One in four people over the age of 45 has diabetes and one in two may have or be at risk of diabetes.
Most people in South Africa know someone with diabetes and this disease is now ubiquitous. One in four people over the age of 45 has diabetes and one in two may have or be at risk of diabetes. It has become a leading cause of death, surpassing HIV, and has a plethora of complications that often require hospitalisation.
The main pathway to complications is damage to blood vessels in any part of the body. This leads to problems such as stroke, kidney failure, heart failure, blindness and amputations. This damage is often compounded by high blood pressure and tobacco smoking. These complications are increasingly seen among younger and working-age adults.
In recognition of this, people observe World Diabetes Day on 14 November. The theme for 2024-26 is Diabetes and Well-being.
Health services are being overwhelmed by the needs of people with diabetes. I spoke recently to a doctor at Mitchells Plain community health centre in Cape Town who said they are already treating 6 000 people with diabetes at this one facility.
One of our national goals is that 90% of people should know if they have raised blood sugar, but currently we only identify half of the people with diabetes. Our teams of community health workers may be able to assist with this.
Another goal is that at least 50% of people with diabetes should have good control of their sugar, but currently only 25% of people are achieving this.
If we are to turn the tide on diabetes, we need to take the problem as seriously as we did for HIV and to commit to resources and innovations.
Diabetes runs in families and although this may reflect a genetic predisposition, it equally reflects a shared lifestyle in families. Type 2 diabetes is associated with overweight and obesity. Healthy eating is key to preventing and controlling the condition. Our diet often contains large amounts of sugar, cheap starchy foods and fats that increase weight and lead to the development of diabetes. Physical activity is important.
To prevent diabetes, we need to not only motivate people to make healthy choices but to place them in an environment where the risk of developing diabetes is lower. We need to make healthier choices easier. The government and the food industry must work together to enable people to afford to have more vegetables and plant protein in their diet. Likewise, we need to make physical activity attractive and safe in our communities.
We must educate our children about healthy eating and physical activity. Children are often effective advocates for behaviour change with their parents and families. Legislation can help, such as the sugar tax, but transformation is also needed at the community level. Government and civil society must tackle the issues which cannot be solved by health services alone.
The health services also need to gear up to the challenge of diabetes. Most people with diabetes are being treated at public sector primary care facilities, where they see nurse practitioners. We must ensure that our nurse practitioners are experts on diabetes and lifestyle changes, and that our primary care teams have access to family physicians to assist with more complicated patients.
While the range of medication in the public sector is limited, the medications are effective and available. We have evidence-based guidelines, although clinical inertia is a problem.
People with diabetes need to be empowered not only to take medication, but also to change their lifestyle. One cannot just swallow tablets or inject insulin. Health services often focus on prescribing medication in mechanistic brief consultations. Effort is needed to empower people with interventions that are feasible in our context. Options include group empowerment by trained facilitators, digital solutions and telehealth. Group empowerment and training (GREAT) for diabetes has been developed locally and shown to be cost-effective.
Many people with diabetes will eventually require insulin as their pancreas makes less and less of their own insulin. Starting insulin is another roadblock in the journey to good control. People are afraid of injections and how this will affect their lifestyle. Recently Novo Nordisk withdrew insulin pens from the South African market to prioritise profits elsewhere. This has made it even more difficult for older adults and those with impaired vision to use insulin.
Patient organisations, such as Diabetes SA, need more traction and resources to speak out on behalf of people with diabetes. Health services must also do a better job of empowering people as they start insulin. Again, group empowerment, digital solutions, and telehealth could help with this.
When people go to their clinic the healthcare workers are meant to check the control of sugar and look for early signs of complications. Currently a blood test is taken (called the HbA1c) to check control, usually only once a year. Unfortunately, the result is not available until the next visit, which may be weeks or months later. Point of care testing is now readily available and would allow people to know immediately if their diabetes is controlled or not. This should become the standard of care.
Healthcare workers are meant to check eyes once a year but using the handheld device is fraught with problems and rarely used successfully or at scale. New technology is easily available to take a photograph of the back of the eye (retina) and mobile fundal cameras should be the norm.
We also check kidneys once a year with a blood test and by checking for protein in the urine. When these tests are positive there is already significant kidney disease and the moment to intervene successfully has been lost. Urine tests are available to identify early kidney disease and intervene.
So, we need to do better all round at tackling diabetes. We need upstream interventions to create environments that do not increase the risk of developing diabetes. We need health services that do not only dispense medication. We need expert healthcare workers at the primary care level with the technology and innovations to empower people for self-management, who can determine control and act, and who can screen for complications at a time when treatment is still possible.
Professor Bob Mash is the executive and divisional head of the Department of Family and Emergency Medicine at Stellenbosch University.