In-depth: Does SA have a diabetes testing problem?

In-depth: Does SA have a diabetes testing problem?According to estimates of the International Diabetes Federation (IDF) around 4.5 million people in the country between the ages of 20 and 79 had diabetes in 2020. It translates to about 12.8% of South Africa's adult population. Image: Andrea Rico/Flickr
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It is difficult to get an accurate estimate of how many people in South Africa are living with diabetes, according to Professor Naomi (Dinky) Levitt, Director of the Chronic Disease Initiative for Africa.

She says this is due to a lack of national surveys that are reputable, have high rates of participation or dial-in by the community as well as diagnostic tests that are acceptable for everyone.

“We don’t have an accurate estimate. (But it’s) probably about 4 and a half to 5 million people,” she says.

This squares with figures from the International Diabetes Federation (IDF) who in 2020 estimated that around 4.5 million people in the country between the ages of 20 and 79 had diabetes. It translates to about 12.8% of the country’s adult population.

According to Levitt, the vast majority of people living with diabetes in South Africa have Type 2 diabetes, which is in keeping with global trends, where 90% of people with diabetes have Type 2.

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Type 1 and Type 2

According to family physician and member of the Faculty of Family Medicine at Stellenbosch University Dr Leigh Wagner, Type 1 diabetes is an autoimmune condition someone is born with, normally caused by an abnormality in the pancreas. It’s usually diagnosed in childhood or adolescence.

Type 2 diabetes on the other hand generally progresses in adulthood, she says, although it is being diagnosed younger and younger. It generally occurs as a consequence of a sedentary lifestyle, inactivity, and bad eating habits. It is also seen in older people who develop a resistance to insulin.

And then there is also something called gestational diabetes, a type of diabetes that develops during pregnancy. According to Levitt evidence from Gauteng and elsewhere indicates that around 10% of pregnant women develop the condition. While many women will recover from gestational diabetes after pregnancy, the condition is associated with a significantly increased risk of going on to develop type 2 diabetes.

diabetes wristbands
Due to a lack of reputable national surveys it is difficult to get an accurate estimate of how many people in South Africa are living with diabetes. Image: Bradley Johnson/Flickr

No mass screening in SA

“South Africa doesn’t have a mass strategised screening programme for (Type 2) diabetes,” says Wagner. She adds that when screening is done, it is typically done in the form of a simple finger-prick blood test that shows a person’s blood sugar levels.  This type of screening can occur at various platforms, such as outreach efforts or at a pharmacy that offers wellness screenings. This test can be done randomly.

“But this is not really well organised, it’s not uniform, it’s not consistent, it really differs across the board and with different access for different people,” she says.

A more powerful screening method is called a Haemoglobin A1C test (HbA1c). This is a blood test that measures blood sugar control over a period of three months, rather than giving just a snapshot of blood sugar control at the moment of the test as with the finger-prick test. While an HbA1c test can be done at the point of care (for example a healthcare facility), Levitt points out that it is a costly test to do, and it is not feasible to use it as a general screening tool. Instead, she suggests it be used to screen people who have already been identified as being at risk for Type 2 diabetes.

“We need to be motivating for these to be put in place in all primary care clinics. In that way, one could screen for diabetes much more easily and one could intervene in terms of management much better with much sounder information than just a finger-prick blood sugar (test),” she adds.

Wagner says that at a public sector healthcare facility, patients are screened using the finger-prick blood test to check their blood sugar levels regardless of the reason they are at the facility if they fall into certain categories. These are if they are over the age of 45, or have a high body mass index or are obese, or have hypertension. They also screen people who present at the facilities if they present with any symptoms that could be related to Type 2 diabetes.

She adds that screening for Type 2 diabetes within communities is sometimes done by community healthcare workers who are employed by NGOs, where they go house to house and look for people who could potentially have Type 2 diabetes or are at risk of developing Type 2 diabetes.

“But as I say this happens very inconsistently, it depends on which city you are in. There is nothing that is uniform (with screening) in South Africa, and that contributes to why we are not picking it up,” she says.

Some private organisations or employers do wellness days or outreaches as part of a company’s wellness program where they test their employee’s blood sugar levels, according to Wagner, but she says they could be doing more in terms of screening for diabetes.

Government figures

According to National Department of Health spokesperson Foster Mohale, for the 2020/21 financial year, 259 093 adults aged 18 to 44 were diagnosed with diabetes and 207 372 adults over the age of 45 were diagnosed with diabetes.

When asked how many of the estimated 4.5 million adults in South Africa (as per the IDF) with diabetes are considered to be controlled, Mohale responds: “The department currently does not collect data on prevalence and control for diabetes. Prevalence according to the most recent data from the IDF is 12.8% with a total adult population of 35 833 200. Control data may be obtained from NHLS by following the necessary protocol,” he says.

In terms of how many people in South Africa have undiagnosed Type 2 diabetes, Mohale says that there doesn’t appear to be much credible data available on this.

“However the National Income Dynamic Study infers that approximately 40 % of persons who have diabetes are diagnosed; of the persons diagnosed only  40% are put on treatment and, of those put on treatment, approximately 40% are controlled,” he says.

South Africa does not have a mass strategised screening programme for (Type 2) diabetes, experts say. Image: Biology Corner/Flickr

Cost of late detection

Because of the multitude of complications associated with Type 2 diabetes, it places a significant burden on the healthcare system, particularly the public healthcare sector, according to Dr Darcelle Schouw, a biokineticist specialising in chronic non-communicable diseases and researcher at the Faculty of Medicine and Health Sciences at Stellenbosch University.

A report, published in 2019, found that in the previous year, the cost of diagnosed Type 2 Diabetes within the public health care sector was about R 2.7 billion and if the estimated patients with undiagnosed Type 2 diabetes were included, the number rose to R 21.8 billion.

“In real terms, (in) the 2030 cost of all type 2 diabetes cases is estimated to be R 35.1  billion. Approximately 51% of these estimated costs for 2030 are attributable to the management of type 2 diabetes, and 49% are attributable to complications,” the report states.

Schouw says that the cost of Type 2 diabetes is not only carried by the healthcare system, but also by the people living with the disease, who may be unable to work due to the complications if their diabetes is poorly controlled or uncontrolled.

“It leads to increased unemployment; increased poverty and it just continues,” she says.

Complications of poorly controlled diabetes

According to Schouw, Type 2 diabetes can be managed if a person’s blood sugar levels are controlled, if they are not, a number of complications might occur.

A person’s blood sugar levels can be classified as either controlled, poorly controlled, or uncontrolled, according to Wagner.

It works on a scale, she explains and is measured in terms of HbA1c levels. A person living with Type 2 diabetes is considered to have controlled blood sugar levels when they consistently have an HbA1c reading of below 7. Poorly controlled Type 2 diabetes is an HbA1c of between 7 and 10, while uncontrolled Type 2 diabetes is having an HbA1c of more than 10.

Both poorly controlled and uncontrolled Type 2 diabetes put an individual at risk of complications such as heart attacks, strokes, eye disease, nephropathy, retinopathy, and kidney disease, according to Wagner.

“It affects every vessel and almost every organ in the body, also your immunity,” she says, adding that having diabetes is also associated with an increased risk of depression and anxiety.

Obesity, physical inactivity, bad diet, stress, and people moving from rural areas to more urbanised areas are all lifestyle factors that put people at risk of developing Type 2 diabetes. PHOTO: PHM-SA

Risk of infections

Poorly controlled diabetes is associated with an increased risk of all infections,” says Schouw. “It’s like honey and bugs love honey.”

According to a study conducted in the Western Cape, published in 2021, people living with diabetes are at almost four times greater risk for hospitalisation and three times more at risk of dying from a SARS-CoV-2 infection than people without diabetes.

Another study published in 2017, which looked at the overlap of tuberculosis, diabetes, and HIV in a TB clinic in Cape Town concluded that diabetes is a significant contributor to the TB burden. The finding was not surprising, since it has been known for some time that people with diabetes are at a significantly higher risk of developing TB than people who do not have diabetes. The increased risk goes the other way as well – the WHO has pointed out that TB can temporarily cause impaired glucose tolerance which is a risk factor for diabetes.

How is Type 2 Diabetes treated?

According to Levitt, the first step in treatment for someone who is diagnosed with Type 2 diabetes is often a “modification of lifestyle”, as well as an oral medication called MetFormin (available as a generic), which enhances insulin action.

She explains that there are a variety of oral medications available to treat Type 2 diabetes, although not all of them are available in the public healthcare sector.

Some oral medications enhance insulin action, while others enhance insulin secretion. Others reduce the amount of glucose being absorbed in the gut. Another type, called an SGLT2 inhibitor, acts at the kidney level and reduces the amount of glucose being absorbed by the body, essentially causing the body to get rid of glucose through urine.

She adds that as far as she is aware, there are currently three options for medication for the treatment of Type 2 diabetes in the public sector. One of these is Metformin, Another class of medication enhances insulin secretion (called Sulphonylureas), and then lastly insulin.

Other options are only available in the private sector. “You don’t have the sort of compendium of drugs (in the public healthcare sector)… so while they have a benefit in terms of the multi-pronged action that they have, they are too expensive,” she says.

Spotlight searched the Master Health Product Procurement List found on the National Department of Health’s website and found three types of medications associated with the treatment of Type 2 diabetes.

The first two are oral medications Metformin and Glimepiride. According to the South African Health Products Regulatory Authority’s website, Glimepiride is a sulphonylurea and “decreases blood glucose concentrations mainly by stimulating insulin release from pancreatic beta cells”.

The third is insulin, which is listed on the health product procurement list as being either biosynthetic or analogue.

However, Levitt says that medication can only go so far for treating Type 2 diabetes. “A lot of it (treating Type 2 diabetes) really relates to the individual and how they respond to a diagnosis, what they are and are not willing to change, (and) what support they need,” she says.

glucose meter and finger-prick needle
According to experts, poorly controlled diabetes is associated with an increased risk of all infections. Image: Magdalene Wiklund/Flickr

Not detecting Type 2 early enough

According to Levitt, the outcomes for diabetes are really poor in South Africa and diabetes is a major cause of premature mortality. She adds that often by the time people living with diabetes are diagnosed, they already have complications caused by the disease and these are then difficult to reverse.

South Africa is not doing very well in detecting Type 2 diabetes early, and a major reason for this, according to Schouw is due to fewer resources being allocated to diabetes than to diseases like HIV, Tuberculosis, and COVID-19.

The private healthcare sector as well as medical aids have tried to reward people for making healthier choices like going to the gym, doing regular wellness checks, and checking their blood sugar levels in order to detect Type 2 diabetes early, according to Wagner. “Unfortunately, it is really for the minority, and for the selected few that can afford healthcare,” she says.

She explains that in the low socio-economic setting where she practices medicine, it is challenging because her patients are often simply trying to survive.  “We really have to work together with our patients to be able to educate them on how they can manage their diabetes, within their context, because it is possible,” she says.

According to Schouw, it is important to frame interventions and lifestyle changes related to preventing or managing Type 2 diabetes in a way that does not make it unattainable or that adds another challenge to people’s lives.

“Also, the key is where we speak about behaviour change, but for every individual to take self-responsibility. Because you cannot come to the clinic and you cannot just expect the medication to be magic and make this change for you,” she says.

Wagner cautions that it is not only people living with diabetes in lower-income communities that struggle to control their blood sugar. “Having the means does not necessarily give you the desired diabetic outcomes, which is control. You know, it both comes down to behaviour, whether you have the means or not,” she says.

Linked to lifestyle

Type 2 diabetes is part of the cost of our lifestyles, says Schouw.

“There is a cost to the way that we eat, there is a cost to the way we don’t engage in physical activity. There is a cost to the way that we drink alcohol. And it’s become a standard, a norm for our lifestyles,” she says.

She lists obesity, physical inactivity, bad diet, stress, and people moving from rural areas to more urbanised areas as lifestyle factors that put people at risk of developing Type 2 diabetes.

A practical thing that everyone can do to reduce the risk of developing Type 2 diabetes is to lose extra weight if they are overweight as well as becoming more physically active in general. She says everyone needs about 150 minutes of physical activity a week, which translates to about 30 minutes of exercise a day. This does not necessarily have to be exercise in a gym, instead, she suggests gardening or walking to work or simply walking a way that expends energy, and breaking those 30 minutes of activity into manageable chunks throughout the day.

Diet also plays an important role according to Schouw. She advises eating more plant-based foods, as well as educating people about healthy fats, drinking enough water, and how to make healthier choices. One way of ensuring this is by teaching people to plant their own vegetable gardens or having communal vegetable gardens.

Wagner adds to this by saying that eating foods that are high in sugar results in needing to eat more, which causes your blood sugar to fluctuate, while healthier foods like plant-based foods keep blood sugar levels more constant.

“That fluctuation in sugar is what we want to avoid, you’re either feeling down or feeling sludgy, you’re feeling unwell, but if you are able to eat a more balanced diet, a more appropriate diet… you will find that your sugar will remain constant for longer and…you’re actually going to eat less food,” she says.