Controlling the diabetes crisis: Insights from UCT researchers on World Diabetes Day 

Unchecked the diabetes epidemic is set to cost the South African government more than 10% of its overall health budget, an unsustainable cost in the face of the country’s high disease burden. Researchers at UCT are working to better understand the impact of the disease, to support evidence-informed policy on what is fast becoming a crisis.  

Diabetes is on the rise globally, with an estimated 537 million people living with diabetes in 2021, that number is projected to increase to 783 million by 2045. According to the International Diabetes Federation’s Diabetes Atlas the greatest increase over the next two decades is set to be in Africa.  

“South Africa has the highest number of people with diabetes on the continent,” said Associate Professor Joel Dave, head of the Division of Endocrinology in the Department of Medicine at UCT’s Faculty of Health Sciences. “According to Stats SA, in the Western Cape, diabetes is the highest cause of mortality of women and the number two cause for mortality of men, after tuberculosis.”  

There are two types of diabetes: type one diabetes, an autoimmune disease most often beginning in childhood, and type two diabetes, which accounts for over 90% of the global cases and for which obesity is the greatest risk factor.  

If left unchecked diabetes causes damage to many of the body’s organs and leads to conditions like cardiovascular disease, nerve damage, kidney damage, lower limb amputations and eye disease, often resulting in visual loss or blindness.   
 

Processed foods, obesity and diabetes  

One of the major drivers of the diabetes crisis, according to Professor Lara Dugas, AXA Chair in Non-Communicable Diseases Epidemiology at UCT’s School of Public Health, is the nutrition transition.   

“As countries become more urbanised there is an increased availability of tasty, easy-to-store, energy-dense foods,” she said in an AXA masterclass on non-communicable diseases. “These are rapidly replacing more traditional foodstuffs and are high in sugar, salt and fat, but not nutrients.”  

These foods are however more available and affordable than healthier alternatives and are driving the obesity epidemic in LMICs, including South Africa. Obesity is the top risk factor for diabetes and other non-communicable diseases.  

Costs and consequences of the diabetes epidemic  

Dr Elton Mukonda, a researcher in the Division of Epidemiology and Biostatistics in the School of Public Health, estimated the costs of diabetes to the South African public healthcare system. He found that in 2019, it cost the government approximately R15 000 per year, on average, to provide basic medical care for one adult living with diabetes in the Western Cape. Over a lifetime, each patient incurs costs of around R280 000 in direct medical costs.  

“If you only account for the two million adults diagnosed with diabetes and accessing public sector diabetes care in 2019 in South Africa, the public healthcare expenditure on diabetes alone is already R30 billion,” said Mukonda.   

This is a significant share of the country’s 2019 total healthcare spending of around R220 billion.  
 

 The real concern is that approximately 52% of people with diabetes in South Africa are undiagnosed.

“The South African government cannot afford a full-blown diabetes epidemic. The real concern is that approximately 52% of people with diabetes in South Africa are undiagnosed, meaning the actual number may be more than four million,” he added.  

This is why research to inform policy interventions to reduce the burden and effectively manage complications from the disease are so critical.  

Policy-relevant research on lower leg amputations  

One of the major effects of diabetes is nerve and blood vessel damage, which can lead to severe infections and lower-limb amputations. These amputations are costly and devastating, impacting patients, their families, and society. Dave, together with postgraduate researcher, Jemma Houghton and colleagues at Oxford University, are conducting a study investigating the prevalence, risk factors, and predictors of lower-limb amputations in people with diabetes. This research will use data from the Provincial Health Data Centre over the past 10 to 15 years and combine insights from effective diabetic foot prevention programs with patient and healthcare worker interviews to try to shape policy.  
 

We are conducting our research within a clinical setting. That means we’re navigating real-world budget and capacity constraints. Research helps us highlight the true costs of certain diseases and assess the policies managing them.

“We are conducting our research within a clinical setting,” said Dave. “That means we’re navigating real-world budget and capacity constraints. Research helps us highlight the true costs of certain diseases and assess the policies managing them.”  

As an example, he notes that Groote Schuur Hospital employs one podiatrist, but research may well show that, in the face of the costs of amputations, it may be more cost-effective to employ a large team of podiatrists to assist in preventing amputations.  

Prevention through early screening and comprehensive policy  

Professor Dugas stressed the importance of comprehensive policies, that go beyond the healthcare sector, to tackle the nutrition transition that lies at the root of so many NCDs. She advocates for better food labelling, greater taxation of unhealthy foods and policies to hold big food companies accountable, including   incentivising investments into better availability and affordability of healthy foods.  

But changes can also be made at the healthcare level. Dave, Dugas and Mukonda all stressed the value of early screening for better diabetes control. 

“Undiagnosed persons with diabetes are often only diagnosed when they begin to develop complications and need hospital treatment,” said Mukonda.  

For Mukonda it is also about strategies to ensure patients are able to manage their diabetes in ways that do not impact too severely on their lives and livelihoods. Patients often need to travel to larger central clinics for their regular monitoring appointments. This can mean loss of income and additional costs such as transport and childcare. Creating more localised infrastructure so that people living with diabetes do not need to travel for monitoring or medication, would greatly improve management and outcomes.  

At Groote Schuur Hospital there is a strong focus on education, for patients and healthcare workers at all levels of care. The hospital has two diabetes nurse educators on staff who have a very positive impact, but, says Dave, they are overwhelmed.  

To help bridge the gap, Dave and Sister Buyelwa Majikela-Dlangamandla run diabetes education courses for healthcare workers and nurses. These courses aim to ensure access to essential diabetes education at all levels of healthcare, with a particular focus on community healthcare centres, where the burden of diabetes is highest. 

 

Good diabetes management requires a multidisciplinary team, so increasing knowledge on diabetes across different clinical areas can go a long way.

“Good diabetes management requires a multidisciplinary team, so increasing knowledge on diabetes across different clinical areas can go a long way,” he said.  

A controllable condition   

The crucial fact about diabetes, stressed Dave, is that it is manageable, all complications are preventable and people with diabetes can lead long, healthy, productive lives with proper care.  

Through policies that ensure access to healthy foods, early screening, and robust primary healthcare support, South Africa can manage its diabetes crisis and reduce the growing toll of this preventable disease.