The estimated national prevalence of diabetes (based on HbA1c) in persons older than 15 years was 9.5% (2012), and about 45% of these individuals were undiagnosed. An additional 9% of the South African population had abnormal glucose regulation defined by an HbA1c between 6.0 and 6.4%.

“Everyone needs to know how to manage and diagnose diabetes. We all need to know about diabetes.”

This is the view of Dr Joel Dave, part of JEMDSA’s expert committee for the 2017 guidelines for the management of type 2 diabetes mellitus. He presented his findings at Qualicare’s Open Day in CapeTown recently.

“NCDs caused most deaths in 2015. Young people in Africa are dying of diabetes,”   he said. The estimated national prevalence of diabetes (based on HbA1c) in persons older than 15 years was 9.5% (2012), and about 45% of these individuals were undiagnosed. An additional 9% of the South African population had abnormal glucose regulation defined by an HbA1c between 6.0 and 6.4%.

The Asian and coloured populations have the highest prevalence of diabetes in SA. The prevalence of diabetes in rural dwellers appears to be increasing rapidly. The number of people living with diabetes in Africa is predicted to increase by 140% by the year 2040. The number of deaths globally from diabetes exceeded the combined mortality from HIV/AIDS, TB and malaria in 2015.There are clearly modifable risk factors driving the diabetes epidemic; the rising prevalence of obesity is one of the most important.

Glucose management

 

Recommendations for metformin

Initiate standard-release metformin therapy in all newly diagnosed obese patients with type 2 diabetes. Initiate standard-release metformin therapy in all newly diagnosed nonobese patients with type 2 diabetes. Dosing: Start with 500mg once daily and up-titrate the dose slowly every 10 to 14 days until glycaemic targets are met or side effects occur. Few patients will achieve and maintain glycaemic targets with 500 mg once daily. Most patients will require1000-2550mg per day in two or three divided doses.

The optimum dose for cardiovascular benefit in obese patients is 2550mg/day (850 mg TDS). The estimated national prevalence of diabetes (based on HbA1c) in persons older than 15 years was 9.5% (2012), and about 45% of these individuals were undiagnosed. An additional 9% of the South African population had abnormal glucose regulation defined by an HbA1c between 6% and 6.4%. The Asian and Coloured populations have the highest prevalence of diabetes in SA, while the prevalence of diabetes in rural dwellers appears to be increasing rapidly.

The number of people living with diabetes in Africa is predicted to increase by 140% by the year 2040. The number of deaths globally from diabetes exceeded the combined mortality from HIV/AIDS, TB and malaria in 2015.

There are clearly modifable risk factors driving the diabetes epidemic; the rising prevalence of obesity is one of the most important.

Recommendations

According to the SEMDSA 2017 Guidelines:

Recognise that the clinical stages of hyperglycaemia include intermediate hyperglycaemia (impaired fasting glucose and impaired glucose tolerance) and diabetes mellitus. Intermediate hyperglycaemia represents a high risk state for future diabetes and cardiovascular disease.

Always consider the aetiological classification of diabetes mellitus at diagnosis and review this periodically. Be aware that latent auto-immune diabetes of adulthood, maturity onset diabetes of the young, other endocrinopathies, glucocorticoid-induced diabetes and pancreatic diabetes are not uncommon disorders.

The clinical distinction between type 1 and type 2 diabetes can be difficult especially in younger individuals, and in those with ketosis-prone (type 2) diabetes. These individuals should be referred to an endocrinologist without delaying treatment. The need for insulin treatment at diagnosis cannot be used as the basis for aetiological classification. Be aware that the classification of hyperglycaemia first detected in pregnancy has been updated by the World Health Organization and adopted by SEMDSA. Patients with diabetes should be seen by dedicated staff at a clinic/facility with adequate space and resources (equipment and medication).

The diabetes consultation should be a structured one. The use of standardised diabetes consultation templates is encouraged to ensure that essential assessments / processes of care are not omitted. At each visit, the patient should have a history taken, undergo a clinical examination and have blood taken for biochemical evaluation. The complexity of each will be dependent on whether it is an initial consultation, follow-up consultation or an annual review.

People living with diabetes should be offered structured diabetes education at diagnosis and this should be consolidated at regular intervals. Diabetes self-management education and support (DSME/S) should be patient-centred, respectful and receptive to individual needs and values; and non-discriminatory towards cultural, ethnic language, socio-economic and educational differences.

DSME/S should incorporate cognitive-behavioural interventions, the practical application of knowledge and aim to increase patient participation in decision making. DSME/S should be managed by accredited health care professionals who have been appropriately trained in the execution of evidence-based principles. Trained community health workers should provide education through home visits, create awareness and encourage adherence. SEMDSA recommends that DSME, provided by health professionals in a format endorsed by SEMDSA and DESSA, should be reimbursed according to NHRPL guidelines.