Revelations at Sanofi Diabetes Summit

• Experts say it’s increasing fast in Nigeria

• Majority of patients not achieving control

• Drugs too expensive due to govt tariffs

They came from far and near. From Cameroon, Ghana, Bauchi , Kano, Ibadan, the Renaissance Hotel  hall in Lagos was, on Wednesday October 18,  packed full of medical professionals that often form the diabetes management team.  Their mission? To discuss diabetes, a disease that is reportedly on a fast increase in all countries but which has remained largely ignored in Nigeria. It was the first edition of the Sanofi Diabetes Summit

The International Diabetes Federation (IDF) defines diabetes as a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces. Insulin is a hormone made by the pancreas. It acts like a key to let glucose from the food we eat pass from the blood stream into the cells in the body to produce energy. All carbohydrate foods are broken down into glucose in the blood. Insulin helps glucose get into the cells.

Not being able to produce insulin or use it effectively leads to raised glucose levels in the blood (known as hyperglycaemia). Over the long-term high glucose levels are associated with damage to the body and failure of various organs and tissues.

It is estimated that there are 415 million people have diabetes globally out of which Nigeria accounts for more than 5 million. Not only that, about 50%  of this number do not even know they have the disease until they come down with one of the numerous complications associated with the disease, some of which are life threatening.

Thus the excitement was palpable, especially in the medical community when Folake Odediran, the young lady at the helm of affairs in Nigeria and Ghana offices of Sanofi announced that that the multinational pharmaceutical giant would be holding the very first edition of the summit to get top experts in Africa and Nigeria to discuss some critical aspects of the disease.

True, the summit lived up to its billing, especially the revelations from the expert that Nigeria, both government and people has been neglecting this disease that is responsible for millions of death every year globally and which is responsible for a limb amputation every 10 seconds.

Prof. Jean Claud Mbanya, a professor of Medicine and Endocrinology from the University of Yaounde, Cameroon in his presentation, “Challenging the Status quo in the current management of diabetes in Sub-Saharan Africa,” revealed that the burden of diabetes in Africa and elsewhere in the worlds is assuming an epidemic proportion and must be checked before it is too late.

He said there must be conscious efforts by Africans to show more consciousness about the disease and educate the people, especially people living with diabetes to be fully involved in the management of the disease.

“You must  change the way you take care of patients,” he urged the care givers,  saying only education and empowerment added to the various therapies required for diabetes management would halt the growing incidence of the disease in Africa.

“The next speaker, Prof. Abiola Oduwole, a Consultant Paediatric Endocrinologist at the College of Medicine, University of Lagos/Lagos University Teach Hospital (LUTH) brought the picture nearer home in her presentation titled: “Concerns in the Management of Type 1 diabetes.”

According the American Diabetes Association, Type 1 diabetes is usually diagnosed in children and young adults. In  this type of diabetes, the body does not produce insulin. The body breaks down the sugars and starches into a simple sugar called glucose, which it uses for energy. Insulin is a hormone that the body needs to get glucose from the bloodstream into the cells of the body. Thus the affected children will require insulin therapy and other treatments to manage their condition.

Oduwole however told the summit that ignorance about this condition in children, both on the part of medical personnel and the public has compounded the diabetes problem in children. Many people in the hall were shocked when she revealed that even some doctors know next to nothing about diabetes in children. This, she said account for why many patients do not get to the specialist on time to prevent complications.

The situation is even worse for the children who depend on their parents to access treatment. A parent who rely on traditional healers for health care is not likely to visit the hospital first if his child develops symptoms of or falls sick as a result of diabetes. Indeed, Oduwole revealed the powerful role parents play in the management of type 1 diabetes when she described how some parents try to cut corners when faced with insulin scarcity or when the cost is beyond their reach. They simply adjust dosage of the medication without informing the doctor. Such a parent could decide to administer a lower dose of insulin to conserve the drug.

The problem of ignorance resonated in virtually all the presentations. At one point, one of the speakers sought to know how many doctors in the hall for instance, checked the feet of their diabetes patient that week. Very few, less than ten, indicated in the affirmative.

Yet, the complication of diabetes foot is becoming rampant in the country.s

According to a 2017 data from the medical ward  of  the University College Hospital Ibadan, shared by  Mrs. Grace Adekoya, an Assistant Director, Public Health Nursing and Nursing Educator in-Charge, Health Education Unit, Medical Outpatient Department of the hospital,  25% of the number of the diabetic patients admitted came in with diabetic foot.

In her paper titled “Nursing care of the diabetic foot ulcer”  Mrs. Adekoya disclosed that diabetic foot is the most common general cause of hospitalization in diabetic patients. It has also been established by experts that most of the diabetic patients occupying medical wards usually comes with diabetic foot.

Explaining the gravity of foot ulcer, Mrs. Adekoya noted: “… these ulcers can lead to infection, gangrene, amputation and even death if the necessary care is not provided. In addition, lower extremity amputation is associated with prolonged hospitalization and rehabilitation and also is required to home care and social support.  In fact, sometimes, by the time some patients are not able to accomplish the care, so many of them just decide to go home and die instead of keeping up with the payment of hospital bills,” she said.

She also noted that the overall rate of lower limb amputation in diabetic patients is like 10-30 times higher than non diabetic. “You can imagine so many people going with one leg all over the place just because of diabetes which we can as well prevent,” she said.

Research has proven that care and treatment of diabetic foot is very expensive all around the world. In developed countries, more than five percent of diabetics have foot ulcers and 20% of the total healthcare resources spent on care the diabetic foot in these countries.  Whereas, in developing countries like Nigeria, not only diabetic foot and its complications are more common, but also even sometimes, up to 40% of health care resources are unique to this disease. “The burden of this disease is high in Nigeria because the money comes out of pocket. The NHIS is not really working especially to the people at down trodden,” Mrs. Adekoya lamented.

Mrs. Adekoya also revealed that only a minority of patients receive  diabetes education in many countries like Nigeria and the  Nigerian case is worse because just few hospitals have education unit.

“The aim of patients education is especially in the prevention of diabetes foot ulcers is for people with diabetes to improve their knowledge, skills, confident enabling them to take precautions, increase control. You can imagine somebody that just hit the leg and then there’s blood and he just clean it up, put spirit and they will be looking at it. The importance of education, it goes a long way in preventing diabetes,” she said.

“That is the importance of task shifting because most of our consultants are overwhelmed already but if there is a standby place where they can report to and the nurse knows what she is doing then they will know this patients needs an attention not waiting until it is the time or the next appointment for that patient to see the doctor,” she said.

Like Prof. Oduwole and other speakers before him, Dr. Mohammed Alkali, National president Diabetes Association of Nigeria (DAN) in his presentation titled “The Diabetes Patient Perspective” also identified ignorance as one of the challenges facing people living with diabetes in the country. This, he said, is compounded with false beliefs and spiritual or religious interference.

Dr. Alkali further revealed that lack of knowledge about the disease has also resulted in stigmatization of people living with debates. This, he further said,  has resulted in concealment by some patients.

The Dan president narrated the story of two Nigerian diabetics to illustrate the situation in Nigeria.

First is the 40 year old farmer from a rural community presented to health centre with serious headache, difficulty in seeing. He had noticed increasing thirst, weakness and inability to sleep in the previous 10days and was going to urinate most of the nights. There was no doctor around and he was treated for malaria and was told to return in two days.

But his condition deteriorated at night and was brought back. He was placed on admission and the malaria treatment  continued. An hour later, he became unconscious and relatives were advised to transfer him to the general hospital. He died while preparation was being made. No investigation was carried out and he was not seen by a Doctor.

The second was the case of a 45 year old woman diagnosed with diabetes about 10 years ago during one of her pregnancies.

“She was managed during her pregnancy and “discharged” after delivery and was told not to take sugars.

“She has had occasional numbness of the feet and went to see a general practitioner where her husband is registered for NHIS.  Although he put her on oral hypoglycaemics and would do FBS during her follow up visits every 3 months, she never had HB1Ac done.

“Because of the high number of patients at the clinic she never had any opportunity to ask many questions on the disease and never had full physical examination. She subsequently never got pregnant and had gained additional weight since then.

“Just  after her visit she noticed a small ulcer on her feet but because it was painless, decided to wait till her next visit after 3 months. Before then, it had increased in size, and she had to walk with a walking stick.

“When she eventually went for her routine visit, she was referred to a specialist doctor at the tertiary hospital in their state capital. However, because she was on NHIS, it took additional 2 weeks to get approval from her HMO before she could be accepted.

“At the tertiary hospital, she was clinically evaluated and went through a series of investigations.  She was informed that a below the knee amputation would be required. Before she finished consultations and finally accepted the procedure, she had spent more than four weeks on admission. She was then informed that she had exhausted the maximum period of admission covered by the scheme and would be responsible for her subsequent stay in the hospital.”

According to Dr. Alkali, the two cases typifies the story of diabetes in Nigeria. They are stories  of ignorance, inadequate infrastructure, lack of policy  to address the many challenges associated with the disease, clear neglect and lack of attention by government.

Perhaps the story will change soon,  given the revelations, the level of discussions and recommendations at this maiden edition of Sanofi Diabetes Summit.