By Dr Ryan Ramdass

November is Diabetes Awareness Month and the 14th November is World Diabetes Day.

The Covid-19 pandemic in 2020 has drawn attention to the risks faced by diabetics if they contract the virus. Diabetes is one of the most common comorbidities that leads to complications from Covid-19 infection. Diabetic patients may have an impaired immune response to viral infection which may predispose them to viral pneumonia as well as to potential secondary bacterial infection in the lungs. They also may have developed kidney disease or cardiac disease which would increase the severity of the risk. In this article, Dr R Ramdass unpacks Type 2 Diabetes (T2D) which afflicts 1 in 10 people in South Africa, according to the SA Heart Foundation, and explains how to manage it.

Diabetes mellitus is a group of physiological dysfunctions characterized by hyperglycemia (elevated blood sugar) resulting directly from insulin resistance, inadequate insulin secretion, or excessive glucagon secretion. Type 1 diabetes (T1D) is an autoimmune disorder leading to the destruction of pancreatic beta-cells. Type 2 diabetes (T2D), which is much more common, is primarily a problem of progressively impaired glucose regulation due to a combination of dysfunctional pancreatic beta cells and insulin resistance.

The classification of Diabetes Mellitus extends far beyond Type 1 and Type 2, but Type 2 diabetes is by far the most common. The International Diabetes Federation estimates that we had 4.5 million diabetics in South Africa in 2019 with an expected growth rate of persons diagnosed with T2D of 126% by 2040. Worryingly, the diabetes epidemic parallels that of the obesity epidemic, itself being a significant risk factor for T2D.

Our understanding of this complex condition has come a long way in recent years with an enormous amount of research leading to insights of the disorder, its complications, how to manage its complications, as well as a more recent emphasis on how to prevent it.

The key to diabetes management is about patient education. A successful diabetic is one who understands their condition, is empowered to self-manage, and has the support of their family and healthcare team.

So why do we treat diabetes? Diabetes is treated to relieve a person of the symptoms of high blood sugar levels (fatigue, excessive thirst and hunger, frequent passing of urine) and to reduce infections for example. But importantly, we treat diabetes to reduce complications which are classified into microvascular or small vessel (eye disease, kidney disease, nerve dysfunction) and macrovascular or large vessel (stroke, myocardial infarction and peripheral vascular disease). Diabetes is also associated with depression and an increased risk of suicide in certain vulnerable groups. Mental health is thus a key and often neglected aspect of care.

To mitigate these complications implies addressing multiple targets such as aiming for specific sugar levels, HbA1c targets, cholesterol levels, blood pressure targets and reducing abdominal obesity. These complications need to be actively screened for by your doctor and will necessitate a thorough history and examination with the performance of an ECG, eye and foot examinations with blood tests at regular intervals to name but a few.

The fundamentals of therapy are; diet, exercise and medications, and of course to stop smoking. Diet and exercise therapy alone may not be sufficient in treating diabetes as they do not adequately address the pathophysiologic dysregulation mentioned above and importantly may not address the complications such as heart, eye and kidney disease which may be undiagnosed in a patient with diabetes.

Diet is more than merely avoiding junk foods and carbohydrate-laden meals. It is about healthy eating choices, regular meals and modest portion sizes. Specialized ‘diabetic’ foods are often very expensive and for the preserve of only a few people afflicted with diabetes. Proper education by a dietician and diabetic nurse educator regarding food, its preparation and habits of eating are more valuable than spending money on exotic foodstuffs.

Exercise as a therapy is well-proven to reduce the burden of diabetes by lowering blood sugar levels and blood pressure, reducing body fat and maintaining a healthy heart. Thirty minutes a day (150 minutes a week) of moderate intensity exercise is recommended by local and international guidelines. Some examples are brisk walking, swimming, aerobics, dancing, bicycle riding etc. There is a plethora of data that even starting an exercise program has significant benefits even if the target duration of exercise is not achieved. A diabetic should always consult their doctor before beginning an exercise program. A Biokineticist is a health practitioner who may assist a diabetic with developing a sustainable exercise program based around resources and physical limitations.

As mentioned earlier, the successful diabetic requires the support of their family. To successfully implement healthy food choices and eating habits, the whole family needs to participate. It is often fruitless to have one member of the family change to a healthy diet while everyone else continues as before. Remember, besides being common in our population, T2D has a strong genetic risk. It stands to reason then that the whole family makes a change towards healthy eating and good exercise habits. It goes a long way towards disease prevention.

Medical therapies play a central role in diabetic management and vary from the well-established drug metformin to sulphonylureas and insulin. In recent years, many more classes of medications with unique actions and advantages have become available in South Africa. Examples include DPP4 inhibitors, GLP-1 analogues and SGLT2 inhibitors as well as a plethora of newer combination insulins. Each diabetic requires a personalized approach as they have different requirements, targets and resources necessitating a unique and frequently reviewed prescription. Some of the newer agents focus on weight loss and have cardiovascular advantages for example, but they may not be appropriate or tolerable for all patients. Sexual health and mental health aspects of a diabetic are often overlooked and these need due attention from your doctor or specialist.

So who should be tested for diabetes? All overweight adults at any age if they have at least one other risk factor for diabetes (a family history of T2D, Polycystic Ovarian Syndrome, physical inactivity, race, presence of hypertension etc). In the absence of these risk factors, all other adults are screened from age 45. The preferred screening test for high-risk individuals is the oral glucose tolerance test as it is more sensitive and is the only method for detecting pre-diabetes. Point of care tests such as random testing with a glucometer are not recommended as they may miss a diabetic or pre-diabetic or even a person at risk and there are often no guidelines for follow-up given in this context.

To return to the context of COVID 19 in South Africa, Diabetic patients are vulnerable to infection as much as any other person. The severity of the infection, its course and complications, may be more severe as diabetics may have an impaired immune response (particularly if uncontrolled). The diabetic may well have established cardiac or kidney disease and these factors have been key in the management and outcome of the infected individual. Secondary bacterial infections are prominent because of the prolonged hospital stay, the use of steroid therapy to treat COVID 19 pneumonia and the necessary use of invasive devices like dialysis and central venous catheters to appropriately treat severely ill patients.

There is data to support that poorly controlled diabetics and those patients who are obese do worse with COVID 19 infection. It is thus important that the diabetic not neglect their health during this difficult time. Compliance to management regimes set out by the treating doctor are important. Self-monitoring plays a vital role. Should a diabetic find themselves missing their targets, we advise consulting their doctors earlier either in the office setting or via telemedicine where appropriate. This may mitigate the need to be admitted in hospital to deal with an advanced complication such as diabetic foot sepsis, stroke, kidney failure and even just severely elevated blood sugar levels.

There are guidelines to manage diabetics infected with COVID 19. An important step is to get tested if one has flu-like symptoms, gastroenteritis or unexplained shortness of breath and cough. We advise that the diabetic’s regular doctor be made aware of the diagnosis so that early assessment and management may take place. This often leads to better outcomes in severely ill patients and appropriate home-based care in the patients with mild COVID 19 disease.

Social distancing protocols and mask wearing should be observed. This is effective in reducing the transmission of SARS COV-2. All persons should take care when engaged in work or social activities and be cognizant of the effect COVID 19 may have on a member of their household who is diabetic.

To conclude, COVID 19 will be a constant threat to all diabetics for months to come. It is imperative that a diabetic patient take special care of their condition. They are advised to adhere to management plans and follow up appointments. They must contact their treating doctor for any concerns relating to infection with COVID 19. Early assessment and management of the infection and diabetes itself is key to better outcomes.

The lenmed Group is a world-class chain of Private Hospitals that brings quality healthcare to communities across Southern Africa.

If you have any concerns, please consult your doctor or specialist for more information.

Dr R Ramdass (Specialist Physician with special interests in Type 2 Diabetes and Antimicrobial Stewardship)
Chairperson of Ethekwini Hospital and Heart Centre’s Physician Advisory Board
Ethekwini Hospital Covid-19 Steering Committee, under Chairperson of PAB
Tel: +27 (0) 31 581 2573
Email: [email protected]

Disclaimer: Any information contained here is merely a guideline. Always visit your healthcare practitioner for any health-related advice or diagnosis.