some resort to alternative medicine such as herbs in attempt to control blood glucose levels, and some stop treatment completely. This results in large numbers of people living with uncontrolled diabetes, leading to severe long-term complications from the disease process (Okoronkwo et al., 2017).
Lack of Medical Resources: Diabetes requires self-monitoring devices including Glucometer and Lancets, which are used to check blood glucose at home. Since these items are imported, the cost may be prohibitive for some individuals to purchase. Therefore, many people do not have the resources to carry out self-monitoring at home, and cannot make appropriate adjustments or know when to seek medical attention until severe complications occur. In addition, prescribed antidiabetic medications may not be available at nearby pharmacies, causing delays in treatment. For those dependent on insulin therapy, the challenge is more daunting, as they must purchase insulin frequently to maintain health, and also look for ways to preserve the potency of insulin which has to stay refrigerated in setting of unstable power supply. Diabetes is a health condition that requires management by expert medical personnel including primary care physicians, endocrinologist, ophthalmologist, podiatrist, and nurses. These all have a role to play. However, in Nigeria, most individuals with diabetes only have limited access to a general medicine doctor, who may not be able to provide the comprehensive follow-up and management required for all potential complications of the disease.
Addressing Challenges to Diabetes Care in Nigeria
Diabetes is a disease with multisystem ramifications if left uncontrolled. However, the cost of self-monitoring, management, and medical follow-up is so expensive and most people are not able to meet such demands. Therefore, it is essential that the Federal Government of Nigeria in collaboration with the Ministry of Health, continue to look for long-term solutions to improve healthcare access and delivery in Nigeria. The Nigerian Diabetic Association (NDA) must aggressively advocate for, and collaborate with healthcare providers to ensure timely diagnosis through health screening of high risk individuals, and push for the federal government to supplement some aspects of care for this vulnerable population. There is also need to raise awareness through public health campaigns, as well as doctor-to-patient counseling to ensure that the population is aware of this disease and the complications that can arise from poor management. It is imperative to emphasize the value of life-style changes including diet and exercise in preventing and controlling diabetes. Nurses can also be trained specifically to go into the community to follow-up with diabetic patients in remote areas, provide education, check blood glucose level with a Glucometer, and, and followup on the patient’s health status in general. This can help to ensure periodic blood glucose monitoring in individuals who are on medications but do not have self-monitoring devices. With expected rise in the number of people with diabetes in Nigeria, the time to act and establish protocols and systems to address this concern is now. If not, the nation will face a crisis of complications from diabetes, that will overwhelm the healthcare system.
Written by Dr. Idongesit Udoh