Over 12% of adults in South Africa have diabetes. Since 2019, researchers at the University of Pretoria have been working on the Tshwane Insulin Project. The project consists of delivering training workshops on comprehensive diabetes and hypertension management in primary care. The researchers also provide technical assistance to healthcare professionals to improve diabetes care. The Conversation Africa spoke to project manager Dr Patrick Ngassa Piotie about what diabetes is and why it’s so difficult to manage.
What is diabetes?
Diabetes mellitus, or diabetes, refers to a group of conditions that affect how the body uses blood glucose (sugar). Diabetes occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces. This leads to elevated glucose levels in the blood. Over time, high blood glucose levels cause damage to the body and the failure of various organs.
There are different types of diabetes. Type 2 is the most common. It accounts for 90% of all cases. With type 2, the body is still able to produce insulin but can’t use it correctly. Type 2 diabetes mostly affects adults of a certain age, who are overweight, don’t exercise, and have a family history of diabetes.
Type 1 diabetes can develop at any age, but it occurs most frequently in children and adolescents. With type 1 diabetes, the pancreas produces very little to no insulin. This means people who have type 1 diabetes need insulin daily to maintain blood glucose levels.
Lastly, there’s diabetes that occurs during pregnancy – gestational diabetes. It affects both mother and child, but usually disappears after pregnancy.
Pre-diabetes is a reversible condition. It happens when blood glucose levels are higher than normal, but not high enough to be called diabetes. It can lead to diabetes unless measures such as lifestyle modifications are taken to prevent it.
The symptoms of diabetes are linked to the high levels of sugar in the blood. They include feeling tired and weak, feeling more thirsty than usual, urinating often, or losing weight without trying. Other symptoms such as blurry vision, recurring infections or slow-healing sores are signs of an advanced stage of the disease.
How is it managed?
This depends on the type of diabetes. For example, people with type 1 diabetes need daily insulin injections. The management of type 2 diabetes consists of adopting a healthy lifestyle including increased physical activity and healthy diet. However, type 2 diabetes is a progressive disease. This means that, as the condition progresses, people with type 2 diabetes will need oral drugs and/or insulin to keep their blood glucose levels under control.
Managing diabetes is not just about keeping the blood glucose levels within normal ranges. Often, people with diabetes and healthcare professionals must control the blood pressure and cholesterol levels as well. In addition, a key aspect of managing diabetes is to prevent complications by protecting target organs such as the kidneys and the heart, or the feet.
At the University of Pretoria Diabetes Research Centre, we have developed an acronym that summarises our approach to good diabetes care: the four “Bs” and four “Cs” or 4Bs 4Cs.
The 4Bs are critical elements to control diabetes:
- Blood pressure control
- Blood glucose control
- Blood cholesterol control
- Breathe air, don’t smoke
The 4Cs are important tests that people with diabetes should receive every year:
- Check eyes, with a diabetic eye screening – a specific test to check for eye problems caused by diabetes
- Check mouth, by going to the dentist
- Check kidneys, with a laboratory test
- Check feet, with a simple easy-to-do foot exam.
To manage diabetes, healthcare professionals need the full participation of people with diabetes and their families. That is why it’s important that people with diabetes and their families receive diabetes education. People with diabetes must be equipped with the skills to navigate self-management decisions and activities.
What are the main challenges in managing the condition?
In South Africa, most people with diabetes rely on the public health system for care. This system is overburdened, overstretched and under-resourced. These systemic challenges have an impact on the delivery of diabetes care, despite the availability of diabetes medication – including insulin – free of charge at primary care clinics.
Healthcare professionals often don’t have time for diabetes education because of long queues and congested health facilities. As a result, people with diabetes don’t receive the education they need. This, in turn, means people don’t have a good understanding of their condition, which affects their ability to adopt appropriate self-management behaviours, and to adhere to their medication.
Research conducted in South Africa has consistently shown that healthcare workers don’t comply with diabetes management guidelines. They also fail to implement the recommended processes of care such as measurements of body mass index, waist circumference or weight.
Having paper-based medical records instead of electronic medical records is an additional barrier. The medical records are often lost or misplaced. In a context where healthcare professionals rotate often between departments, it becomes difficult to preserve patient history and to ensure continuity of care. A paper-based system makes it difficult to implement structured diabetes care.
South African studies have found that screening for diabetes-related complications is lacking. For example, healthcare professionals are not able to screen patients for eye problems caused by diabetes. Diabetic eye screening requires a specific camera that is not available in most clinics and community health centres.
How can these be addressed?
Diabetes care should be structured, evidence-based and facilitated by a multidisciplinary team trained in diabetes management.
South Africa’s health system should be strengthened. Investments are needed to improve the delivery of diabetes care. There is a pressing need for the continuous training of healthcare professionals in diabetes management.
Because of the heavy workload on primary care nurses and doctors, allied healthcare workers, community health workers and health promoters should be trained to carry out non-clinical duties like diabetes education and support.
The recognition and integration of diabetes educators within the public healthcare system should be a priority. This will ensure that diabetes education becomes systematic and consistent. It should be repeated at regular intervals. Families of people living with diabetes should also be involved and receive diabetes education because their support is crucial.
Technology, digital health solutions and telehealth can improve the delivery of quality diabetes care. Clinical information systems such as electronic medical records and electronic patient registries can have a positive impact on evidence-based diabetes care. Those systems should be introduced as a matter of urgency.
What are some of the key lessons from the Tshwane Insulin Project so far?
The use of digital health, enhancing the role played by community health workers and following patients proactively are some of the innovations that were introduced.
Most healthcare professionals are eager to embrace change and new knowledge. And people with diabetes and their families were appreciative of the education they were receiving. They qualified it as life changing.
Improving diabetes care and outcomes in South Africa will require a strong will and unwavering support from the health authorities, the introduction of clinical information systems, the use of technology and digital solutions, advocacy and accountability.
