There's a lot the world can learn from a medical team working in small-town KwaZulu-Natal, and treating diabetes through innovation and collaboration.
Tongaat is synonymous with one thing – sugar. Sugar cane plantations radiate out into the distant horizon from the KwaZulu-Natal provincial town’s commercial centre. Located about 35 km north of Durban, the local sugar agriculture and agri-processing industry has, for over a century, employed generations of locals – many of them members of what is said to be the oldest Indian community in South Africa.
Ironically, the over-consumption of refined, processed sugars is one of a number of factors that precipitate a deadly non-communicable disease (NCD) - a disease caused by unhealthy living or what medical experts call ‘modifiable risk factors’. It’s a disease that is ravaging Tongaat, the rest of South Africa, Africa. In fact, Type 2 diabetes mellitus (T2DM), in both its insulin medication-dependent and non-dependent forms, has reached epidemic proportions across the planet.
There are also two other, less common, forms of diabetes. Type 1 (early-onset) diabetes is immune-mediated, and occurs when the insulin-producing cells in a person’s pancreas are damaged. Then, Gestational diabetes affects pregnant women who start to exhibit high blood glucose levels for the first time during pregnancy as a result of hormonal changes.
In contrast, T2DM is part of the so-called Metabolic Syndrome spectrum - largely the result of unhealthy living. The Mayo Clinic explains Metabolic Syndrome as a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels - that occur together, increasing risk of heart disease, stroke and diabetes. T2DM is generally found in people with a large waist circumference, high blood pressure, high cholesterol and fatty liver. While the T2DM epidemic closely follows the epidemic of overweight and obesity, it doesn’t require obesity to develop. But, its prevalence increases with weight gain and an escalating Body Mass Index (BMI). Most people with T2DM have a BMI of between 25-30kg/m2.
Diabetes costs an arm and a leg
According to a landmark study on diabetes in Sub-Saharan Africa, published in the journal Lancet, between 1980 and 2015, the number of people older than 20 years with a BMI of greater than 25 kg/m² increased from 28 million to 127 million, while the disease burden attributed to diabetes increased by 88%. Authors add, “More than 90% of diabetes cases in sub-Saharan Africa are T2DM, suggesting that modifiable risk factors are major contributors to the burden of disease.”
Which modifiable risk factors trigger T2DM? They include a genetic predisposition for diabetes (strong among Indian people) that’s activated by the very same lifestyle choices that cause diabetes overall: unhealthy eating a diet high in junk or refined food that’s high in sugar and fat, and lacking in whole grains, fibre, fruit vegetables and healthy protein sources, poor stress management, smoking, excess alcohol intake, inadequate sleep and the highly sedentary lifestyle typical of most urban people.
These habits are costing us a fortune. Authors of the Lancet study estimate that in 2015, the overall cost of diabetes in sub-Saharan Africa was $19.45 billion or 1.2% of cumulative gross domestic product (GDP). “We estimate that the total cost will increase to between $35.33 billion (1.1% of GDP) and $59·32 billion (1.8% of GDP) by 2030.”Dr Maurice Goodman, Discovery Health’s Chief Medical Officer adds, “The accumulated losses to South Africa’s GDP between 2006 and 2015 from diabetes, stroke and coronary heart disease alone are estimated to have cost the country USD 1.88 billion.”
Symptoms of diabetes include fatigue, excessive thirst and urination, slow wound healing and skin infections, blurred vision and regular bouts of thrush. “As these symptoms can be very mild and develop gradually, many people fail to recognise them as warning signs of diabetes,” says Dr Goodman. “Around a third of people have already developed T2DM’s complications – from heart disease to stroke, blindness, amputations and kidney failure – by the time they are diagnosed. Prevention is first prize. Then, early diagnosis and proper treatment are fundamental.”
Alarmingly, particularly on the African continent, outdated registries mean that the true extent of the diabetes problem isn’t known. What do we know? The International Diabetes Federation reports that, globally, 425 million people have diabetes. There were 1 826 100 cases of diabetes in South Africa in 2017. In Africa, diabetes affects an estimated 16 million - and by 2045 this will sky rocket to around 41 million people.
A recent report from the Centre for Diabetes and Endocrinology (CDE) takes the story further: “We need to look back. In 2010, the prevalence of type 2 diabetes in South Africa was estimated at 4.5 %. In the six years that followed, there’s been a 155% increase.” The report asks whether, six years from now, there will be another 155% increase, with 5.97 million adults living with diabetes, or whether the increase will be even greater? The limited data also suggest that there are up to 2.4 million people with undiagnosed diabetes. And, the prevalence uncertainty range is between 3.6 and 14.1% so the data is a ‘guesstimate’. A review protocol published in June 2018 in British journal, BMJ Open reports that globally, approximately 50% of diabetes cases are undiagnosed, with the majority of these occurring in low-income and middle-income countries. In Africa, the proportion of undiagnosed diabetes is 69.2%. Furthermore, 77% of deaths due to diabetes in Africa occurred in individuals younger than 60 years of age, emphasising the magnitude of the diabetes epidemic.
Here’s a fascinating warning sign of what could come: impaired glucose tolerance (IGT). The CDE states that, “Approximately 30% of people with IGT develop diabetes within 11 years. In 2013, it was estimated that 2.653 million people in South Africa have IGT. Thus, a further 795 900 from this population may develop diabetes within 11 years. Given that rates of progression from IGT to diabetes in South Africa are unclear, could it be more than 30% over 11 years?”
And, according to another Lancet study published in June 2018, nearly six percent of new cancers diagnosed worldwide in 2012 - some 800,000 cases - were caused by the combined effects of T2DM and excess weight (high BMI). The prevalence of both these risk factors has increased substantially in the past four decades in most countries – South Africa no exception. Examining 12 cancers in populations in 175 countries, researchers noted, “The largest proportion of cancer cases attributable to the increase in prevalence of diabetes and high BMI during this period (1980-2002) was in low-income and middle-income countries (LMICs) in Asia and sub-Saharan Africa. Our results suggest that the increases in diabetes and BMI worldwide could lead to a substantial increase in the cancer burden in future decades.”
Diabetes ravages Dr Govender’s family
These grim statistics call for radical new ways of battling diabetes and brings focus back to Tongaat where Dr Sudeshan Govender (Tongaat born-and-raised) runs a practice in the town’s centre - as he says, “on the Harley Street of Tongaat.” Once inside, one hears constant rhythm of vehicles and passengers arriving at the adjacent taxi, train and truck ranks (convenient for patients in transit who require medical care) along with the bustle of the local marketplace with its pavement-based hawkers, busy bakeries and local stores selling everything from fruit and veg to fast food, fabric and pharmaceuticals.
Few people understand the tragedy of diabetes better than, Dr Govender: “Many members of my mother’s side of the family never made it past their fiftieth birthday,” he says. “I watched family members die of heart attacks, kidney failure, amputation of limbs and strokes – all the complications associated with unmanaged diabetes.” Over the past few years, he’s seen the same tide sweep through his practice’s doors. He’s approaching diabetes with a novel approach, backed by the Diabetes Care programme and getting excellent results. “I’ve surrounded patients with an interdisciplinary team of experts to cover every front in the fight against diabetes. “It’s affordable and practical,” he says.
Dr Govender eats, sleeps and breaths gadgets and new tech. So, when Discovery Health’s Electronic Health Record – HealthID – was launched in 2012, he suddenly had access to data, analysed to reflect his practice-trends. “It was an epiphany. Looking at the data year-on-year, I saw that the majority of my patients had diabetes and that I needed to do something about it. So, in 2015, we cordoned off a section of the clinic and dedicated it entirely to treating diabetes. It’s impossible for GPs and primary care providers to fight a solitary battle against one of the world’s leading threats. You have to do it as an Interdisciplinary Team (IDT).” Dr Govender also uses the app-based platform Discovery DrConnect, to carry out virtual consultations with established, remote patients to ensure regular contact.
Many of Dr Govender’s patients are low-income earners, on entry-level, private healthcare plans. Those who are members of medical schemes administered by Discovery Health and registered on a Chronic Illness Benefit, have voluntary access to Diabetes Care.
Members are reminded to visit a team of healthcare providers including their GP, biokineticist, dietician, ophthalmologist and podiatrist, who access each other’s notes and patient data electronically through HealthID,” says Dr Goodman. “Typically, our private health care system offers no one-stop shop. So, patients deal with different doctors who don’t talk to each other. That leads to poor outcomes. An interdisciplinary team (IDT) approach overcomes this. “Members on Diabetes Care access a network of service providers who are incentivised to actively manage the patient through consultations and regular laboratory tests to assess and monitor their diabetes control, kidney function, and cholesterol.”
Diabetes Care backs Tongaat-team’s diabetes fight
Back in Tongaat, in 2015, this model fuelled the creation of the diabetes-dedicated wing at Dr Govender’s practice. Here, his hand-picked team - a dietician and biokineticist, a podiatrist and ophthalmologist - meet patients at over two consecutive days. “Patients can’t afford to travel to five individual practices, so we bring the experts to them,” says Dr Govender. “We provide integrated input and make decisions together about each patient’s care. We involve the patient all the way as they show far much more endurance in maintaining the healthy habits we try to instil, if they are part of the decision-making.” He says.
In line with global trends, over the past five or six years, there’s been a 40% increase in diabetes among members of South Africa’s largest open scheme - Discovery Health Medical Scheme members, with an 8.8% increase (to 110 626 people) between 2017 and 2018 alone. “People living with chronic illnesses such as diabetes, cost this scheme four times more than the average patient costs every year, raising healthcare costs across the board,” says Dr Goodman.
Diabetes Care was launched in January 2017. By June 2018, 13003 Discovery Health Medical Scheme members had signed up. “The majority are Type 2 non-insulin dependent (8603), followed by Type 2 insulin-dependent diabetes (3949) and Type 1 diabetes (451),” says Dr Goodman. “Around 80% of members have chronic heart problems too. Many have also had a stroke or have retinopathy (damage to retina) or peripheral vascular disease linked to unmanaged diabetes. Their cardiac and cardiac-renal co-morbidities are behind the highest diabetes-related claims to the Discovery Health Medical Scheme.”
Meet the diabetes expert team
Dr Govender and his team are not alone. A 2016 study, cites various real-world examples of globally-based IDTs working towards T2DM management: “IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT is paramount to enabling the best care to be delivered. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical.”
As, registered dietician on the team, Barbara Knoetze’s role is to focus on medical nutritional therapy. She tailors eating plans to each patient’s needs and uses affordable, culturally-typical foods that patients already consume – making minor changes to bring in more vegetables and decrease sugar and fat content. “As the right foods and fluids are critical to stabilising blood glucose levels, we set goals such as blood-glucose testing before and after meals. When patients finally understand how foods affect their diabetes, there is a real enthusiasm to make necessary changes.”
Podiatrist, Dinesh Deonarain, plays a key role: “High blood glucose levels damage small and large blood vessels and nerves throughout the body. Once blood flow is affected, circulation decreases – particularly in the feet as the vessels in this area are furthest from the heart and particularly narrow. My patients know to regularly examine their feet for any marks or lesions, discoloration, moisture entrapment between the toes, cracks and wounds in the heels, lack of feeling and pins and needles.” Ultimately Deonarain ensures early diagnosis of any issues that might escalate to amputations - typical of unmanaged diabetes.
Ophthalmologist, Dr. Yavische Reddy, carries out routine screening tests for diabetic eye disease, so to prevent blindness. “Most patients develop complications, ten to fifteen years after the onset of diabetes,” she says. “Diabetic retinopathy happens when high blood glucose levels damage the small-calibre blood vessels that supply blood to the eye, triggering inflammation and cutting off oxygen and nutrients to the retina - which then starts to make its own, abnormal blood vessels. They are fragile and break. The bleeding destroys vision and the optic nerve. Diabetes also causes cataracts, dry-eye, as well as cranial nerve palsy.”
Biokineticist, Kiruben Naicker’s father, four brothers and five sisters are all diabetic. And, a few years back, pre-diabetic symptoms manifested in his own body. “I changed my diet, exercised and lost 8 kg,” he says. “These are the benefits I want patients to see.” He develops individualized, aerobic and resistance training exercise plans for each patient and demonstrates them over the two-day visit. “Exercise improves health on so many levels and enhances insulin sensitivity.”
Four case studies: ‘Diabetes in control’ to ‘Diabetes control’
Ashorilall Madho grew up on a farm near Tongaat. “We were very poor. We began to drink alcohol and smoke at a very young age,” says the 65-year-old. Madho lost all six of his brothers to diabetes and was diagnosed in 1999. “One day, while cooking dog food outside over a fire, I stood on a big piece of red charcoal that burnt through the sole of my foot, into my skin. I didn’t feel a thing,” he says. His disease worsened progressively, and in 2014 he started seeing Dr Govender. By then he had a stent in his heart and in one leg and he’d had two mild heart attacks. Today, he sings the praises of the IDT approach. “These professionals have changed my life,” he says. Dr Govender adds, “Mr. Madho has really educated himself about diabetes and now teaches people in his community about healthy living. His HbA1c has gone down 0.8%, and though he has many co-morbidities, I believe he will only continue to show progress.”
Both Dhevan Govender’s mother and father were diabetic. When diagnosed with diabetes at age 20, he was morbidly obese. No scale could read his weight. He wore a 6 XL shirt. “He’s worked hard and come down to a 2 XL and brought his blood pressure under control. “Diabetes caused my father to go into kidney failure before he died. He was on constant dialysis and lost his sight. I had to take on running the family business (selling ice-cream wholesale) at a young age when he died. I gained even more weight then,” says the 30-year-old. When his daughter was born in December 2014, he determined to end the diabetes cycle in his family. “I walked morning and evening and cut down on my food intake. The support of the IDT at Dr Govender’s practice has made all the difference and helped me through every kilo that I lost.”
Mrs Shusheelathavee Chunder was born in Tongaat and also grew up in a very poor family. Today, she and her children run a local events and catering business. Her deceased mother, father and brother, as well as two living sisters have all been affected by diabetes. Her symptoms began in the early 1990s. She lived with unmanaged diabetes for years, often going into diabetic coma when her blood sugar levels plummeted to dangerously low levels. “I was rushed to hospital in the middle of the night, countless times.” After joining Diabetes Care and accessing the IDT’s advice, she lost 12 kg to date and also lowered her HbA1c readings. “I walk and go to gym every day. And, we no longer prepare food using excess unhealthy oils and sugars. I feel like I’m twenty again, not sixty plus years old,” adds Chunder. “Her cholesterol has dropped from a dangerous level of 10 mmol/L to a healthy 4mmol/L. She has cataracts and these are managed through Dr Reddy,” explains Dr Govender.
Tongaat-born, Siboniso Ntuli was diagnosed with diabetes in 2011. “My blood sugar levels were so high, I ended up in ICU and missed a near-stroke,” he recalls. “I want to see my children grow up and so I have dedicated myself to living healthily since meeting Dr Govender and his team. I walk three to four kilometres, twice or four times a week, and have lost weight. I eat far less oily food and drink water instead of fruit juices and cold drinks. And, I don’t overeat,” he adds. His is an insulin-dependent Type 2 diabetes – which means he injects himself with insulin-medication, daily. “I have educated so many people in my community about diabetes and taking responsibility for the condition.”
Two years in, what do the results show?
“Two years in, my patients with diabetes show between a 0.5% and 2% drop in their HbA1c levels,” says Dr Govender. When the body processes sugar, glucose in the blood stream attaches to haemoglobin in red blood cells. The lower one’s HbA1c reading (measured via blood test) the lower one’s average level of blood sugar over the past few months, indicative of good blood sugar control. “We’ve dropped the insulin doses some patients take and some have come off insulin entirely and now manage their diabetes solely through lifestyle modifications. And, on average, patients have achieved around a 15% reduction in weight. We are encouraged to continue,” adds Dr Govender.
Compared to non-programme members, members engaged in Diabetes Care have almost triple the number of visits to dieticians, biokineticists, podiatrists and optometrists. “In terms of screening and monitoring tests we also see a significantly higher number of HbA1c, lipogram and kidney function tests among Diabetes Care members. Overall, they do far better across all metrics. Diabetes Care members show far higher enrolment in chronic illness programmes that govern cancer, kidney and heart disease care, have between 10 and 20% lower admission rates as well as up to 6% lower re-admission rates. Their in- and out-of -hospital claims are also up to R2000 less per member, per month,” adds Dr Goodman.
“Exercise and healthy eating are fundamental to diabetes management. So, it’s interesting that majority of Discovery Health Medical Scheme members who have diabetes are either not on Discovery Vitality (the science-based wellness programme that rewards members for healthy living) – or are on Blue Vitality status, the lowest of five status levels,” says Dr Goodman. “Recently, results of the largest study done on physical activity (tracking 130000 people in 17 countries) showed that one in 12 deaths could be prevented through a mere 30 minutes of physical activity, five times a week. “That’s only 150-minutes a week of anything from walking to vigorous household chores. The results also showed that prevalence of diabetes decreased from 12% to 8% as levels of physical activity increased from ‘low’ to ‘high’.”
Placing diabetes high on the global political agenda
Stats SA’s 2016 Mortality Report (tweeted released end march 2018) reported that tuberculosis (TB) and diabetes (diabetes is responsible for 5.5% of deaths recorded in 2015) remain the top two killers among South Africa’s population – ahead of heart disease, cerebrovascular disease, HIV and hypertension. Diabetes was also ranked second in ‘underlying natural causes of death for people aged 45-64’, followed by HIV.
“NCD Countdown 2030” is a recently launched, collaborative effort from the World Health Organisation, NCD Alliance, Imperial College, and The Lancet and uses trends in mortality from 2010 to 2016 to determine country-specific baseline data and rates of decline in premature mortality from the four major NCDs: cardiovascular disease, cancer, chronic respiratory disease, and diabetes. This global problem requires team work. On 27 September 2017, representatives of member states gathered for the third UN High-Level Meeting on NCDs to review global prevention, treatment and management progress towards fighting the global NCD burden, diabetes front and centre.
Words from a recent article by President of the International Diabetes Federation, Dr Shaukat Sadikot say it all: “The 415 million people living with diabetes today may be seen as a statistic on a health report. The real crisis can be too easily underestimated, misunderstood and ignored. In 2011 when the 5th edition of the IDF Diabetes Atlas came out, it had a significant amount of data but one stood out. One person died of diabetes related complications every SEVEN seconds! Then in 2013 when the 6th edition came out, it showed that one person dies of diabetes related complications every SIX seconds! It is time to come down from the ivory towers and experience the ground realities. Big “talk” and quoting statistics have little value if we do not do initiatives which will improve the lives of all our people with diabetes.”