A critical shortage of specialists to treat diabetics is contributing to the treatment challenges for patients in South Africa where the disease is now at “pandemic” proportions, notes MedicalBrief.
This comes as a major international study by The Lancet has found that the number of diabetics worldwide has doubled over the past three decades – up to 800m people – with the increase being worst in low- and middle-income countries.
In South Africa, cases are at “pandemic” proportions, especially among younger people, the experts say, warning that half of those affected have not even been diagnosed and of those who have, most do not have their blood sugar under control.
Contributing to the situation are the limited treatment options available, particularly to the public sector, and the desperate shortage of specialists required by diabetics, including endocrinologists, nephrologists and cardiologists.
There were at least 5.6m diabetics in SA in 2019, and this is projected to rise to 5.7m by 2025 and to 7.2m by 2030, according to advisory firm Percept.
“Only 15% of people with diabetes in our facility are well-controlled. There are similar figures from other facilities and in the private sector,” said Zaheer Bayat, head of internal medicine at Helen Joseph Hospital in Johannesburg.
At an event marking World Diabetes Day last Thursday, Bayat said the country’s growing obesity epidemic is driving the prevalence of type 2 diabetes, which is increasingly being diagnosed in children and young adults.
The event was hosted by the Society of Endocrinology, Metabolism and Diabetes of SA (Semdsa) and Africa’s biggest generic drug maker, Aspen Pharmacare, reports BusinessLIVE.
The Lancet study, published on the same day revealed that globally, diabetes among adults had risen from 7% to 14%, with the fastest increase in low and middle-income countries.
The study put the prevalence of diabetes in SA at 15.5% among women, and at 11.9% among men. The gender gap was apparent in body mass too, with 47% of women and 15% of men classed as overweight in 2022. Among SA children, 9% of girls and 5% of boys were overweight.
It’s the leading cause of death in South African women, and, warn the experts, could potentially turn back the gains made in increasing life expectancy in this country.
Bayat said there was huge disparity in the treatments available to patients, with limited options available to those relying on government facilities and clinics.
“If you have money, there are various oral treatments, and doctors have an armamentarium of drugs. But we have hardly any of them in the public sector.”
Yet even patients in the private sector had limited access to GLP-1 diabetes drugs because of their high cost. Few medical schemes would pay for GLP-1 medicines, and those that did generally only partially funded the treatment, he added.
GLP-1 drugs were originally developed to treat diabetes, but are increasingly also being used for weight loss.
Semdsa president Reyna Daya said it was vital to raise public awareness of the dangers posed by uncontrolled diabetes, which increased the risk of kidney disease and cardiac complications, both of which required highly specialised care.
But, she added, SA is critically short of the necessary specialists like endocrinologists, nephrologists and cardiologists.
In Sub-Saharan Africa, an estimated 24m people have diabetes, and numbers are expected to swell by 130% to reach 55m in 2045.
“So what does that mean for us? Clinicians in the healthcare sector will see two to three times the number of patients we currently see. We already have an overburdened system, and I’m not sure how we’ll be able to manage this increasing number of patients,” she said.
South Africa has the highest prevalence of diabetes on the continent, she added. “Numbers have doubled from 2011. We’re seeing a whole lot of younger patients. And we’ve seen that the youngest reported case of type two diabetes on the continent was actually a child aged four, all related to obesity.
“Compared with the rest of the population and in the world where people are dying at over 60, our patients are dying between the ages of 30 and 60. That’s people who are young adults leaving behind either a single-income household or orphans. This then creates further financial strain and further perpetuates the poverty burden.”
The increase in diabetes cases could drastically affect the life expectancy of South Africans, reducing their lives by between six and 11 years. It also essentially eliminates the gains made in life expectancy through effective HIV treatment.
“This means patients will be dying in their late 40s. Again, I’m going to say the same thing. These are young patients who should be contributing to the economy,” said Daya.
Another challenge facing doctors grappling with the “pandemic” of diabetes is the lack of qualified specialists to treat the disease and its complications.
Daya said that international norms recommend an endocrinologist for every 100 000 patients.
“We ideally should have 675 endocrinologists to focus on the adult population with diabetes and 160 paediatric endocrinologists to treat patients with type 1 diabetes. But the sad reality is that we only have 101 in South Africa
“We’re losing people to retirement. We’re losing people to immigration. So this number is probably underrepresented.”
There is an additional mental health burden accompanying the disease: a global survey by the International Diabetes Federation (IDF) found that the condition has an impact on the mental well-being of three in four South Africans diabetics.
More than three-quarters (84%) of people with diabetes in this country have experienced anxiety, depression or another mental health condition.
Bridget McNulty, co-founder of Sweet Life Diabetes Community SA, said at least 80% of South African diabetics suffer from burnout, a state of physical or emotional exhaustion caused by the daily requirements of managing their condition.
“While diabetes affects both physical and mental well-being, care often focuses only on blood sugar management, leaving many in our community overwhelmed. We need to look beyond blood sugar for a better diabetes life.”
NCD awareness
Aspen Pharmacare has announced it will fund a new Semdsa fellowship in endocrinology, and hopes other corporations would follow suit. The company is pushing into diabetes care, with a contract to manufacture Novo Nordisk’s human insulin and a marketing and distribution agreement with Eli Lilly for its GLP-1 drug Mounjaro that will ultimately see the product made in SA.
Aspen, with Semdsa, has also launched an awareness campaign around the alarming rise and associated risks of non-communicable diseases (NCDs), saying that the increase in diabetes mirrors growing global diagnoses of NCDs.
In South Africa, major NCDs have increased almost 60% over the past decade, and Stavros Nicolaou, Aspen’s senior executive for strategic trade, described this increase as “staggering”.
“Africa was always known as the continent of infectious diseases, but …the face of public health in Africa is changing dramatically. NCDs are now the biggest global killer. And the most prevalent of those is diabetes.”
Nicolaou highlighted the link between obesity, diabetes and cancer, with the former triggering what has become known as the metabolic-cardio-renal complex of diseases.
“If left unarrested, the economic impact of NCDs will significantly over-burden an already highly stretched healthcare system and impact lives and livelihoods,” he said.
He told News24 that South Africa’s biggest medical aid puts 15% of its spending towards diabetes treatment, at a price tag of R9bn.
“In the United States, the spend on diabetes is $210bn. So that’s the size of many economies around the world. It’s not just a public health issue. It’s also an issue around the economy,” he said.
Lancet sounds alarm
In The Lancet analysis, the scientists described the lack of treatment for diabetes as “concerning”, saying that more than half of all cases were found in just four countries in 2022: more than a quarter (212m) lived in India, 148m were in China, 42m were in the US and 36m in Pakistan. Indonesia and Brazil accounted for a further 25m and 22m cases, respectively
Their findings – the first global analysis of diabetes rates and treatment in all countries – revealed that rates of diabetes in adults had risen from about 7% to about 14% between 1990 to 2022.
For their study, the scientists at NCD Risk Factor Collaboration (NCD-RisC), in collaboration with the World Health Organisation, used data from more than 140m people aged 18 or older from more than 1 000 studies in different countries. They applied statistical tools to enable accurate comparisons of prevalence and treatment between countries and regions.
The Guardian reports that growing health inequalities were highlighted in the study.
Dr Ranjit Mohan Anjana, the joint first author and president of the Madras Diabetes Research Foundation in India, said: “Given the disabling and potentially fatal consequences of diabetes, prevention of the condition through healthy diet and exercise is essential for better health throughout the world.
“We need to see more ambitious policies, especially in lower-income regions, that restrict unhealthy foods, make healthy foods affordable and improve opportunities to exercise, through measures like subsidies for healthy foods and free healthy school meals as well as the promotion of safe places for walking and exercising, including free entrance to public parks and fitness centres.”
Despite the availability of effective, off-patent glucose-lowering medications, lack of treatment is also fuelling inequalities, the study found. While many, often higher-income countries have seen vast improvements in treatment rates, with more than 55% of adult diabetics receiving treatment in 2022, for many low and middle-income countries the proportion receiving treatment has not improved.
Consequently, more than half of adults with diabetes – 445m (59%) – aged 30 and over did not receive treatment in 2022.
MSF slams Novo Nordisk
Meanwhile, Doctors Without Borders (MSF) staged a protest last Thursday outside Novo Nordisk’s Johannesburg headquarters, calling for the corporation to not discontinue producing human insulin in pens, and for all other insulin manufacturers to price insulin pens at US$1 per pen.
Since 2014, South Africa’s public health system has provided insulin in pen format, making it easier for patients to accurately dose insulin on-the-go. But a decision by Novo Nordisk to discontinue the pens will force patients to revert to syringes, complicating diabetes care.
For millions of people on insulin who overwhelmingly prefer pens for their convenience, safety, and reduced risk of incorrect dosing, this switch is both challenging and risky.
Candice Sehoma, MSF Access Campaign Advocacy Advisor, told Health-e News that at least 82% of people with type 1 diabetes prefer using insulin pens.
“Some people have been using these since 2014 when South Africa first started administering them…. now they have to get acquainted with a whole new method,” she said.
She accused Novo Nordisk of double standards. “Diabetics in high-income countries don’t have to use vials. Even the agreement between Novo Nordisk and Aspen does not include Aspen making insulin pens, only vials and syringes, which is telling. People living in low- and middle-income countries deserve a better standard.
“When South Africa made the switch from pens to vials, we did a cost-of- production study looking at the price to actually make these diabetes medicines. This includes insulin and the new innovative drugs like Ozempic and Wegovy.
“We found these insulin pens can be sold for at least $1… and that pharmaceutical companies can still make good profits selling them at that price. So at this point, it’s still being overcharged.”
Drugmakers, she added, were making greater profits in high-income countries through Ozempic and Wegovy and had thus shifted manufacturing priorities to making human insulin in pens.
MSF and public health authorities have explored potential avenues of supply for the pens, and one solution was analogue pens.
But they cost more than human insulin pens, being at least two to three times more expensive.
“So we want pharmaceuticals to drop the price of human insulin pens to around $1,” Sehoma added.
Last week’s protest also called for pharmaceutical companies to share their technology.
“If they’re having limitations in capacity to manufacture human insulin and pens, they should share their technology and licensing with other local manufacturers, like Aspen, to ensure a diversification of the manufacturing of these medical tools.”
BusinessLIVE article – Experts warn SA in the grip of a diabetes pandemic (Restricted access)
News24 article – SA’s life expectancy gains plummet with diabetes rise (Restricted access)
See more from MedicalBrief archives:
At least 60% of Africa’s diabetes goes undiagnosed – global report
SA’s insulin pens supply dries up as weight-loss drugs take priority
SA stocks of diabetes drug drained after global weight loss frenzy
SA’s diabetes crisis needs urgent response
Aspen contracted to produce insulin for Africa