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Diabetes mellitus exists in two distinct forms: type 1, which usually occurs in younger people who require insulin injections from the time of diagnosis, and type 2, which usually occurs in older, overweight people who start treatment on lifestyle modifications and tablets.
Type 2 diabetes is a progressive disease, and after five years as many as 50% of people living with type 2 diabetes may require insulin injections to control their blood glucose levels.
High obesity levels in SA
Obesity is the main driver of the current type 2 diabetes epidemic. People living with diabetes also frequently have high blood pressure and high cholesterol levels that require treatment.
In South Africa, diabetes is of particular concern. South Africa has the highest prevalence of overweight or obese citizens in Sub-Saharan Africa. Indeed, close to four out of 10 men and seven out of 10 women are either overweight or obese.
The prevalence of type 2 diabetes varies depending on age and ethnic group. This ranges from 7% of the population to as high as 25% in some communities. South Africans of Indian descent are particularly at risk.
Alarmingly, the International Diabetes Federation predicts that between the years 2000 and 2030 there will be a 261% increase in diabetes in Sub-Saharan Africa. Worldwide, more people die from diabetes than from tuberculosis (TB), HIV and malaria put together. In 2016, Statistics South Africa revealed that diabetes was second only to TB as a natural cause of death.
The majority of people living with diabetes receive treatment in the public sector primary care environment. Early in the disease, treatment consisting of lifestyle modifications and oral medication is straightforward and done according to acceptable guidelines and algorithms.
However, over time, management becomes more complex and complications such as foot ulcers and amputations, renal disease including renal failure, eye disease including blindness and stroke and heart attacks may occur. This complexity demands care that is often not available or suboptimal, most often due to resource constraints such as medical personnel and equipment.
Early detection and treatment
In response to these challenges in diabetes management in the primary care sector, which affect thousands of South Africans, the Department of Internal Medicine at the University of Pretoria is leading a multidisciplinary team of physicians, nutritionists, sport scientists, nurses and public health experts in finding innovative and evidence-based ways to improve care for people living with diabetes.
The team interacting with the clinics consists of a project leader, a nurse coordinator, nurses and clinical associates. The Tshwane Insulin Project (TIP) is a translational research programme funded over five years by the Lilly Global Health initiative. This project aims to improve early detection and treatment of diabetes at primary care in the Tshwane district, which includes approximately 68 health facilities (primary care clinics and community health centres).
Of particular significance is the focus on addressing the challenges of safely initiating and titrating insulin in diabetes patients at primary care level should they require it. The goal is to design, implement and evaluate a nurse-led, community worker-assisted and patient-centred innovative model of care that will facilitate insulin use in primary care.
Nationally, many clinics do not have doctors available on site, and the TIP study will evaluate the use of a mobile app to facilitate communication between healthcare workers (nurses and community health workers) with a designated primary care physician.
This novel approach has significant operational as well as economic benefits in the delivery of care. Patients are started on insulin and the dose is adjusted weekly as required. A unique feature of the TIP strategy is the implementation of home-based visits. The patient is visited at home by a trained community health care worker and a team leader who is a registered nurse.
This ensures treatment compliance as well as safety of the people who are injecting insulin and testing their blood glucose with glucose meters provided to them by the project. During the home visits, patients receive personalised education sessions around diabetes and living with insulin. Through those education sessions, they are empowered and equipped to better take care of their diabetes and take control of their disease.
Complete spectrum of care
Initial baseline surveys with healthcare workers and patients were conducted during 2019 to evaluate the barriers and opportunities regarding insulin use in primary care. These highlighted the desire of nurses to be empowered to use insulin, the challenge of time dedicated to diabetes education, other clinical tasks and unavailability of glucose meters and glucose strips, as well as the fear of injections and reluctance to start insulin by the patients.
Through training interventions facilitated by the TIP experts, we work with the Department of Health and City of Tshwane to empower primary care nurses and doctors to improve the complete spectrum of care for people living with diabetes. These efforts are an important long-term investment which will lead to improved disease control as well as earlier detection and management of complications.
In 2020, the TIP study will expand with a bold aim, which is to initiate at least 400 people on insulin all around the Tshwane District and improve their quality of life as they bravely live flourishing lives despite having diabetes.
TIP is an embodiment of the ethos of the University of Pretoria as passionate and dedicated UP staff members implement innovative ground-breaking research which has the potential to positively impact the lives of thousands of South Africans living with diabetes.
Professor Paul Rheeder is a Senior Lecturer in the University of Pretoria’s Department of Internal Medicine based at Pretoria’s Steve Biko Academic Hospital.
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