For decades, the African continent was known as the land of famine where many lives were lost because of drought and precarious food production systems. In recent years, Sub-Saharan Africa has experienced remarkable economic growth, leading to an improvement in the living conditions of its inhabitants. Modernisation and economic development have resulted in profound changes in African societies, which have adopted Western lifestyles, especially in urban areas. A direct consequence of westernisation in Africa is the increased prevalence of risk factors associated with non-communicable diseases (NCDs) such as tobacco use, physical inactivity, harmful use of alcohol and an unhealthy diet. As a result, NCDs like diabetes, cardiovascular diseases (CVDs) and cancers are rising rapidly and projected to surpass communicable, maternal, perinatal and nutritional diseases as the most common causes of death by 2020 in Africa.⁽²⁾

Previously, diabetes mellitus (DM) was said to be “very uncommon” in Africa.⁽³⁾ However, DM is now considered to be an epidemic with devastating consequences - to the extent that some epidemiologists predict that the economic impact of diabetes, as well as the consequent death toll, will surpass the ravages of HIV and AIDS in the near future.⁽⁴⁾ Is the African continent ready to face this public health issue? After reviewing the specificity of African diabetes in terms of epidemiology and major risk factors, this paper, which is part one of a two-part series, assesses the preparedness of health systems in Sub-Saharan Africa to respond to the diabetes epidemic.

What is diabetes mellitus?

DM comprises a heterogeneous group of metabolic diseases that are characterised by chronic hyperglycaemia (high blood sugar) and disturbances in carbohydrate, lipid and protein metabolism resulting from defects in insulin secretion and/or insulin action.⁽⁵⁾ Insulin is a hormone produced by the pancreas, which regulates blood sugar level by causing body cells to absorb glucose from the blood. Hyperglycaemia is largely responsible for the acute, short-term and late complications of DM that affect all body organs and systems.⁽⁶⁾

The two main types of DM are type 1 and type 2 diabetes:

Type 1 diabetes mellitus (T1DM) is often called insulin-dependent or juvenile-onset diabetes. Although it can affect people of any age, it typically develops in children or young adults. People with T1DM need injections of insulin every day to survive.⁽⁷⁾

Type 2 diabetes mellitus (T2DM), sometimes referred to as non-insulin dependent diabetes or adult-onset diabetes, is usually diagnosed after the age of 40, though it can occur earlier. Often, the disease may remain undiagnosed for many years, and the diagnosis is then made from associated complications or through an abnormal blood or urine glucose test.⁽⁸⁾ This type is the main driver of the diabetes epidemic.

Diabetes in Sub-Saharan Africa

Worldwide, there is an increase in the prevalence of NCDs, including diabetes. The developing world is experiencing the biggest increase, and by the year 2025, over 75% of people with diabetes will be residing in developing countries.⁽⁹⁾ In 2000, the prevalence of diabetes in the World Health Organisation (WHO) African Region was estimated at 7.02 million people, including 0.702 million (10%) people with T1DM and 6.318 million (90%) with T2DM. In the same year, about 113,100 people died from diabetes-related causes, 561,600 were permanently disabled, and 6,458,400 experienced temporary disablement.⁽¹⁰⁾The International Diabetes Federation (IDF) then estimated that there would be a 98% increase in the number of adults with DM on the African continent in 2009, with those affected reaching 12.1 million in 2010 and 23.9 million in 2030.⁽¹¹⁾ Today, Africa is the hardest hit region in terms of diabetes-related mortality;⁽¹²⁾ in 2010, mortality attributable to diabetes was estimated at 6% of total mortality.⁽¹³⁾

In a review conducted in 2005, the estimated prevalence of diabetes in Sub-Saharan Africa was 1% in rural areas, up to 5%-7% in urban Sub-Saharan Africa, and between 8% and 13% in more developed areas such as South Africa and among populations of Indian origin.⁽¹⁴⁾ In the Seychelles, between 1989 and 2004, the prevalence of diabetes increased from 6.2% to 9.6% in men and from 6.1% to 9.2% in women.⁽¹⁵⁾ In general, T2DM represents over 90% of diabetes cases in Africa.⁽¹⁶⁾ The prevalence of T2DM in the general population recorded in selected studies at the time ranged from 0.6% in rural Uganda to 12% in urban Kenya; from 0 to 7% in Cameroon, Ghana, Guinea, Kenya, Nigeria, South Africa and Uganda; and more than 10% in Zimbabwe.⁽¹⁷⁾ Meanwhile, the observed prevalence for T1DM ranged from 3.5 per 100,000 persons in Mozambique, to 12 per 100,000 persons in Zambia. Recorded incidence ranged from 1.5 per 100 000 persons per year in Tanzania to 2.1 per 100 000 persons per year in Ethiopia.⁽¹⁸⁾

These figures are likely to have increased substantially, given the increasing adoption of Western lifestyles by African societies; a trend that goes hand in hand with rapid urbanisation.

The issue of complications in African diabetes

Diabetes in Africa is associated with higher complication rates compared to developed countries.⁽¹⁹⁾ Diabetes complications, particularly metabolic disorders and infections, are the main reasons behind the high mortality rates associated with diabetes in Africa.⁽²⁰⁾ Because of limited economic resources and a poor healthcare system, most diabetic patients are diagnosed at advanced stages of disease progression when diabetes-related infections or complications, such as retinopathy, nephropathy, foot ulceration, myocardial infarction and stroke, already exist.⁽²¹⁾

In the review cited above, the recorded prevalence of diabetic retinopathy ranged from 7% in Kenya, to 63% in South Africa; neuropathy ranged from 27% in Cameroon to 66% in Sudan, and the prevalence of microalbuminuria (nephropathy) ranged from 10% in Tanzania to 83% in Nigeria.⁽²²⁾ Furthermore, several reviews have reported the common occurrence of gangrene, infection and sepsis associated with diabetic foot ulcer disease and with trauma to the hand (tropical diabetic hand syndrome) in Sub-Saharan Africa.⁽²³⁾ About 12% of all diabetic patients have foot ulcers, and amputations occur in up to 7% of all hospitalised diabetic patients.⁽²⁴⁾

The above complications have detrimental consequences for the patient, his/her family and, consequently, society as a whole. Diabetic nephropathy is a major concern, given the fact that once a patient reaches the stage of renal failure, therapeutic options are limited. Dialysis and kidney transplantation are almost completely inaccessible to the majority of African patients.⁽²⁵⁾ Diabetic retinopathy is a leading cause of adult blindness, and diabetic neuropathy may lead to lower extremity amputation. Moreover, foot complications are the main cause of prolonged hospital stays for people with diabetes in Africa, and are in turn associated with high mortality.⁽²⁶⁾

A study conducted in 2009 revealed that the presence of complications, along with inadequate glycaemic control, was the major predictor of resource use in T2DM patients in developing countries.⁽²⁷⁾ Resources referred to in this regard include the financial costs associated with visits to specialists, medication, diabetes educator visits and hospitalisation. Furthermore, absenteeism was also identified as an indirect cost of diabetes, specifically incurred by the employer and, on a larger scale, the economy.⁽²⁸⁾ According to the researchers, substantial savings in this regard could be generated through the implementation of strategies of prevention or delay of complications and adequate control of hyperglycaemia.⁽²⁹⁾ Finally, they stated that “the economic consequences of the diabetes epidemic in the developing countries will be particularly dire if diagnosis of patients with type 2 diabetes continues to occur at advanced stages of disease progression.”⁽³⁰⁾

Besides being a major cause of deaths, disabilities and economic losses, DM has the potential to increase the prevalence of certain diseases which are already burdensome in the African context.⁽³¹⁾ For instance, DM is a major contributor to CVDs in Africa. In a study conducted in South Africa, subjects with DM were three to four times more likely to present with a stroke than non-diabetic subjects.⁽³²⁾ Two out of three diabetic patients will die as a result of cardiovascular complications (stroke, heart attack), and approximately 30% of patients treated in cardiovascular intensive care units have DM.⁽³³⁾ The incidence of hypertension in patients with DM is approximately twofold higher than in age-matched subjects without DM.⁽³⁴⁾ Furthermore, studies have shown an increased risk of tuberculosis (TB) infection in individuals with both T1DM and T2DM.⁽³⁵⁾ TB is two to five times more common in people with DM, and the prevalence of multidrug-resistant TB (MDR-TB) is higher amongst diabetics.⁽³⁶⁾ As a result, an increasing prevalence of DM may have a negative impact on TB control, by increasing the number of susceptible individuals in populations where TB is endemic, and making successful treatment harder.⁽³⁷⁾ Lastly, there is evidence of increased risk for Plasmodium falciparum infection in T2DM patients.⁽³⁸⁾ Therefore, by preventing new diabetes cases, public health authorities would help to avoid a number of new TB and malaria cases, as well as CVDs.

Risk factors associated with diabetes in Africa

The increasing prevalence of DM on the African continent can be attributed to a combination of factors. Although some of the risk factors associated with DM in Africa, especially T2DM, are non-modifiable, quite a number of them are modifiable. Therefore, the effective implementation of preventive interventions addressing those modifiable factors could help curb the progression of the diabetes epidemic in many African countries.

Non-modifiable factors: Increasing age, family history and ethnic origin

In Sub-Saharan Africa the prevalence of diabetes increases with age,⁽³⁹⁾ with most reports indicating a peak at the age of 65 years or older in countries with low overall diabetes prevalence, and 55-64 years in countries with moderate to high prevalence rates.⁽⁴⁰⁾ As the diabetes epidemic matures, the age of onset will shift to younger sub-populations, resulting in the emergence of early-onset T2DM.⁽⁴¹⁾ Studies from Sudan and South Africa have reported that a positive family history of DM is an independent risk factor for the disease.⁽⁴²⁾ Furthermore, findings from Tanzania and South Africa show that disease frequency is lower in the indigenous African community than amongst migrant Asian-Indians and a population of mixed ancestry (Southwest African, East Indian and white European).⁽⁴³⁾

Modifiable factors: Urbanisation (diet, physical activity) and obesity

Urbanisation, as well as the migration of populations from rural to urban areas, plays a major role in the increase of diabetes prevalence in Africa.⁽⁴⁴⁾ Sub-Saharan Africa is undergoing the fastest rate of urbanisation worldwide.⁽⁴⁵⁾ Today, the population is predominantly rural, but by 2025, more than 70% of African populations will live in urban areas.⁽⁴⁶⁾ Urbanisation leads to the adoption of the so-called urban or Western lifestyle, characterised by changes in dietary habits involving higher consumption of refined sugars and saturated fat, and a reduction in fibre intake; accompanied by reduced physical activity.⁽⁴⁷⁾ More than 90% of the adult population in Sub-Saharan Africa report an absence of or low physical activity at leisure time.⁽⁴⁸⁾

In the past 20 years, the rates of obesity have tripled in developing countries because of ‘westernisation’, which includes decreased physical activity and the over-consumption of cheap, energy-dense food.⁽⁴⁹⁾ Obesity is also at least 4 times higher in urban areas than in rural areas.⁽⁵⁰⁾ The term ‘diabesity’ is used to highlight the strong link between obesity and T2DM. Indeed, about 90% of T2DM is attributable to excess weight.⁽⁵¹⁾ South African researchers have reported very high rates of obesity (58% to 65%) in diabetic patients compared to their Tanzanian (9.1%) and Sudanese (7.7%) counterparts.⁽⁵²⁾ Studies in Mali, Tunisia, South Africa, Sudan and Egypt have shown higher mean body mass index (BMI) in people with DM as opposed to non-diabetics.⁽⁵³⁾ Moreover, a notable pattern in developing countries is the emerging prevalence of obesity and, specifically, abdominal obesity among children, thus placing them at risk for T2DM in adulthood.⁽⁵⁴⁾ Efforts to address obesity in Sub-Saharan Africa may meet resistance because of the cultural perceptions of body size. For example, a larger body size has many positive connotations in black communities, as it is associated with affluence, health, attractiveness and happiness.⁽⁵⁵⁾

Economic burden of diabetes in Africa

DM exerts a heavy economic burden on society. This burden is related to health system costs incurred by society in managing the disease, the indirect costs resulting from productivity losses due to absenteeism, patient disability and premature mortality, time spent by family members accompanying patients when seeking care, and intangible costs (psychological pain to the family and loved ones).⁽⁵⁶⁾ Diabetes is an expensive disease, especially when the cost of complications is considered, including the many diseases associated with diabetes, as mentioned earlier.⁽⁵⁷⁾ Diabetic patients are more than twice as costly to manage as non-diabetic patients.⁽⁵⁸⁾ The IDF has estimated that, in 2010, national funding for the healthcare of patients with DM in Africa was US$ 111 per person, which already amounts to 7% of national healthcare expenditure.⁽⁵⁹⁾ Kirigia, et al. conducted a study to estimate the economic burden associated with DM in the countries in the African Region.⁽⁶⁰⁾ They found that the total economic cost (direct and indirect) of diabetes in the WHO’s Africa region in 2000 was Int$ 25.51 billion (US$ 67.03 billion), or Int$ 3363 (US$ 8836) per person with diabetes per year (numbers converted from International dollars to their equivalent value in US dollars). It was also estimated that the direct cost of treating diabetes in 2000 ranged from Int$ 876 (US$ 2302) to Int$ 1220.6 (US$ 3207) per person.⁽⁶¹⁾

On the African continent, the economic cost of diabetes and its accompanying complications is unaffordable for most individual patients and their families.⁽⁶²⁾ Often, national funding is limited and government subsidies are insufficient. Consequently, patients and their families may have to spend significant proportions of their income on treatment for diabetes, a level of expenditure that may not be affordable or sustainable.⁽⁶³⁾ In countries with an average yearly income of about US$ 300, the care of a person with DM can cost as much as half or two-thirds of that sum, about half of which is the cost of insulin.⁽⁶⁴⁾ Furthermore, T2DM mostly affects people of working age.⁽⁶⁵⁾ Therefore, a reduction in the economic activity of this group and consequent loss of productivity can be anticipated with an impact on both household and national economies.⁽⁶⁶⁾ Families struggle financially because of the diabetic member’s loss of income.

Conclusion

An increasing prevalence, the preponderance of modifiable risk factors, and a high frequency of complications are the key features of the diabetes epidemic in Africa. Already, serious economic consequences have been reported and, unfortunately, diabetic patients and their families are paying a heavy price. Now more than ever, there is a need for action since the cost of inaction in terms of deaths, disabilities and loss of productivity will far outweigh that of action.

The second part of this series explores the different options available on the African continent to combat this epidemic.

Written by Patrick Ngassa Piotie ⁽¹⁾

NOTES:

(1) Contact Patrick Ngassa Piotie through Consultancy Africa Intelligence’s Public Health Unit (public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) ‘Global status report on noncommunicable diseases 2010’, World Health Organisation, 2011, http://www.who.int.
(3) Cook, A.R., 1901. Notes on the diseases met with in Uganda, central Africa. Journal of Tropical Medicine, 4, pp. 175-178.
(4) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(5) Barnett, P.S. and Braunstein, G.D., 2004. “Diabetes mellitus”, in Carpenter, C.C.J, Griggs, R.C. and Losclzo, J. (eds.). Cecil’s essentials of medicine (6th edition). Saunders: Philadelphia.
(6) Ibid.
(7) International Diabetes Federation website, http://www.idf.org.
(8) Ibid.
(9) Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634.
(10) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6).
(11) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66; Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(12) ‘IDF Diabetes Atlas Update 2012’, International Diabetes Federation, 2012, http://www.idf.org.
(13) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(14) Kengne, A.P., Amoah, A.G.B. and Mbanya, J.-C., 2005. Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601.
(15) Bovet, P., et al., 2009. Diabetes in Africa: The situation in the Seychelles. Heart, 95, pp. 506-507.
(16) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564); Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(17) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(18) Ibid.
(19) Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634; Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(20) Gill, G.V., et al., 2009. A Sub-Saharan perspective of diabetes. Diabetologia, 52, pp. 8-16; Tuei, V.C., Maiyoh, G.K. and Ha, C.E., 2010. Type 2 diabetes mellitus and obesity in Sub-Saharan Africa. Diabetes/Metabolism Research and Reviews, 26, pp. 433-445.
(21) Ringborg, A., et al., 2009. Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: Results from the International Diabetes Management Practices Study (IDMPS). International Journal of Clinical Practice, 23(7), pp. 997-1007; Tuei, V.C., Maiyoh, G.K. and Ha, C.E., 2010. Type 2 diabetes mellitus and obesity in Sub-Saharan Africa. Diabetes/Metabolism Research and Reviews, 26, pp. 433-445.
(22) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(23) Ibid.
(24) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.
(25) Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382; Naicker, S., 2009. End-stage renal disease in Sub-Saharan Africa. Ethnicity & Disease, 19, pp. S1-13-S1-15.
(26) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(27) Ringborg, A., et al., 2009. Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: Results from the International Diabetes Management Practices Study (IDMPS). International Journal of Clinical Practice, 23(7), pp. 997-1007.
(28) Ibid.
(29) Ibid.
(30) Ibid.
(31) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(32) Kengne, A.P., Amoah, A.G.B. and Mbanya, J-C., 2005. Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601.
(33) Ibid.
(34) Ibid.
(35) Young, F., et al., 2009. A review of co-morbidity between infectious and chronic disease in Sub-Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome, and the impact of globalization. BMC Globalization and Health, 5(9).
(36) Sahay, B.K., 2013. “Infections in diabetes mellitus”, in Muruganathan, A. and Geetha, T. (eds). Medicine update 2013 (volume 23).The Association of Physicians of India.
(37) Young, F., et al., 2009. A review of co-morbidity between infectious and chronic disease in Sub-Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome, and the impact of globalization. BMC Globalization and Health, 5(9).
(38) Danquah, I., Bedu-Addo, G. and Mockenhaupt, F.P., 2010. Type 2 diabetes mellitus and increased risk for malaria infection. Emerging Infectious Diseases, 16(10), pp. 1601-1604.
(39) Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634.
(40) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66; Motala, A.A., 2002. Diabetes trends in Africa. Diabetes Metabolism Research and Reviews, 18, pp. S14-S20.
(41) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(42) Ibid.
(43) Ibid.
(44) Ibid.
(45) Ibid.
(46) Kengne, A.P., Amoah, A.G.B. and Mbanya, J-C., 2005. Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601; Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634; Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(47) Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634; Mbanya, J.C.N. et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(48) Kengne, A.P., Amoah, A.G.B. and Mbanya, J-C., 2005.Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601.
(49) Hossain, P., Kawar, B. and El Nahas, M., 2007.Obesity and diabetes in the developing world – a growing challenge. New England Journal of Medicine, 356(3), pp. 213-215.
(50) Sobngwi, E., et al., 2001.Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634.
(51) Hossain, P., Kawar, B. and El Nahas, M., 2007.Obesity and diabetes in the developing world – a growing challenge. New England Journal of Medicine, 356(3), pp. 213-215.
(52) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(53) Motala, A.A., 2002. Diabetes trends in Africa. Diabetes Metabolism Research and Reviews, 18, pp. S14-S20.
(54) Tuei, V.C., Maiyoh, G.K. and Ha, C.E., 2010. Type 2 diabetes mellitus and obesity in Sub-Saharan Africa. Diabetes/Metabolism Research and Reviews, 26, pp. 433-445.
(55) Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(56) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6).
(57) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(58) Zimmet, P., 2003. The burden of type 2 diabetes: Are we doing enough? Diabetes & metabolism, 29, pp. 6S9-6S18.
(59) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(60) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6).
(61) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6); Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(62) Kengne, A.P., Amoah, A.G.B. and Mbanya, J-C., 2005. Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601.
(63) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(64) Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(65) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(66) Ibid.