Diabetes in Underserved Youth. Antoinette Moran, MD University of Minnesota

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1 Diabetes in Underserved Youth Antoinette Moran, MD University of Minnesota

2 In the last 3 years Dr. Moran has Disclosures Served on an DSMB for Novo Nordisk Served on advisory boards for Debiopharm, Vertex, Caladrius and Genentech Received research grant supplies only, investigator initiated, from Novo Nordisk and Lifescan Received industry research grant support pharma-initiated from Pfizer, Novartis

3 Outline Type 1 diabetes in sub-saharan Africa Type 1 diabetes worldwide: Life for a Child Type 1 diabetes in American youth of color including immigrants

4 Diabetes in Sub-Sararan Africa

5 Incidence & Prevalence of TID in African Children Actual incidence and prevalence unknown the acute presentation is often unrecognized, associated with high mortality poor infrastructure for health reporting Uganda <200 known children with TID in the entire country, now ~1000 Tanzania ~500 children with diabetes in country, now >1000 The true numbers are undoubtedly higher than this: African immigrant children have T1D incidence rates similar to children in the new country (Finland, Minnesota) The vast majority of children in Africa with T1D are 10 years of age and older----younger children are dying undiagnosed

6 Type 1 Diabetes in Africa: Clinical Most children present in DKA (<20% in the US) Until the last 10 years almost 100% mortality 1-6 years after diagnosis Patients often older than in resource-rich nations Complications are the rule if they survive to adulthood: Severe cognitive dysfunction from prolonged and repeated hypoglycemia, death from hypoglycemia Growth stunting and pubertal delay common Infection May not live long enough to develop microvascular or cardiovascular complications Limited microvascular treatment options

7 Impediments to Diabetes Care in Africa National Level---lack of sufficient medications, supplies, personnel Cost, corruption, inefficient bureaucracy Distribution of supplies, refrigeration (80% of population is rural) Focus is on acute rather than chronic illness Regional Level Inadequate health care facilities not enough, poorly equipped Inadequate availability and training of health care workers Prohibitive cost of treatment or transfer Public Level Little public awareness of disease Cultural practices, belief in traditional medicine Socioeconomic factors

8 2006 Today: lack of a diagnosis EAM Gale Lancet 368, , 2006

9 Two major initiatives are changing the face of pediatric diabetes in Africa Trained pediatric endocrinologists Pediatric Endocrinology Training Centre for Africa (PETCA) created and maintained by ESPE and ISPAD Availability of insulin and supplies Novo Nordisk CDiC Program Life for a Child

10 PETCA: Pediatric Endocrinology Training Centre for Africa Located in Nairobi, recent 2nd PETCA in Lagos Since 2009, ~80 pediatric endocrinologists from all over Africa have been trained; almost all have remained in their home countries Originally all US and European tutors, now mostly local Team workshops to train nurses, dietitians, psychologists Planning a nurse PETCA next year, will be looking for volunteers.

11 Institution of an Intensive Education and Treatment Program in Moshi, Tanzania 81 children age 3-19 Seen monthly for 6 months by the first trained pediatric diabetes team in Moshi. Provided sufficient NPH and Regular insulin, 3 test strips per week, and 3 hour of diabetes education (1/2 hour per visit). A1c baseline vs 6 mos: 12.4% vs 11.2% Severe hypoglycemia 6 months before versus during the 6 month study: 52% vs 17%

12 Diabetes Worldwide: Life for a Child No Child Should Die of Diabetes

13 2018 IDF Life for a Child Program Over 18,000 children in 41 countries Central America Guatemala Mexico South America Bolivia Ecuador Guyana Caribbean Dominican Rep Haiti Jamaica St Lucia Africa Burkina Faso Burundi Central African Rep Congo DR Congo HbA1c Eritrea Ethiopia Ghana Kenya Liberia Mali Mauritania Morocco Nigeria Middle East Syria Insulin, Syringes Meters and strips Central Asia Azerbaijan Tajikstan Uzbekistan South Asia Bangladesh India Nepal Maldives Pakistan Sri Lanka East Asia North Korea South East Asia Vietnam Western Pacific Philippines Complications screening Rwanda Education (patients and staff) Sudan Tanzania Camps (assistance Togo for start up /activity days) Uganda Mentoring Zimbabwe / twinning relationships Research Technical Advice and Capacity Building

14 Life For A Child Data: Full provision by government of insulin for children <15 years 100% 95.0% 80% 60% 57.1% % of countries 40% 20% 10.5% 0% 0.0% Low Income (n=19) Lower-middle Income (n=18) Upper-middle income (n=14) High income (n=20) Income Group Ogle, Middlehurst, Silink. Pediatr Diabetes 2015; Jul 8.

15 Life For A Child Data: Full provision by government of 2+ blood glucose strips per day for children <15 years 100% 90.0% 80% % of countries 60% 40% 35.7% 20% 0% 0.0% 0.0% Low Income (n=19) Lower-middle Income (n=18) Income Group Upper-middle income (n=14) High income (n=20) Ogle, Middlehurst, Silink. Pediatr Diabetes 2015; Jul 8.

16 Life For A Child Data: HbA1c MEAN HbA1c %

17 Diabetes in the US: Children of Color

18 Racial disparities exist in insulin pump use and HbA1c in youth with T1D, even after adjusting for socio-economic status

19 Diabetes in the US: Somali Immigrant Children

20 Somali Immigrant Children have Typical T1D Prevalence in Minnesota and Finland is similar to Caucasian children They have typical T1D autoantibodies 93% of those studied in Minnesota had HLA-type DR3---a typical T1D HLA type, but much higher prevalence than in Caucasian or African-American populations. DR3 is also common in the non-diabetic Somali population.

21 HbA1 in Somalis <10 yr not different than peers 8.8% 9.3% 8.8% 8.5% 8.4% p= p=

22 HbA1c worse in Somali children 10 yr 10.6% 9.7% 8.8% p= 0.02 Somali (n=18) Non-Somali (n=292)

23 The majority of Somali families were coping well with diabetes Majority had a positive attitude towards the diabetes team (especially appreciated diabetes education) 91% did not use folk medicine 69% felt no religious/cultural hurdles Struggle with carbohydrate counting of traditional Somali foods was a frequently mentioned concern

24 Sunni, Brunzell et al: A picture-based carbohydratecounting resource for Somalis. The Journal of international medical research, Jul

25 Summary: Diabetes in Underserved Youth In the resource-poor world, diabetes in children often has dire consequences, although the situation is gradually improving. There are multiple opportunities for health care providers to volunteer in developing countries. Support for organizations like Life for a Child really helps. Even within the US, children of color have worse diabetes control and are less likely to be prescribed the latest technology, regardless of socioeconomic status. Somali immigrants are at particularly high risk of diabetes. There is a specific carbohydrate counting resource available for them, other resources are in process.