The 2012 SEMDSA Guideline for the Management of type 2 Diabetes

Clinical and Economic Assessment of MyDiaCare, Digital Tools Combined With Diabetes Nurse Educator Support, for Managing Diabetes in South Africa: Observational Multicenter, Retrospective Study Associated With a Budget Impact Model

BACKGROUND

In South Africa, diabetes prevalence is expected to reach 5.4 million by 2030. In South Africa, diabetes-related complications severely impact not only patient health and quality of life but also the economy.

OBJECTIVE

The Diabetes Nurse Educator (DNE) study assessed the benefit of adding the MyDiaCare program to standard of care for managing patients with type 1 and type 2 diabetes in South Africa. An economic study was also performed to estimate the budget impact of adding MyDiaCare to standard of care for patients with type 2 diabetes older than 19 years treated in the South African private health care sector.

METHODS

The real-world DNE study was designed as an observational, retrospective, multicenter, single-group study. Eligible patients were older than 18 years and had at least 6 months of participation in the MyDiaCare program. The MyDiaCare program combines a patient mobile app and a health care professional platform with face-to-face visits with a DNE. The benefit of MyDiaCare was assessed by the changes in glycated hemoglobin (HbA1c) levels, the proportion of patients achieving clinical and biological targets, adherence to care plans, and satisfaction after 6 months of participating in the MyDiaCare program. A budget impact model was performed using data from the DNE study and another South African cohort of the DISCOVERY study to estimate the economic impact of MyDiaCare.

RESULTS

Between November 25, 2019, and June 30, 2020, a total of 117 patients (8 with type 1 diabetes and 109 with type 2 diabetes) were enrolled in 2 centers. After 6 months of MyDiaCare, a clinically relevant decrease in mean HbA1c levels of 0.6% from 7.8% to 7.2% was observed. Furthermore, 54% (43/79) of patients reached or maintained their HbA1c targets at 6 months. Most patients achieved their targets for blood pressure (53/79, 67% for systolic and 70/79, 89% for diastolic blood pressure) and lipid parameters (49/71, 69% for low-density-lipoprotein [LDL] cholesterol, 41/71, 58% for high-density-lipoprotein [HDL] cholesterol, and 59/71, 83% for total cholesterol), but fewer patients achieved their targets for triglycerides (32/70, 46%), waist circumference (12/68, 18%), and body weight (13/76, 17%). The mean overall adherence to the MyDiaCare care plan was 93%. Most patients (87/117, 74%) were satisfied with the MyDiaCare program. The net budget impact per patient with type 2 diabetes, older than 19 years, treated in the private sector using MyDiaCare was estimated to be approximately South African Rands (ZAR) 71,023 (US $4089) during the first year of introducing MyDiaCare.

CONCLUSIONS

The results of using MyDiaCare program, which combines digital tools for patients and health care professionals with DNE support, suggest that it may be a clinically effective and cost-saving solution for diabetes management in the South African private health care sector.

Nutritional deficiency in South African adults scheduled for bariatric surgery

Background

Globally, there is a rising trend in obesity, known to increase morbidity and mortality. Metabolic surgery and adequate weight loss decrease mortality but may worsen pre-existing nutrient deficiencies. Most data on pre-existing nutritional deficiencies in the population undergoing metabolic surgery is from the developed world, where an extensive micronutrient assessment is achievable. In resource-constrained environments, the cost of a comprehensive micronutrient assessment must be weighed against the prevalence of nutritional deficiencies and the potential harm if one or more nutritional deficiencies are missed.

Methods

This cross-sectional study investigated the prevalence of micronutrient and vitamin deficiencies in participants scheduled to undergo metabolic surgery in Cape Town, South Africa, a low-middle income country. 157 participants were selected and 154 reported on; who underwent a baseline evaluation from 12 July 2017 to 19 July 2020. Laboratory measurements were conducted, including vitamin B12 (Vit B12), 25-hydroxy vitamin D (25(OH)D), folate, parathyroid hormone (PTH), thyroid-stimulating hormone (TSH), thyroxine (T4), ferritin, glycated haemoglobin (HbA1c), magnesium, phosphate, albumin, iron, and calcium.

Results

Participants were predominantly female, aged 45 years (37-51), with a preoperative BMI of 50.4 kg/m2 (44.6-56.5). A total of 64 individuals had Type 2 diabetes mellitus (T2D), with 28 undiagnosed cases at study entry (18% of study population). 25(OH)D deficiency was most prevalent (57%), followed by iron deficiency (44%), and folate deficiency (18%). Other deficiencies (vitamin B12, calcium, magnesium, phosphate) were rarely encountered and affected ≤1% of participants. Folate and 25(OH)D deficiency were related to obesity classification, with a higher prevalence in participants with a BMI ≥40 kg/m2 (p <0.01).

Conclusion

A higher prevalence of some micronutrient deficiencies was noted compared with data from similar populations in the developed world. The minimum baseline/preoperative nutrient evaluation in such populations should include 25(OH)D, iron studies, and folate. Additionally, screening for T2D is recommended. Future efforts should seek to collate broader patient data on a national scale and include longitudinal surveillance after surgery. This may provide a more holistic picture of the relationship between obesity, metabolic surgery and micronutrient status inform more appropriate evidence-based care.

Prevalence of kidney injury in patients taking tenofovir based antiretroviral therapy at a primary health care clinic, in East Rand,Gauteng Province

Background: Tenofovir disoproxil fumarate (TDF) is currently one of the key medicines in the management of HIV-1 infection across the globe. Conversely, various studies indicate that TDF is associated with an increased risk of kidney injury. Furthermore, data from different studies indicate that clinically significant TDF-related kidney toxicity is uncommon, with an estimated incidence of reduction in creatinine clearance to below 50 ml/min ranging from 3% to 8%.Objective: This study investigated the prevalence of TDF-induced kidney injury, risk factors associated with the exacerbation of kidney injury, and reversibility of TDF-induced kidney injury in a South African cohort.Methods: A retrospective cross-sectional descriptive study was conducted, where quantitative data were collected through patient file reviews. Files of 600 patients initiated on TDF-based antiretroviral therapy (ART) were reviewed. The degree of kidney function was monitored using the eGFR at baseline, 3, 6, 12, and 36 months of TDF therapy. eGFR after TDF discontinuation was monitored to determine its reversibility. HIV parameters (CD4 count and viral load) were monitored to determine patients' immune response to treatment throughout the study. Comorbidities and other factors that affect kidney function were extracted from the patients' files.Results: Final sample comprised 413 files, 272 (65.9%) were females. Significant variability in the eGFR overtime was observed; 20 (5.9%) experienced mild-moderate kidney injury, four (1.2%) developed moderate-severe kidney injury and three (1%) had severe kidney injury. Significant association with decline in eGFR included high viral load, low CD4 count and long duration of treatment. Six (1.5%) patients were discontinued from TDF treatment and five patients of those fully recovered.Conclusions: TDF-induced kidney injury was uncommon in this setting and where it occurred was associated with full reversibility after discontinuation. Therefore, lack of resources in health-care settings in terms of frequent monitoring of renal function should not prevent prescribing TDF-based therapy.

Treatment Gaps Found in the Management of Type 2 Diabetes at a Community Health Centre in Johannesburg, South Africa

AIMS

The management of cardiometabolic goals or "ABCs" (HbA1c, blood pressure (BP), and cholesterol) ultimately determines the morbidity and mortality outcomes in patients with type 2 diabetes mellitus (T2DM). We sought to determine if patients with T2DM attending an urbanized public sector community health centre (CHC) were having their ABCs measured, were treated with appropriate cardioprotective agents and finally, were achieving guideline-based targets.

METHODS AND RESULTS

A cross-sectional record review of 519 patients was conducted between May and August 2015. The mean age was 54 years (SD: ±11.5) and 54% (n = 280) were females. Testing of ABCs occurred in 68.8% (n = 357) for HbA1c, 95.4% (n = 495) for BP, and 58.6% (n = 304) for LDL-C. Achievement of ABC targets was as follows: 19.3% (HbA1c < 7%), 22.0% (BP < 140/80 mmHg), and 56.3% (LDL-C < 2.5 mmol/l).

CONCLUSION

There were a significant number of patients who were not tested nor received adequate pharmacotherapy or achieved their ABC targets. This places these patients at an increased risk for the development of diabetes-related complications. Although the realities of resource constraints exist in South Africa's public sector settings, a wider implementation of evidence-based guidelines must be instituted in order to ensure better patient outcomes.