Cost Burden of Diabetes Melitus on Nigerian Patient

Cost Burden of Diabetes Mellitus on the Nigerian Patient
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Abstract
According to WHO, diabetes is among the leading cause of mortality globally. The most common types of diabetes include juvenile diabetes, diabetes mellitus, prediabetes, and gestational diabetes. The cross-cutting nature of diabetes makes patients vulnerable to communicable and non-communicable complications. Diabetes imposes a global economic burden on the global economy regarding direct medical costs, premature mortality, negative impact on a country's gross domestic product, and indirect cost associated with productivity loss. The direct medical cost associated with diabetes comprises outpatient and emergency care, self-monitoring expenses, medication, medical supply, long-term care, and in-patient care. In this regard, developing countries such as Nigeria incur a large portion of the diabetes health expenditure burden than high-income countries such as America. Besides the economic burden on the national economy and the healthcare system, diabetes can impose catastrophic medical expenditure on patients and families, resulting in out-of-pocket or cash healthcare payments and the loss of family income. This write-up will explore the complications, symptoms, and risk factors related to diabetes, diabetes mellitus in Nigerian patients, IDF Diabetes Atlas 2021 Nigeria, diagnosis criteria for diabetes, and FDA-approved drugs and insulin for treating diabetes. The paper further discusses the financial burden of diabetes mellitus in Nigeria and a diagonal approach to the healthcare sector in Nigeria and other developing countries.
Diabetes
Poorly controlled diabetes seriously affects kidneys, feet, eyes, blood vessels, nerves, and the heart. Type 2 diabetes is the most prevalent caused by the body becoming resistant to insulin or when the body does not make enough insulin (Zheng et al., 2018). In this regard, diabetes mellitus has risen drastically over the past three years in both developed and developing countries. On the other hand, Juvenile diabetes, also called type 1 or insulin-dependent diabetes, is a condition where the pancreas produces little or no insulin. In the United States, approximately 62 million people have diabetes (Roglic, 2016). Other forms of diabetes include prediabetes, where the glucose levels in the bloodstream are extremely high and can be mistakenly diagnosed as diabetes mellitus. Gestation diabetes develops in particular women during expectancy and goes away after delivery. Other types of diabetes that rarely occur include cystic fibrosis-related diabetes, diabetes insipidus, monogenic diabetes syndromes, and drug or chemical-induced diabetes.
The first WHO Global Diabetes Report approximates 422 million people worldwide in both developing and developed countries with a chronic disease. In 2012 alone, roughly 1.5 million mortality indexes were directly tied to diabetes. For people with diabetes, access to affordable treatment and insulin is vital for survival. In 2019, the 6th leading cause of death in the U.S. was diabetes, with an estimated 244,084 deaths (Saeedi et al., 2019). The ninth edition of Diabetes Atlas estimated that 62 million people in the U.S. are diabetic, indicating a threefold increase in new cases since 1980. The number is anticipated to reach 109 million in 20 years-period. Additionally, diabetes is the second leading disability-adjusted life years cause that explains the complications people living with diabetes suffer throughout their lives. Therefore, the prevalence of diabetes has been rising drastically in developing countries such as Nigeria compared to high-income countries.
Causes, Symptoms, Risk Factors, and Complications of Diabetes
Risk aspects that boost an individual's vulnerability of acquiring diabetes differ depending on the type of diabetes you ultimately develop. The cause of diabetes, regardless of its kind, is high blood sugar circulating in the bloodstream. Type 1 diabetes is an immune system disease resulting from a virus or a certain genetic composition that makes the body attack and destroys the cells that produce insulin. In this case, high glucose levels build up in the bloodstream without insulin to allow glucose to enter the body cells (Ogle et al., 2022). In type 1 diabetes, genes or a virus can trigger the immune system attack. In prediabetes and diabetes mellitus, the body cells resist insulin to work as they should, allowing glucose into its cells. Therefore, the pancreas cannot keep up with the immune resistance resulting in high glucose levels in the body. Resistance to insulin by body cells is also evident in gestational diabetes due to hormones produced by the placenta. In this regard, the pancreas cannot withstand the resistance, and too much blood sugar is available in the bloodstream.
The symptoms associated with diabetes include slow healing of sores or cuts, dry mouth, frequent urination, weak or tired feeling, increased thirst, numbness and tingling in the fingers and toes, recurring unexplained infection, blurred vision, and unexpected weight loss (Zheng et al., 2018). Insulin-dependent diabetes symptoms can develop quickly in a few months or weeks. Additional symptoms in women include frequent yeast infections, dry and itchy skin, and urinary tract infections. The symptoms for men comprise decreased muscle strength, low sex drive, and erectile dysfunction. Signs and symptoms of insulin-compliance diabetes begin at a tender age as a child, teen, or young adult. Additional symptoms include urinary tract infection, nausea, stomach pains, and vomiting. In gestational diabetes, the obstetrician will test for the condition between 24 and 28 weeks of pregnancy, in which one will not notice symptoms (Johns et al., 2018). In diabetes mellitus and prediabetes, the symptoms develop slowly over several years. Therefore, one may not have symptoms at all or may not even notice them.
Risk factors for juvenile diabetes include injury or inflammation to the pancreas due to surgery, infection, accident, or tumor and having a family history of a parent or sibling with insulin-dependent diabetes. Other factors include exposure to illnesses caused by a virus, the presence of autoantibodies that attack body organs and tissues, and physical stress (Ogle et al., 2022). Risk factors for diabetes mellitus and prediabetes include racial ethnicity being Native American, Pacific Islander, black, Hispanic, or Asian-American (Zheng et al., 2018). Type 2 diabetes mellitus is also triggered by low HDL cholesterol and high triglyceride level, being overweight or obese, having a family history, having high blood pressure, being 45 years and older, being a smoker, having gestational diabetes, being physically inactive, having a history of heart stroke or disease, and having the polycystic ovarian syndrome. Lastly, risk factors for gestational diabetes include being obese before pregnancy, having a family history, and being Native American, Hispanic, Asian-American, or Black (Johns et al., 2018).
Some complications of diabetes as a result of blood sugar remaining high over a prolonged period can cause damage to body organs and becomes life-threatening. The longer a patient has diabetes without measures to control the blood sugar, the higher the risk of contracting other communicable and non-communicable complications. Several complications accompany the chronic disease, including neuropathy or nerve damage that causes tingling and numbness in the toes and fingers (Papatheodorou et al., 2018). The high blood sugar level in the bloodstream damages the walls of capillaries that distribute nourishment in the body, resulting in a tingling and burning sensation at the toes and fingers, gradually spreading upwards to the rest of the body. Another complication is cardiovascular issues ranging from high cholesterol atherosclerosis, chest pain, hypertension, heart attack, coronary artery disease, and stroke. The third complication is nephropathy which results in kidney failure, the need for a kidney transplant, or frequent dialysis schedules. The kidneys comprise millions of glomeruli that filter waste from the blood, whereby high glucose composition in the bloodstream damages this delicate filtering system. Thirdly, type 2 diabetes elevates the risk of dementia and Alzheimer's disease. The fourth complication is retinopathy, which leads to eye damage, cataracts, blindness, and glaucoma.
The fifth complication is foot ulceration due to poor blood flow, nerve damage, and poor healing of cuts and sores, which can eventually lead to amputation. Additionally, diabetes makes the patient prone to skin and mouth conditions associated with bacterial and fungal infections. Other complications include hearing loss, depression, dental problems, and erectile dysfunction. Complications related to gestational diabetes result from uncontrolled blood sugar levels that harm the mother and the child. Complications to the baby shortly after birth include hypoglycemia because their insulin production is high, resulting in low blood sugar (Johns et al., 2018). Excess growth caused by excess glucose crossing the placenta triggers the baby's pancreas to make extra insulin. This results in difficulties when giving birth. Other complications include death before or shortly after birth and the onset of diabetes mellitus and obesity later in life. Complications to the mother include preeclampsia resulting from too much protein in the urine, high blood pressure, and swollen legs and feet. Additionally, the mother is prone to having gestational diabetes again with the next pregnancy.
Diabetes Mellitus on Nigerian Patients
Nigeria is located in the western part of Africa, with the seven largest population in the world, amounting to approximately 200 million. Data from the United Nations suggest that the northwestern region of Nigeria is densely populated, with an estimated 45 million among the six geopolitical zones in the country. According to the National Population Commission of Nigeria, 65% of the population dwells in rural areas, whereas 36% is in an urban setting (Adeloye et al., 2017). In 2010, the United Nations estimated that 50.2 Nigerians lived in rural areas, whereas 49.4% dwelled in metropolitan areas. Type 2 diabetes is a digestive-absorption disorder of hyperglycemia resulting from insulin resistance or deficiency in the body organs caused by disturbances to fat, carbohydrate, and protein metabolism. Based on previous studies, diabetes mellitus has indicated a drastic increase in prevalence in terms of doubled demographic statistics in its epidemiology.
On the other hand, populations not affected by type 2 diabetes in previous years are now reporting high prevalence levels, which becomes an economic burden to health financing by individual patients and government agencies (Mapa-Tassou et al., 2019). According to IDF, the prevalence of diabetes mellitus worldwide is 425 million people, whereby nearly 50% of the population is undiagnosed. In this regard, a greater population of African and Asian origin contributes a significant fraction of the figure.
Extensive research conducted in Nigeria indicates that increased cases of diabetes are prevalent in urban areas compared to rural places, whereby 0.8% of cases are in rural places and over 8% for urban dwellers in Lagos. Therefore, the Nigerian prevalence rate contributes to an average of 2.2% globally. The sixth edition of the IDF Atlas indicates that Nigeria has the most diabetic individuals in Africa (da Rocha Fernandes et al., 2016). Nigeria is one of the forty-eight countries of IDF Africa. In this regard, the total population of Nigeria is 96,812,400 adults, whereby the real cases of diabetes among adults is 3,623,500, which is 3.7% of the total adult population. Currently, 537 million people in the world have diabetes, whereby 24 million of the population are of African origin.
The Diabetes Association of Nigeria(DAN) has chapters in every federation state and was founded in Benin twenty-six years ago. The association comprises people with diabetes and healthcare providers who specialize in diabetes. DAN is in partnership with other professional bodies, such as the Nigerian chapter of the AACE, the Society for Diabetes Educator of Nigeria, and the Nigerian society of endocrinologists and metabolism NSEM. The organization's main focus is to disseminate diabetes information, promote the illness-wellness continuum of diabetic individuals in Nigeria, and improve the disease’s treatment (Salawu et al., 2018). DAN organizes several activities, including administering research funds for diabetes mellitus, public screening on diabetes, and encouraging and facilitating the creation of the branches, units, and chapters of DAN in Nigeria. It is also responsible for developing awareness initiatives and educational programs to give people living with diabetes a better understanding of their conditions. Others include organizing inter-school debate competitions on diabetes, advocacy visits and audio and video documentaries, and public education about early recognition and the importance of treatment.
IDF Diabetes Atlas 2021 Nigeria
According to the 10th edition of IDF Diabetes Atlas 2021 in Nigeria, people living with diabetes are 3.6 million, which is projected to be 4.9 million in 2030. The age-adjusted comparative prevalence of diabetes is at 3.6% and is projected to be 3.7% in 2030 (Saeedi et al., 2019). People with undiagnosed Diabetes in Nigeria in 2021 was approximately 1.9 million, whereas the proportion of people with undiagnosed diabetes is 53.3%. Patients with Impaired Glucose Tolerance between 20-79 years is about 9.4 million, whereas the age-adjusted comparative prevalence of IGT is 11%. The number of patients with Impaired Fasting Glucose in Nigeria is approximately 4.9 million, with an age-adjusted majority of 4.9%.
Additionally, the mortality attributed to diabetes between 20-79 years is roughly 48 thousand, and the statistics of diabetes-related mortality for people under 60 years is 4.5%. In the Nigerian demographic data, the total population of children and adolescents is approximately 144 million. Insulin-dependent diabetes for children and teenagers between 0-14 years is 1600, whereas 0-19 years at 3800 (Sun et al., 2022). Diabetes-related health expenditure in 2021 was approximately 1.8 million USD, whereas ID million's total related health expenditure was 5.0. Conversely, the diabetes-related health expenditure per person is 499.7 USD, whereas for person ID at 1390.0. Lastly, the prevalence of gestational diabetes mellitus for pregnant women between 20-49 years is 18.2%.
Diagnostic Criteria for Diabetes
When checking blood sugar levels, healthcare providers administer several blood tests to diagnose diabetes. Several tests are used to diagnose diabetes or restrict blood glucose levels, including hemoglobin A1c, oral glucose tolerance, fasting glucose, and casual glucose tests. An HbA1c of 48mmol/mole, which is 6.5 percent, is recommended as an appropriate limit for testing for diabetes mellitus (Sherwani et al., 2016). A value less than 6.5 percent does not limit or exclude diabetes tests using a glucose test. In this regard, HbA1c tests should be used when the healthcare provider demonstrates that they can match the required quality assurance results in the laboratory within the national quality assurance scheme. For patients without diabetic symptoms, the laboratory HbA1c venous should be redone. In this case, if the second sample is six point five percent, the patient should be considered at high risk of contracting diabetes, and a healthcare provider should repeat a test after six months. Conversely, situations that are not appropriate for conducting the HbA1c test include patients taking medication that cause rapid glucose rise, patients suspected to have juvenile diabetes, patients with acute pancreatic damage, children and young people, and in pregnancy. Other limitations include patients with hematologic, genetic, and illness-related factors influencing the HbA1c test, patients at high risk but accurately ill, and patients with diabetic symptoms for less than two months.
The American Diabetes Association describes a fasting plasma glucose test as an examination to check blood sugar levels when the patient is fasting. (American Diabetes Association (ADA), 2018). Fasting means foregoing food substances, drinks, or food at least 8 hours before the test. On most occasions, a fasting plasma glucose test is conducted early in the morning before the patient eats breakfast. In this case, diabetes is diagnosed at a fasting plasma sugar level of 126mg/dl.
The Oral Glucose Tolerance Test (OGTT) checks the blood sugar level within a time limit of two hours before and after taking a sweetener. The test tells the healthcare provider how a patient's body processes or breakdown sugar (Pippitt et a., 2016). Therefore, diabetes is diagnosed at OGTT blood of 200mg/dl or more. The normal OGTT is less than 140 mg/dl, whereas, for prediabetes, it ranges from 140mg/dl to 199mg/dl. In the Casual Plasma Glucose Test, a blood test is conducted in situations where the patient has severe conditions or as a routine at any time of the day. For this test, diabetes is diagnosed with a blood sugar of 200mg/dl or more. Lastly, blood and urine samples are tested if the healthcare provider suspects type 1 diabetes in a patient. The urine is checked for ketones, whereas the blood is checked for antibodies.
FDA-Approved Oral Drugs to Treat Diabetes
The keys to managing your diabetes include exercising regularly, taking insulin and medications prescribed by healthcare providers, quitting smoking, and monitoring blood glucose levels at home. Others include achieving a healthy weight, keeping your appointment with healthcare providers, having lab tests, and following a healthy meal plan. Oral medications and insulin work to treat diabetes by slowing down the release of glucose in the liver helps get rid of excess glucose in the bloodstream. It does this through frequent urination, stimulating the pancreas to increase insulin release, and blocking the breakdown of carbohydrates to make body tissues sensitive to insulin. The Food and Drug Administration has approved over 40 medications to treat and manage diabetes. The healthcare providers are responsible for deciding the right medicines for a patient.
Some drugs for treating diabetes include Glinides or Meglitinides, which trigger the pancreas to release more insulin that is later used to lower blood glucose. Examples of Meglitinides include Starlix R and Prandin R. Alpha-glucosidase inhibitors are responsible for reducing absorption in the ileum and delaying the breakdown of carbohydrates during digestion. An example of an Alpha-glucosidase inhibitor is Precose R (Gourgari et al., 2017). Thirdly, sulfonylureas, like Meglitinides, stimulate the pancreas, releasing more insulin and lowering blood glucose. Examples of the drug include DiaBeta, Amaryl, Glucotrol, glyburide, Micronase, and glipizide. Biguanides are the fourth FDA-approved drug that reduces the glucose the liver produces in the body and slows down the conversion of carbohydrates to sugars. An example of Biguanides is Metformin with the trade name Glucophage. Fifthly, Thiazolidinedione manages how insulin accesses body systems by allowing more glucose to enter the liver, fatty cells, and muscles. Examples of Thiazolidinedione include Actos and Avandia. Bile acid sequestrants are the sixth FDA-Approved drugs. They work by lowering blood sugar levels and cholesterol; examples include colesevalam, cholestyramine, and Colestid.
Other FDA-Approved drugs for managing diabetes include Dopamine agonist that regulates the release of glucose by the liver. An example is bromocriptine with the trade name Cyclocet. Glucagon-like peptide-1 receptor agonists work to lower blood sugar levels by delaying the metabolism of food in the stomach and regulating glucose release from the liver after meals. Examples of Glucagon-like peptide-1 receptor agonists include Rybelsus, Trulicity, Tanzeum, Victoza, and Byetta. Sodium-glucose cotransporter2 inhibitors work to excrete excess blood sugar in the kidneys through urine (Gourgari et al., 2017). Examples include Jardiance, Invokana, and Farxiga. Lastly, DPP-4 inhibitors, like Tradjenta, Nesina, saxagliptin, Onglyza, and Januvia, enable the pancreas to release more insulin after meals. Examples include.
FDA-Approved Insulin Medications to Treat Diabetes
There are several types of insulin for insulin that are combined with oral medications in managing diabetes. The patient and the healthcare provider decide on the right delivery method based on insurance coverage, lifestyle, preference, and insulin needs (Shah et al., 2016). Among the insulin types for managing diabetes include short-acting insulin that takes about thirty minutes to reach the bloodstream and reaches its peak within three hours, lasting six hours. An example of short-acting insulin is insulin regular with the trade name Humulin. The second type of insulin is a long-acting insulin that works to stabilize and regulate the blood sugar level all day. Examples include Lantus, Tresiba, Basadlar, and Levemir. Rapid-actin insulins are the third type, taken fifteen minutes before meals, responsible for lowering blood glucose within an hour and have a lasting effect of two to four hours. Examples include Humalog, Novolog, and Apidra. Lastly are intermediate-acting insulins that reach the bloodstream within two to four hours and have lasting effects for up to 18 hours. An example is NPH.
Additionally, several methods deliver insulin in the bloodstream to lower high blood sugar levels. One of these methods is needle and syringe, where one inserts a needle into a vial of insulin and pull the syringe to draw the proper dosage using the needle. One then injects insulin into the upper arm, belly, buttocks, or thighs. It is administered once or several shots daily to regulate glucose levels in the blood. The second method is the jet injector, an insulin delivery method that does not use needles but rather high pressure through the skin. The third method is an insulin inhaler that allows the patient to breathe a powdered inhaler through the mouth (Mohanty & Das, 2017). Once the insulin is inhaled into the lungs, it slips into the bloodstream, which is only approved for adults with diabetes mellitus and juvenile diabetes.
The fourth delivery method is through an insulin pump, a portable computerized device worn under the clothes, on the belt, or in the pocket. The insulin pump delivers rapid-actin insulin within twenty-four hours through a cannula. The cannula should be replaced every two to three days to prevent infection at the administration site. In other cases, the insulin pump is attached to the skin and does not require tubes (Shah et al., 2016). The fifth delivery method is the insulin injection port, which incorporates placing a small delivery tube underneath the skin held in place by an adhesive patch. The port provides a site for injecting insulin instead of having injections at several sites in the body.
Additionally, an artificial pancreas links a glucose monitor to an insulin pump which acts as a pancreas backup. In this case, the glucose monitor test for blood sugar every five minutes and delivers the appropriate insulin dosage to the bloodstream. Lastly, an insulin pen is a pen-like delivery system that comes prefilled with insulin inserted and replaced after use. Other treatment options involve surgery, especially for patients with diabetes mellitus and obesity, where bariatric surgery is where much-improved blood glucose levels are viable.
The Burden of Diabetes Mellitus in Nigeria
Diabetes’s burden is growing in Africa. It is estimated that the African region will have the biggest percentage of people living with diabetes at 143% from 2019-2045 (Uloko et al., 2018). Similarly, there has been a drastic rise of new diabetes mellitus cases in adults in Nigeria, even in populations that had not previously reported. Vast literature reports a prevalence rate between 0.8-4.4% in rural areas and 4.6-7% in urban areas in Nigeria. A recent systemic meta-analysis of diabetes mellitus among Nigerians reported a pooled prevalence of 5.8%. In this case, approximately 8.2 million Nigerians had impaired glucose tolerance in 2019, which is expected to escalate in 2030. Impaired glucose reliance is a great risk, given that impaired glucose tolerance leads to the future development of diabetes mellitus and heart diseases. Therefore, diabetes mellitus has become a significant cause of morbidity and mortality in Nigeria and the world (Agofure et al., 2020). The leading causes of diabetic mortality and morbidity comprise diabetic foot ulceration, chronic kidney disease, stroke, and hyperglycemic emergencies.
Several risk factors are listed for the cause of the high prevalence of diabetes mellitus in the country, including urbanization an...