WORLDWIDE, there is a growing epidemic of what is being termed ‘diabesity’, and therefore, efforts to strengthen global strategies towards controlling diabetes and obesity by the World Health Organization (WHO) is welcomed.
That’s how local experts at the Diabetes Research Centre at the University of Pretoria have reacted to news that WHO Diabetes Compact will likely be completed by next year. The effort will likely see a heightened global effort towards tackling diabetes – similarly to how diseases like HIV and Aids have been prioritised at these levels.
You can read more detail about the WHO programme here.
Professor Paul Rheeder, the director of the Diabetes Research Centre, which is based at the University of Pretoria’s Faculty of Health Sciences, said diabetes and obesity were intimately linked.
Diabetes, which is caused when blood glucose levels are too high, is the second most common natural cause of death in South Africa – where 4.6 million people live with the condition.
“Because obesity is on the rise worldwide, and particularly in South Africa, diabetes is on the increase also. There is a compact document, which we agree with, which basically indicates a massive rise in diabetes will be from above 420 million worldwide to about 570 million worldwide by 2030, so that's about a 260% increase in diabetes over the last 20 or 30 years.
“But, if you look at the world figures, it is most markedly in the developing world. So in sub-Saharan Africa, we are bearing the brunt, as is the Middle East and Asia, but in particular sub-Saharan Africa is going to see a huge increase in obesity and diabetes.
“So, from that point of view, it is incredibly important that diabetes becomes a priority. It has never really been a prime objective, like, for example, HIV and TB have been the main focus worldwide together for the last 30 or 40 years. The feeling is that now it's time for diabetes, together with the likes of hypertension and obesity, the so-called non-communicable diseases, to have a global effort in terms of strategy,” he said.
Significance of global strategies
Rheeder said the importance of a global strategy was to prevent diabetes, obesity and hypertension.
“It's expected that each country should now have a strategy as to how they will address these three main conditions and also how they will focus on prevention. Because that is one thing that is severely lacking across the globe but again, specifically maybe more so in low-income countries and developing countries.”
He said it was also key to addressing treatment.
“There's this huge challenge regarding treatment globally. South Africa is actually quite fortunate in the sense that if you look at our healthcare system, we actually have most things in place to deal with the diagnosis of diabetes. So we have the drugs available. Even something like insulin is quite readily available, whereas, if you look at this globally, you have to realise that they are many countries where, for example, clinics do not provide free insulin. Patience will get a script and will have to go to a local pharmacy to buy these drugs.
“South Africa is a little fortunate in that we have a reasonable healthcare system, so there are many things that we can deal with, but again, the idea is that everybody globally should be on the same page and should have the same goals, just like you have global goals set for HIV. You should have clear measurable goals for diabetes, so that you can diagnose more patients earlier to prevent diabetes, to get better control over the disease.”
Rheeder said the feeling was that the WHO, together with many countries, could strategically focus on the key areas that could improve prevention and management and progress towards global control of diabetes.
Challenges
He said South Africa had made strides towards managing diabetes already, but a number of challenges remained.
“South Africa has had a number of these strategic documents on managing diabetes. I stand corrected, but I think they are in the process of, or have just finished their documents, on obesity and the prevention of obesity in South Africa. So, the South African health authorities have been focusing on this quite extensively over the last five to 10 years.
“I'm a physician, and I work with patients. I think maybe another key aspect of this project would be to bring the patient back into focus. We tend to focus on talking about the patients but never with them, and I think there's a strong focus here to bring people living with diabetes, like they did people living with HIV, into the discussion and to ask: what matters to you? What do you think we should be focusing on?”
He said, globally, people with Type 2 diabetes live with the condition somewhere between seven and 11 years before they are diagnosed.
“And these are global figures. They say not exclusively South African figures. So you can imagine if you are in environments where access to healthcare is restricted: maybe you live far away, you don't have money for transport, you don't want to take time off work, etcetera, that could probably cause an even further delay in diagnosis.
“I think the second challenge is the general level of expertise and need to up-skill in our public sector. We actually have a wonderful public sector system. Our primary health care clinics are actually well staffed in terms of their supplies and their resources, which are quite adequate.
“But you have staff who have to deal with anything from HIV, to pregnancy, to paediatrics; now you throw something as complicated as diabetes with blood pressure, cholesterol and other complications. It's quite a complex disease to manage. There are multiple things to consider. You have to follow up with the patients over time, and this disease also changes over time. For example, you become more insulin-dependent as the disease progresses.
“If you look at the skill sets or the skill levels and the general expertise and knowledge regarding diabetes management at primary care level, many primary care nurses do a sterling job in general, but they are struggling to provide the kind of service that we really need to get control of diabetes.”
But it was not all doom and gloom, he said.
“I think there is a possibility out there, but a lot has got to do with training and up-skilling. The drugs are available generally, laboratory tests are available. We are extensively involved in training healthcare workers in the primary health care clinics in Tshwane, and I would imagine there are similar programmes in other provinces to recognise the people who come into the clinics, who are at risk and to test them for diabetes.
“For example, should someone come in with a sprained ankle, but this is an obese patient with a strong family history of diabetes, he should be tested. So, we should have a lower threshold for screening in general. I don't think there is a sufficient sensitivity for screening patients who deserve screening, and I think we need to increase that awareness in general in the healthcare setting.”
How to help yourself
Rheeder said, while on the one hand, there was the need to up-skill the nursing and medical staff, on the other hand, patience needed to know what good diabetic care consisted of.
“It's a double responsibility,” he said.
“Patients must take responsibility for their own disease: I must go to the clinic. I must get my medication. I must take my medication. I must try as much as I can to live a healthy lifestyle, that is, I must watch my diet and get some exercise. That's my part of the bargain.
“Good control at the clinic means that you as the patient know your rights in terms of what needs to be controlled and tested at the clinic.”
- Blood glucose control. There's a laboratory test called HBA1C test that should be done at least once a year because that tells what one’s sugar control has been like over the last three months, so clinics should be doing HBA1C testing on every patient at least once a year, minimum.
- Blood pressure control. You should have your blood pressure measured at every visit.
- Blood cholesterol control, and you must. You should have some form of cholesterol testing. You should have some type of cholesterol testing at least once a year and more often if your treatment is changing.
- Breathe air, not smoke (patients need to be asked if they are smoking, and if they are, they must be assisted in stopping).
He said your clinic should, in some way, have your eyes assessed for diabetic eye disease. Diabetic patients should visit a dentist at least once a year as they are more prone to oral problems. You should have a blood test to test your kidneys and a urine test to test your protein – these tests need to go to the laboratory. And feet should be checked at least once a year.
“Your socks and shoes should come off, and the clinic should check for any nerve damage on the feet, check that the pulses are palpable in the feet and that you don't have a vascular problem in the feet.”
The Diabetes Research Centre at the University of Pretoria officially opened in August, bringing together a number of experts on diabetes, cross-disciplines.
They have each been involved in research, projects and programmes in diabetes within their respective fields over the past 10 to 20 years.
The centre’s research strategy is organised around six clusters: the prevention of diabetes, diabetes management in primary healthcare, its management in hospitals, gestational diabetes (developed during pregnancy), diabetes in children and adolescents, and diabetes technology.