Over 12% of adults in South Africa have diabetes. Since 2019, researchers from the University of Pretoria have been working on the Tshwane Insulin Project. The project consists of conducting training workshops on comprehensive management of diabetes and hypertension in primary care. Researchers also provide technical support to healthcare professionals to improve diabetes care. The Conversation Africa spoke to project leader Dr. Patrick Ngassa Piotie on what diabetes is and why it’s so difficult to treat.
What is diabetes?
Diabetes mellitus or diabetes refers to a group of conditions that affect how the body uses blood sugar (blood sugar). Diabetes occurs when the pancreas can no longer produce insulin or when the body cannot properly use the insulin it produces. This leads to increased levels of glucose in the blood. Over time, high blood sugar levels lead to damage in the body and failure of various organs.
There are different types of diabetes. Type 2 is the most common. It accounts for 90% of all cases. In type 2, the body is still able to produce insulin but cannot use it properly. Type 2 diabetes primarily affects adults over a certain age who are overweight, do not exercise, and have a family history of diabetes.
Type 1 diabetes can develop at any age, but it is most common in children and adolescents. In type 1 diabetes, the pancreas produces very little to no insulin. This means that people with type 1 diabetes need daily insulin to maintain blood sugar levels.
Finally, there is diabetes that occurs during pregnancy – gestational diabetes. It affects both mother and child but usually goes away after pregnancy.
Prediabetes is a reversible condition. It occurs when blood sugar levels are higher than normal but not high enough to be called diabetes. It can lead to diabetes if measures such as lifestyle changes are not taken to prevent it.
The symptoms of diabetes are related to high blood sugar levels. These include feeling tired and weak, feeling thirstier than usual, urinating frequently, or losing weight without trying. Other symptoms such as blurred vision, recurring infections, or slow-healing wounds are signs of advanced disease.
How is it managed?
This depends on the type of diabetes. For example, people with type 1 diabetes need daily insulin injections. Treatment for type 2 diabetes consists of a healthy lifestyle, including increased physical activity and a healthy diet. However, type 2 diabetes is a progressive disease. This means that as the disease progresses, people with type 2 diabetes will need oral medications and/or insulin to keep their blood sugar levels under control.
Managing diabetes isn’t just about keeping blood sugar levels within the normal range. Often people with diabetes and healthcare professionals also need to check blood pressure and cholesterol levels. In addition, an important aspect of treating diabetes is preventing complications by protecting target organs such as the kidneys and heart or the feet.
Read more: Technology and home visits can help South Africans with diabetes cope with insulin
At the University of Pretoria Diabetes Research Center we have developed an acronym that summarizes our approach to good diabetes care: the four ‘Bs’ and four ‘Cs’ or 4Bs 4Cs.
The 4Bs are critical elements in controlling diabetes:
blood pressure control
blood sugar control
Control of blood cholesterol levels
Breathe air, don’t smoke
The 4Cs are important tests that people with diabetes should have every year:
Check the eyes with a diabetic eye screening — a special test to check for eye problems caused by diabetes
Check the mouth by going to the dentist
Check the kidneys with a lab test
Check feet with a simple, easy-to-perform foot exam.
To manage diabetes, healthcare professionals need the full participation of people with diabetes and their families. It is therefore important that people with diabetes and their families receive diabetes education. People with diabetes need to be equipped with the skills to guide self-management decisions and activities.
What are the biggest challenges in treating the condition?
In South Africa, most diabetics rely on the public health system. This system is overloaded, overburdened and under-resourced. These systemic challenges are affecting diabetes care, despite the free availability of diabetes medications—including insulin—in primary care clinics.
Due to long queues and overwhelmed healthcare facilities, healthcare professionals often do not have time for diabetes education. As a result, people with diabetes are not getting the education they need. This, in turn, means people do not understand their condition well, affecting their ability to adopt appropriate self-management behaviors and adhere to their medications.
Research conducted in South Africa has consistently shown that healthcare professionals are not following diabetes management guidelines. The recommended care processes such as measurements of body mass index, waist circumference or weight are not implemented either.
Having paper-based medical records instead of electronic medical records is an additional obstacle. Medical records are often lost or misplaced. In a context where healthcare professionals move frequently between departments, it becomes difficult to preserve patient history and ensure continuity of care. A paper-based system makes it difficult to implement structured diabetes care.
Read more: Our research reveals gaps in South Africa’s diabetes management program
South African studies have found that screening for diabetes-related complications is lacking. For example, healthcare professionals are unable to screen patients for eye problems caused by diabetes. Diabetic eye screening requires a special camera that is not available in most clinics and community health centers.
How can these be addressed?
Diabetes care should be structured, evidence-based and supported by a multidisciplinary team trained in diabetes management.
South Africa’s health system is to be strengthened. Investment is needed to improve diabetes care. There is an urgent need for continued education of healthcare professionals in diabetes management.
Because of the heavy workloads of primary care nurses and physicians, health workers, community health workers, and health promoters should be trained to undertake non-clinical tasks such as diabetes education and support.
The recognition and inclusion of diabetes educators in the public health system should be a priority. This ensures that diabetes education becomes systematic and consistent. It should be repeated at regular intervals. Families of people with diabetes should also be involved and receive diabetes education as their support is vital.
Technology, digital health solutions and telemedicine can improve the delivery of quality diabetes care. Clinical information systems such as electronic patient records and electronic patient registries can have a positive impact on evidence-based diabetes care. These systems should be introduced urgently.
What are some of the key lessons learned from the Tshwane Insulin Project so far?
Leveraging digital health services, empowering health workers in the community and proactively accompanying patients are some of the innovations introduced.
Most healthcare professionals are willing to embrace change and new knowledge. And people with diabetes and their families have been grateful for the education they received. They qualified it as life changing.
Improving diabetes care and outcomes in South Africa will require strong will and unwavering support from health authorities, adoption of clinical information systems, use of technology and digital solutions, advocacy and accountability.