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VOLUME 14 NUMBER 1 • JULY 2017
15
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
are some of those in the system that have an influence on diabetes
care and psychosocial well-being. For instance, there are beliefs that
girls with diabetes cannot give birth, and in developing countries, a
good number of patients with diabetes consult traditional healers
who claim to be able to cure diabetes.
32
National health policies also influence diabetes care. Diabetes
and obesity, for example, have social aetiological roots in the
structure and lack of regulations on the food and tobacco industry,
and the cultural tradition of a sedentary lifestyle. Santé diabètes,
a non-governmental organisation working in the area of diabetes
in Africa, points out that in recent years, there has been an
overweight problem in Africa, especially with the sharp increase in
the consumption of food that contains more saturated fat, and an
increasing number of people with a sedentary lifestyle, as a result of
rising income and urbanisation in Africa.
43
Urban lifestyle in Africa is
characterised by changes in dietary habits involving an increase in
consumption of refined sugars and saturated fat and a reduction in
fibre intake.
44
These changes will probably further increase the risk
of obesity and death.
Obesity in turn is particularly associated with an increased risk of
developing T2DM. Moreover, sub-Saharan African consumers are
increasingly aspiring to fast-food choices and most African countries
such as Zambia, South Africa and Nigeria are among the top fast-
food establishment destinations.
45
Consequently, urbanisation and
its consequences on diabetes may increase the risk of stress and
depression, which may compromise diabetes care. The development
of stress and depression associated with urbanisation may also lead
to the development of diabetes. The circle is a vicious one, which
may also lead to other psychosocial problems such as increase in
treatment costs, discrimination and poor QoL, among others.
Other macrosystem influences on diabetes include healthcare
policies or guidelines such as the standards for diabetes medical
care by the America Diabetes Association, which spell out how
diabetes care should be effected.
13
Although in some countries, non-
communicable disease policies and departments are in existence,
their capacity to provide adequate medical care for persons with
diabetes mellitus and also the prevention of T2DM is way below
expected standards. For instance, in Zambia and Mozambique,
referral pathways are poorly used and sometimes non-existent.
46
The Diabetes Foundation and International Insulin Foundation
(IIF) found that three main problems were related to referrals in
Zambia:
• lack of information given to users about their diagnosis in
general and specifically about the reason for the referral
• many of the patients referred were not given a letter, which
should have facilitated their entry into the hospital system
• lack of linkage from the hospital, back to the urban health
centres for follow up.
A survey by IIF showed that healthcare workers where often (no
figures reported) unfamiliar with the management of uncommon
diseases such as diabetes. Diabetes was often mistaken for cerebral
malaria; 21 out of 199 patients in Tanzania who were diagnosed
as having cerebral malaria actually had diabetes mellitus.
46
To make
matters worse, there is a lack of qualified human resources, essential
medical drugs and poor access to health facilities, especially among
rural clients. When medical drugs are available, they are expensive
due to taxes and the procurement procedures.
47
Budget allocations to healthcare, especially diabetes, are crucial
determinants of the nature of care patients will receive. In 2009,
the World Health Organisation reported that the 7.02 million cases
of diabetes recorded by the WHO in African countries resulted
in a total economic loss of US$ 25.51 billion, a figure which has
since increased.
48
Political will and increased budget allocation to
non-communicable diseases such as diabetes remain a challenge
in most developing countries. Some countries such as Zambia
subsidise the cost of medicines to make them accessible to patients.
In addition, educational policies that encourage physical education
can contribute to reducing the traditional sedentary lifestyle in
children.
Time
A good example of how the chronosystem affects diabetes
care and psychosocial well-being can be seen by examining the
‘honeymoon’ period. The honeymoon period is the time in people
with T1DM shortly following diabetes diagnosis when the pancreas
is still able to produce a significant amount of insulin to reduce
insulin need and aid blood glucose control. Children with T1DM
have often shown adjustment problems at the onset of diagnosis
and after the honeymoon period is over.
49,50
Children find it difficult
to adjust, especially injecting themselves with multiple insulin doses
and adjusting their diet. This period is also when most adolescents
experience stress related to diabetes care.
32
The duration of diabetes from diagnosis plays a role in a child’s
psychological well-being. Thedevelopmental stage andphysiological
differences related to sexual maturity are crucial in deciding and
implementing an optimal diabetes regimen plan.
13
In adolescents,
non-adherence problems can be a result of the increase in counter-
regulatory hormones (e.g. growth hormones, cortisol, epinephrine
and glucagon) responsible for insulin resistance, a situation also
known as the ‘dawn phenomenon’.
51
This phenomenon is the
night-to-morning elevation in blood glucose levels before and after
breakfast in subjects with both T1DM and T2DM. In people without
diabetes mellitus, blood glucose and plasma insulin concentrations
remain remarkably flat and constant overnight, with a modest
transient increase in insulin secretion just before dawn to restrain
hepatic glucose production and prevent hyperglycaemia.
52
People
without diabetes mellitus do not show symptoms of the dawn
phenomenon.
Another issue worth discussing that occurs during the course
of a person’s development is the types of diabetes in relation to
their age. The onset of T1DM can occur at any age, but is generally
before the age of 40 years, while T2DM often has its onset after
the age of 50 but can also develop before the age of 50 years.
2
However, due to demographic changes, people younger than 18
years old are now increasingly being diagnosed with T2DM.
The time component of Bronfenbrenner’s model refers not
only to chronological age and duration but also to the nature of
periodicity. As alluded to earlier, in developing countries, changes
in demographic characteristics and the rise of the middle class
entails there will be a sharp increase in the consumption of food
containing more saturated fat and an increasing number of people
with a sedentary lifestyle.
Clinical and research implications
Tobeginwith,cliniciansandresearchersshouldtakeintoconsideration
the processes (proximal and distal), personal characteristics of the
child with diabetes, micro-, meso-, exo- and macrosystems in which
a child with diabetes lives and the chronosystem, and how these
influence diabetes care and psychosocial well-being. Clinicians and