https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/03/11/diabete-africain
An atypical form of diabetes prevalent in African populations, but with no known cause
By Nathalie Côté, Kassandra Dignard, & Elena Hunt
March 11, 2024
istockphoto.com/pecaphoto77
Providing culturally competent care is of great importance, and the treatment of diabetes in Canada’s ethnocultural populations involves understanding their culture and physiology.
Takeaway messages
- It’s important that we understand “African diabetes” and how it differs from other types of diabetes.
- The role of the nurse consists of recognizing African clients at risk — with the aim of intervening preventively with close monitoring during treatment — because rapid improvement under insulin can cause numerous hypoglycemias.
- Treatment includes an initially aggressive process, followed by the application of standard type 2 diabetes management to achieive potential remission.
Usually, when an article focuses on African-Canadian clients, we mainly think about culture, beliefs, and lifestyle habits. This article, however, will highlight an atypical diabetes, a little-known pathophysiology in this clientele.
In 2021, approximately 10 per cent of Canadians were diagnosed with type 1 or type 2 diabetes (Diabetes Canada, 2021). The prevalence of the disease has been increasing steadily for several years and is expected to affect 12 per cent of Canadians by 2031 (Diabetes Canada, 2021).
If the diabetic person does not receive an early diagnosis and the right treatment, the risks of complications have significant repercussions on those affected. Complications also represent a significant financial burden, costing the Canadian health-care system almost $4 billion in 2021 (Diabetes Canada, 2021).
African immigrants have the highest prevalance of diabetes (Diabetes Canada, 2021). Some studies, including those by Belhadi et al. (2007) and Bavuma et al. (2019), showed that not all Africans responded to typical treatments for type 1 diabetes. This finding calls into question the measures to be taken for adequate treatment and awareness of this clientele.
Let’s start by reviewing what we know about the different types of diabetes.
Types of diabetes
Diabetes is a chronic disease characterized by the presence of abnormally high blood sugar levels, attributable to a reduction in insulin secretion or its effectiveness. Insulin is a hormone that allows cells to use glucose for energy, a process essential for the proper functioning of the body. Insulin and glucose must be within a range of acceptable physiological values; otherwise, the disease sets in insidiously.
It is important to be able to distinguish the type of diabetes, once it is detected, in order to choose the treatment that will prove most effective. In the long term, uncontrolled blood sugar levels linked to diabetes is associated with several specific microvascular complications, affecting the eyes, kidneys, and nerves, as well as an increased risk for cardiovascular disease (Diabetes Canada, 2018).
Type 1 diabetes
Type 1 diabetes occurs when the pancreas is unable to produce insulin; people who suffer from it are called insulin dependent. This diabetes is associated with an immune process of destruction of the beta cells of the pancreas, causing hyperglycemia, which can lead to ketoacidosis.
Ketoacidosis is characterized by the accumulation of ketone bodies in the blood, attributable to the breakdown of fats, as the body draws on its fatty tissue reserves to obtain the energy it needs. This process is the result of a lack of cellular glucose, meaning that blood glucose cannot be transferred from the blood to the cells owing to the absence of insulin.
Ketoacidosis can cause serious symptoms including nausea, vomiting, abdominal pain, confusion, and loss of consciousness (Diabetes Canada, 2018).
Type 2 diabetes
Type 2 diabetes affects 90 per cent of the population with diabetes (Diabetes Canada, 2021). It occurs when the pancreas cannot secrete enough insulin, or when the body does not use the secreted insulin efficiently.
Unlike type 1, this type of diabetes is not characterized by the presence of anti-islet antibodies. It can appear at any age, but more frequently after the age of 30. It is generally treated by lifestyle modification and the addition of oral hypoglycemic agents, and sometimes requires the use of insulin therapy to prevent hyperglycemia (Diabetes Canada, 2018).
Gestational diabetes
Gestational diabetes occurs during pregnancy and is caused by glucose intolerance that often resolves after delivery (Diabetes Canada, 2018).
Atypical diabetes
Rarer types of diabetes are identified as “atypical.” They are attributable to other diseases, to the use of medications, or to genetic origin (Diabetes Canada, 2018).
The incidence of diabetes in African and Canadian populations
According to the World Health Organization (2016), 10 per cent of the population of South Africa has diabetes.
The health problems of the African population have long been associated with communicable diseases. But in recent years, there has been an increase in non-communicable conditions such as cardiovascular disease and diabetes, which accounted for 44 per cent of deaths in South Africa in 2016 (WHO, 2016).
In Canada, despite efforts toward prevention, many people suffer from diabetes. Many immigrants are part of this group, particularly South Asian, Chinese, and Black populations, all of whom are at high risk for developing diabetes (Diabetes Canada, 2021).
In Canada, the mortality rate of people with diabetes is twice that of people without diabetes (Diabetes Canada, 2021).
The scale of the phenomenon, incidence, and prevalence of diabetes within the Canadian population of African origin requires knowledge and awareness on the part of all health-care professionals.
What is the origin of “African diabetes”?
This type of diabetes was observed in the early 1980s in Africa and is now known by various names, such as “African diabetes,” diabetes type 1B, and idiopathic or ketosis-prone diabetes (Belhadi et al., 2007). It mainly affects African adolescents and adults. Some of them are found in North America and Europe (Belhadi et al., 2007; Bavuma et al., 2019).
Despite its name, cases of this form of diabetes, with a similar symptomatic presentation, have also been reported in Asian and White populations (Belhadi et al., 2007). The causes are unknown, and the disease is more significant in Black populations of immigrant African origin, although the prevalence of this type of diabetes has been noted in 30 per cent of Africans in Cameroon (Bavuma et al., 2019).
A study by Njuieyon et al. (2010) demonstrated that this type of diabetes also exists in the African pediatric population. This condition requires special attention, since it can be confused with type 1 diabetes, which differs in its course and treatment.
How does “African diabetes” differ from other types of diabetes?
This type of diabetes presents with severe ketone hyperglycemia that requires emergency treatment, such as hydration and intravenous insulin. The clinical picture seems specific to type 1 diabetes, but its evolution and subsequent manifestations are more similar to type 2 diabetes.
The results of blood tests do not demonstrate the anti-glutamic acid decarboxylase (GAD) antibodies that would identify type 1 diabetes. After several weeks of treatment and the stabilization of blood sugar, insulin therapy causes repeated hypoglycemia, which raises the question of the typical treatment for type 1 diabetes.
The progression of type 1 diabetes allows the use of subcutaneous insulin, but also treatment with oral hypoglycemic agents or, in the long term, simple dietary control. The approximate duration of the acute period of this form of diabetes varies from 6 to 72 months (Choukem et al., 2013). It is then described as diabetes having symptoms that begin quickly, requiring high-level treatments like those for type 1 diabetes, but which is subsequently treated like type 2 diabetes (Belhadi et al., 2007).
A study by Lontchi-Yimagou et al. (2018) compared the inflammatory ratio in patients with “African diabetes” in the keto phase against those after the keto phase and those with type 2 diabetes (n=72). The result demonstrated that there is a greater pro-inflammatory reaction in the ketone phase in patients with this type of diabetes compared to the two other groups whose pro-inflammatory ratio was lower and comparable.
The pro-inflammatory reaction could induce a decrease in insulin secretion by the beta cells of the pancreas, contributing to the production of ketones in the body. However, we recommend further research to better understand inflammatory reactions during the various phases of the disease.
A cross-sectional study by Balti et al. (2015), which sampled 172 participants, focused on different metabolic, genetic, and viral factors that could be associated with the presence of ketone-prone diabetes. The study showed no association between genetic profile and susceptibility to a ketoacidosis reaction in people with antibody-negative type 2 diabetes.
Further research is required to better understand “African diabetes” and to consider its prevention and adequate treatment.
Prevention and nursing interventions
Providing culturally competent care is of great importance, and the treatment of diabetes in Canada’s ethnocultural populations involves understanding their culture and physiology.
Myths surrounding diabetes reinforce stigma. This is why it is important to improve understanding of diabetes among African immigrant populations in Canada, and subsequently to guide prevention strategies aimed at reducing the burden of the disease.
Despite the growing interest among scientists in diabetes that affects the African population, little research has focused on this population group (Bakombo & Laperrière, 2017). Yet, the mobilization of nursing staff in managing this disease, and the transmission of knowledge, are gaining momentum.
Prevention is the first step in detecting patient risk factors. Primary care nurses who manage African clients with abnormal blood sugar levels will have to adapt their intervention by recognizing the symptoms of “African diabetes.”
Clinical cases presenting with a polyuric–polydipsic syndrome as well as weight loss require urgent insulin treatment (Belhadi et al., 2007).
Emergency care nurses who treat African patients presenting in a ketone state must ensure, once blood sugar is controlled by insulin and the ionic disorders have been corrected, that they are referred to a medical team for longitudinal monitoring.
Close monitoring is required in order to control blood sugar levels and avoid hypoglycemia, which is also common, and which may be followed by progression toward remission once blood sugar levels have stabilized (Bavuma et al., 2019). Once the crisis is resolved, treatment is identical to that of type 2 diabetes. Nurses must provide awareness and support to promote patients’ independent management of diabetes so that blood sugar levels of people with “African diabetes” are controlled.
The integration of oral anti-hyperglycemic medications and awareness regarding self-management of lifestyle (healthy diet, physical exercise program, and self-monitoring of blood sugar) are part of the therapeutic process (Diabetes Canada, 2021; Bavuma et al., 2019).
Conclusion
Type 2 diabetes is a major health problem in Canada, and it is more pronounced in people of African origin. “African diabetes” needs to be understood by health-care professionals because its treatment differs from that of type 1 diabetes, even though its initial presentation is similar. This type of diabetes requires special attention to blood sugar levels to prevent serious hypoglycemia and avoid dire consequences.
To better understand the types of diabetes and treatment management in this population, it is imperative to direct research on the African population who immigrate to Canada. Continuing research can help reduce the risks of complications and mortality related to diabetes in this clientele.
References
Bakombo, S., & Laperrière, H. (2017). Cultural sensitivity in diabetic interventions among African and Caribbean immigrants in Canada: a systematic review. University of Ottawa. https://ruor.uottawa.ca/handle/10393/36627
Balti, E.V., Ngo-Nemb, M.C., Lontchi-Yimagou, E., Atogho-Tiedeu, B., Effoe, V.S., Akwo, E.A., … Sobngwi, E. (2015). Association of HLA class II markers with autoantibody-negative ketosis-prone atypical diabetes compared to type 2 diabetes in a population of sub-Saharan African patients. Diabetes Research and Clinical Practice, 107(1), 31–36. https://doi.org/10.1016/j.diabres.2014.10.002
Bavuma, C., Sahabandu, D., Musafiri, S., Danquah, I., McQuillan, R., & Wild, S. (2019). Atypical forms of diabetes mellitus in Africans and other non-European ethnic populations in low- and middle-income countries: a systematic literature review. Journal of Global Health, 9(2). https://doi.org/10.7189/jogh.09.020401
Belhadi, L., Chadli, A., Bennis, L., Ghomari, H., & Farouqi, A. (2007). Diabète atypique avec tendance à la cétose ou diabète « africain » : à propos de deux cas. Annales d’endocrinologie, 68(6), 470–474. https://doi.org/10.1016/j.ando.2007.005
Choukem, S., Sobngwi, E., Boudou, P., Fetita, L., Porcher, R., Ibrahim, F., … Gautier, J.-F. “[Beta]- and [alpha]-cell dysfunctions in Africans with ketosis-prone atypical diabetes during near-normoglycemic rémission.” Diabetes Care, 36(1), 118–123. https://doi.org/10.2337/dc12-0798
Diabetes Canada. (2018). Definition, classification and diagnosis of diabetes, prediabetes and metabolic syndrome. Canadian Journal of Diabetes, 42, S10–S15. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Health-care-providers/2018%20Clinical%20Practice%20Guidelines/Ch3-Definition-Classification-and-Diagnosis-of-Diabetes-Prediabetes-and-Metabolic-Syndrome.pdf
Diabetes Canada. (2021). Diabetes in Canada: Backgrounder. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2021_Backgrounder_Canada_English_FINAL.pdf
Lontchi-Yimagou, E., Boudou, P., Nguewa, J.L., Noubiap, J.J., Kamwa, V., Djahmeni, E.N., … Sobngwi, E. (2018). Acute phase ketosis-prone atypical diabetes is associated with a pro-inflammatory profile: a case-control study in a sub-Saharan African population. Journal of Diabetes and Metabolic Disorders, 17(1), 37–43. https://doi.org/10.1007/s40200-018-0336-8
Njuieyon, F., Guilmin Crepon, S., Bismuth, E., Carel, J.C., & Tubiana Rufi, N. (2010). P17 Le diabète de type 2 cétonurique africain existe aussi chez l’enfant. Diabetes & Metabolism, 36, A43–A44. https://doi.org/10.1016/S1262-36(10)70165-8
World Health Organization. (2016). Diabetes South Africa 2016 country profile. https://cdn.who.int/media/docs/default-source/country-profiles/diabetes/zaf-fr.pdf?sfvrsn=f529a483_36&download=true
Nathalie Côté, BScN, CDE, MScN, PIA, is a nurse specialist in diabetes and clinical head nurse at Centre francophone du Grand Toronto.
Kassandra Dignard, RN, BScN, MScN, is a teaching coordinator at Monfort Hospital, Ottawa.
Elena Hunt, BScN, MScN, PhD, holds a licence in economics and is a professor emeritus at Laurentian University.
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