Lorna Perez, Ethan Gough Diabetes Mortality and Morbidity in Belize 2004-2009 Lorna Perez, Ethan Gough Basic Level, Field Epidemiology Training Program, Ministry of Health, Belmopan, Belize South Africa, December 2010

Background Demographics Diabetes is a pandemic disease The Americas account for over 25% in the world 13 million diabetics in Latin America and Caribbean Diabetes attributed to 4% in all deaths 6th leading cause of deaths In Belize: In 2007, 13% prevalence among those >20 years In 2008, ranked as 5th leading cause of hospitalizations and 1st underlying cause of deaths , 3 to 5 times higher among the older age groups 40-64 and 65 years and older

Belize Located in Central America Population density: 30.9 inhabitants per square mile (2003) Demography: 333,200 inhabitants Population growth rate: 2.7% The population is comprised of a mix of ethnicity and cultures Mestizos 49% Creoles 25% However, due to its location Spanish is widely spoken The percentage of the population over 65 years is 4.3% and that less than 15 years was 40.9%. creoles 24.9%, Mayas 10.6%, Garinagu 6.1%, Mennonite 3.6%, and East Indians 3.0%. The remainder of the population (3.1%) is made up of Chinese, Arabs, Africans and white Caucasians. English is the official language of the country but several other languages including Spanish are widely spoken

Objectives To describe diabetes and its complications by analyzing routinely collected surveillance data on diabetes in Belize. To increase recognition of the public health burden of diabetes guiding the formulation of health-care policies identification of high-risk groups development of strategies to reduce the burden of this disease evaluation of disease prevention and control.

Methods Study type: Descriptive Sources of data: Admission and discharge records, medical certificates of deaths, aggregated data of hospitalizations and deaths 2004-2008 Electronic records Belize Health Information System 2009 Variables: age, sex, district, ethnicity, educational level, main and other discharge diagnoses, and underlying causes of death Only 1st listed hospitalization diagnosis used Analysis: Data described using rates and proportions Disrepancies in age , occupation

Methods (2) Discharge Diagnoses/UCD ICD 10 classification for hospitalization discharges and underlying cause of deaths had 4 categories: Insulin-dependent, Non-insulin dependent, other specified and unspecified diabetes mellitus and further described by the contributing cause as follows: Cardiovascular Nephropathy Hypertension Peripheral Vascular Complications Others 130 death records 599 hospitalization records for 449 patients

Diabetes Hospitalization and Death Rate by Sex, Belize 2004-2009 Hospitalization Rate by Sex Death Rate by Sex Hospitalizations: average rate: 163/100,000 per yr……….highest peak in 2007 (219/100,000) AND although it fell to 169/100,000 in 2008 it increased again to 180/100,000 in 2009 Females more affected than males at 1.9:1 Deaths: Average death rate 35/100,000 per year with the highest in 2009 39/100,000 Females more affected than males at 1.4:1

Frequency of Diabetes Hospitalization by Ethnicity and Education, Belize 2009  Level N= 479 Percentage (%) None 43 9 Preschool Primary 325 68 Secondary 33 7 Tertiary 14 3 Others 5 1 Unknown 57 12 Ethnicity  Ethnic Group N= 479 Percentage (%)   Creole 163 34 Mestizo 201 42 Garifuna 53 11 Maya 14 3 East Indian 19 4 Others 10 2 Unknown The group most affected are the Mestizos accounting for 42% of those hospitalized with Diabetes followed by the Creoles at 34% and 68% reported their highest level of education as primary school

Hospitalization rate by age Diabetes Hospitalization and Mortality Rate by Age Group, Belize 2004-2009 Mortality rate by age Hospitalization rate by age Age Group (Years) Per 100,000 population 2004 2005 2006 2007 2008 2009 <40 40 48 51 52 41 43 40-64 618 639 662 669 496 461 65+ 1509 1298 1398 1320 1076 1177 Age Group (Years) Per 100,000 population 2004 2005 2006 2007 2008 2009 <40 2 1 40-64 74 81 92 66 73 102 65+ 455 482 573 458 363 353

Diabetes Death Rate, Belize 2004-2009

Frequency of Hospitalization Diagnoses, Belize 2009 Main Condition (583)   Contributing Cause Cardiovascular Complication % Peripheral Circulatory Complications Nephropathy Essential Hypertension Others Insulin Dependent(160) 2 1 25 16 10 58 36 59 37 Non-Insulin Dependent (230) 14 6 68 30 27 12 33 88 38 Other Specified DM (83) 55 66 3 4 17 Unspecified DM (110) 23 21 35 32 47 43 Average 5 26 34 52

Frequency of Diabetes Death Diagnoses, Belize 2009 Main Condition (n130) Contributing Cause Cardiovascular Complication % Peripheral Circulatory Complication Nephropathy Insulin Dependent (n6) 2 33 4 67 Non-Insulin Dependent (n47) 15 32 3 6 29 62 Other Specified DM (n61) 48 7 11 25 41 Unspecified DM (n16) 19 1 12 75 Average 38 8 18 54

Conclusion Diabetes is affecting these sub-groups: Females 65 years and older Mestizo population Mostly residents of urban Belize and rural Corozal Majority dying of preventable conditions- years to develop Complications are comparable to Central America and the Caribbean (nephropathy, CV complications)

Limitations No outpatient/ private clinic data Sample limited to hospital data ICD 10 classification- broad Incomplete description of diagnoses

Recommendations Prevention strategies (lifestyle change) Education and support Diet and exercise (obesity, diet, hypertension and life style are all reversible and controllable) Prevention of complications Supportive services: dialysis, specialist services Further studies: Why rural/urban?, cost of the disease

Acknowledgements CDC-CAP MOH Ifeoma Adimora Nweke Health Care Workers National AIDS Program Epidemiology Unit Thanks