VOLUME 9 NUMBER 4 • NOVEMBER 2012
151
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
availability of equipment that works. Useful and relevant data must
be available for research, planning, organisation, management and
policy decisions in the district, clinic or practice. A diabetes check
list that profiles results to facilitate managing individual patient
targets, the early detection of complications or the need for early
follow up or referral is recommended.
18
Strategies for prevention of type 2 diabetes
The prevention of diabetes and promotion of optimal health is
the ultimate goal of family physicians. To achieve this, they need
to actively participate with the individuals and communities they
serve, in promoting good health. Early detection of those at risk
for the development of diabetes and early intervention strategies
can prevent the progression of diabetes and its associated
complications.
The development of approaches and materials to help people
understand their risks for pre-diabetes and how to prevent or cure
the condition should be implemented. This can also be done within
the health district by family physicians at a broader community level
outside of the consultation.
Changing patients’ behaviour through brief motivational
interviewing techniques has been shown to work. Family physicians
should tailor their approach to the patients’ readiness to change.
21
Every consultation in family practice should be seen as a potential
opportunity for prevention of disease and promotion of health,
and behavioural modification where appropriate: the ABCD of the
consultation.
29
Family physicians should play an important role in the
South African Declaration for Prevention and Control of Non-
Communicable Diseases 2020 targets, especially in addressing those
who are overweight or obese, and lifestyle issues such as smoking,
alcohol, hypertension, diabetes, dietary issues, physical activity and
weight loss. Research trials have shown an almost 60% relative risk
reduction for progression of impaired glucose tolerance (IGT) to
type 2 diabetes, providing solid evidence for lifestyle intervention
such as weight loss, diet and exercise modification.
8
Metformin has shown a preventive potential of about 25–30%.
This should be considered for diabetes prevention in high-risk
IGT patients, such as those who have associated hypertensive
disease, hyperlipidaemia, underlying cardiovascular disease, and
previous gestational diabetes, as recommended in the SEMDSA
guidelines.
18
Chronic disease-management programme or model
for diabetes care
There are several barriers to translating the current knowledge
of diabetes care and management into better patient care and
outcomes. Some of these include access to information, additional
decision support, identifying patients with the condition, ready
information at the time of patient visit, burden of care with a
single provider, and lack of community resources. Others, such as
cost, reimbursement, time, staffing, and lack of preparation may
also be barriers to adequate care. The elements of a chronic model
should include a clinical information system, a delivery system
design, decision support, self-management and community
resources.
30
Essentially, healthcare providers, especially family physicians,
need to work together and not in isolation if we want to make a
difference in diabetes care in South Africa. A partnership between
the person with diabetes and healthcare professionals and other
stakeholders (a team approach) is necessary.
In South Africa, the best example of such a chronic disease
management programme is the CDE diabetes management
programme. Diabetic patients should preferably belong to a
chronic disease-management programme for their diabetes care.
Family physicians should encourage their patients in this regard
or alternatively put systems in place to ensure the components
of such a model exist in the practice or in the district for all non-
communicable diseases.
Screening of high-risk individuals
Currently there is no policy for population screening. However, the
consensus is on active case finding and opportunistic screening
based on risk perception. Family physicians have an important role
to play in this regard.
The high-risk groups who should be offered opportunistic
screening are those with a body mass index (BMI) > 25 kg/m
2
with one or more additional risk factors, such as family history of
diabetes (first degree), obesity or central obesity, high-risk ethnic
groups (Indians, all Coloured individuals, black females), age >
45
years, previously identified impaired fasting glucose (IFG) or
IGT, hypertension, polycystic ovarian syndrome, low high-density
lipoprotein (HDL) or raised triglyceride levels, reduced physical
activity, history of gestational diabetes or delivery of a large baby
> 4.5 kg, patients with cardiovascular disease or other conditions
associated with insulin resistance, patients on medications such as
glucocorticoids, thyroid hormones, beta-blockers, thiazides and
phenytoin.
Conclusion
Diabetes is an ever-increasing healthcare problem in South Africa
and throughout Africa. Recent figures for the incidence of diabetes
in districts in the public sector in KwaZulu-Natal indicate that it
may even be higher than that of HIV/AIDS and is increasing rapidly.
This has important financial and human resource implications for
managing non-communicable diseases as aggressively as that
of communicable diseases at present. There is little doubt that
diabetes presents considerable challenges for the family physician,
for other health and allied health professionals, specialists and
endocrinologists and for the patients and their families.
The need for integrative, comprehensive, coherent and
multifaceted preventative strategies is necessary. It is important to
target school children and to screen high-risk individuals. The main
objective for the family physician is to diagnose diabetes early.
Family physicians have a major responsibility to improve care
for people with diabetes, detect and prevent complications early,
and make timeous and appropriate referrals. Several action plans
have been proposed for the optimal management of diabetes in
family practice, such as cardiovascular risk assessments, patient
self-management education, health professional education,
maintaining quality in diabetes care, strategies for prevention of
type 2 diabetes, a chronic disease management plan or programme
for diabetes care, and screening of high-risk individuals in family
practice.
Acknowledgements
I thank Dr Faz Mahomed and Dr Rekha Mohan from Greys Hospital,
Pietermaritzburg for their contributions.
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