Diabetes is South Africa’s second biggest killer but there is a critical lack of consensus among experts and policy makers about how this growing epidemic should be tackled. Human resource personnel like dieticians, which research has shown can help patients maintain dietary goals and prevent resource-intensive complications of the disease like blindness and amputations, are seemingly not a priority for government.
Dieticians are an “essential investment” if “we want to make inroads into this epidemic”, according to Dr Aslam Amod, Durban-based endocrinologist who is also the Chairperson for the country’s 2017 Diabetes Guidelines launched last Friday.
The guidelines are developed every few years by the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA), in consultation with officials in the Department of Health (DoH) and other experts, and are meant to guide the treatment and prevention of diabetes in both the public and private sector and “reflect the best available evidence at the time”.
Worst cases have access
But according to Lynn Moeng, Chief-Director for Health Promotion, Nutrition and Oral Health at the DoH, only “the worst” cases in the public sector are actually referred to dieticians. She attributes this to a shortage of registered dieticians in the country and resource constraints in the public health sector.
A 2012 policy brief, commissioned by the Human Sciences Research Council (HSRC), stated that although “human resources are an essential component for the delivery of nutrition services, the nutrition workforce in South Africa is undoubtedly insufficient”.
According to the HSRC, by December 2008, only 1 704 dietitians were registered with the Health Professions Council of South Africa (HPCSA). Less than half (650) were employed in the public health sector where more than 80 percent of the population go to receive health services. This resulted in a ratio of only one dietician for over 60 000 people.
Little change in 10 years
Almost a decade later, even though more and more evidence shows how important nutrition is in preventing and managing diabetes, not much has changed.
Moeng said there are approximately 3000 dieticians registered with the HPCSA.
Private dietician Ria Casticas told Health-e News there is no shortage of dieticians in the private sector and that most private sector patients have relatively easy access to these professionals.
But patients reliant on public facilities are not as lucky.
According to Moeng, most large public hospitals and state diabetes clinics employ dieticians.
“But it is not possible for all diabetic patients to see a dietician in the public sector as there is a shortage but the worst cases are referred for specialised support. Even if we had 4000 dieticians and released all of them into the public sector, it would still not be enough for every diabetic patient to access,” she said. “This is an area we have identified as a gap which we are attempting to address.”
Government solution: standard nutrition guide
But instead of employing more dieticians, incentivising private dieticians to work in public facilities or focussing on training more people to become dieticians, the department’s ‘solution’ is to develop standardised nutrition guidelines for diabetic patients. This, she said, would allow other health professionals to be upskilled and provide standard nutrition advice to all patients across the country. She said these guidelines are in the final stage of development and will be printed for use across the public sector, especially in hospitals, “soon”.
This is quite removed from the interventions put forward by SEMDSA’s 2017 guidelines which advocate for much more intensive and individualised nutrition support in the form of medical nutrition therapy (MNT).
MNT is a “vital aspect of both diabetes prevention and diabetes management”, state SEMDSA’s guidelines. It consists of at least three or four one-on-one sessions with a registered dietician who can give patients individualised nutritional advice. Sessions should be between 45 and 90 minutes each and start as soon as a patient is diagnosed. These contact sessions should occur in the first three to six months and should then happen annually to make sure patients are able to cope.
The case for individualised care
“Everybody is different and has different obstacles to diabetes management in their day-to-day lives,” said Casticas, who co-authored the MNT section in SEMDSA’s new guidelines.
“The advice I give to a middle-aged woman who is a vegetarian housewife with a sedentary lifestyle would be vastly different to the advice I can give to a 25-year-old man who cycles twice a week but is a bachelor who eats out often,” she explained.
According to the American Diabetes Association, there is evidence to show that adequate MNT can reduce a patient’s three-month average plasma glucose concentration, one of the best ways to monitor diabetes control, by between 0.5 and two percent.
Casticas, and other experts, do not agree that standardised dietary advice and education can solve South Africa’s escalating diabetes epidemic which is being driven by unhealthy eating habits and sedentary lifestyles – largely a result of urbanisation.
Amod said “instructions from a doctor or nurse or giving a pamphlet of what to eat and what not to eat doesn’t work, the evidence shows that”.
“MNT does need a dietician and it does need to be intensive for it to work. It can be seen as an extra expense for an over-extended health budget but it is definitely cost-effective in the long run,” he said.
MNT not possible fro government
But Moeng said this is simply not feasible.
“Not every diabetic patient can see a dietician but every single one will see a nurse. Why shouldn’t nurses be upskilled to help so that every patient can leave a facility with some knowledge on how to manage their condition? A nurse will also definitely be able to identify the worst cases for referral to a dietician,” she said. “But I do think all patients admitted to hospital should at least not be discharged without seeing a dietician”.
According to University of the Witwatersrand researcher Thabang Matlhafuna, who published a 2013 report on the challenges faced by community dieticians in Gauteng’s state facilities, there is a “notion that the nutrition personnel, including dietitians, are not an essential workforce in the public sector”.
Diabetes patients are often only given generic nutrition advice and medication to control their disease.
But Casticas said “you can take all the medication in the world but if your nutrition isn’t good you are not going to be able to control your blood sugar”. “And if you don’t control your blood sugar you will do damage to your nervous system, eyes and kidneys which can lead to dangerous complications.”
Lifestyle change is complex
“It is very difficult to change one’s lifestyle and there are many barriers which are different for every single individual. What do you do for example during tea-time at church? What does a young person do if they get a glycemic attack while clubbing or at the pub? What about patients who have budget restrictions when purchasing food?” she asked.
It is not only food but the behaviours around food that need attention, for example snacking and emotional eating, she said.
“You can’t only address all these barriers and behaviours in one session and you can’t keep a patient motivated without follow-ups,” she said. “At the end of the day food has societal and emotional value and you have to consider this if you truly want to help a patient change his or her lifestyle. It’s not about a diet, it’s about a lifestyle. Diabetes is not going away and we need to find practical ways for individuals to limit the damage it can do to their health, their lives, and the lives of their families.”
*An edited version of this story was published by the Daily Maverick