Type 2 diabetes: Diagnosis, management, weight loss, remission

• In 2021, there were 529 million people globally and 4.2 million people in South Africa, living with diabetes (the vast majority of whom have type 2 diabetes).
• Approximately fifty percent of people who have diabetes are undiagnosed, and therefore not on treatment, with serious consequences for their health.
• Type 1 diabetes (T1D) can appear at any age but typically occurs in children and adolescents as a result of the pancreas not producing sufficient insulin to adequately control glucose levels.
• Type 2 diabetes (T2D), usually affects adults but is increasingly, diagnosed in children as a result of an increased prevalence of overweight and obesity in children.
• Up to 90% of adults with type 2 diabetes have a weight range measured as overweight or obese.
• Across the Discovery Health Medical Scheme (DHMS), the prevalence of diabetes has increased at a rate of 5.9% per annum from 2018 to present, with more than 148,000 members currently diagnosed and living with diabetes.
• T2D has been for many years thought to be a progressive disease. In recent years, however, medical and lifestyle interventions associated with weight reduction have been shown to halt the progression of diabetes with a return of glucose levels into the normal range without requiring medical treatment, also known as remission.

The world’s focus turns to diabetes on 14 November 2023 – World Diabetes Day. This year the theme is Know your risk, Know your response. And this message comes at a time when 1 in 10 adults worldwide are living with diabetes. They also highlight the opportunity for bringing diabetes into remission.

Clinical leadership from Discovery including Head of Vitality Wellness, Dr Mosima Mabunda and Chief Clinical Officer at Discovery Health, Dr Noluthando Nematswerani, urge a focus on knowing your risk and managing your weight in tackling diabetes. They offer this based on strong evidence that diabetes can be well controlled, and in achieving this people dramatically reduce their long-term health risks. They also highlight the opportunity to achieve type 2 diabetes remission.

“The diabetes global health crisis is mainly driven by type 2 diabetes, which accounts for 96% of people living with diabetes,” says Dr Mabunda. “While type 2 diabetes is caused by several factors, it is firmly established that the risk for type 2 diabetes increases with obesity. For example, we know that people living with obesity have an up to six times higher likelihood of developing type 2 diabetes, compared to people who are not obese or overweight.”

Dr Nematswerani agrees: “Diabetes is one of the most serious health issues facing the world. It can be easily recognised in people presenting with fatigue along with increased thirst or hunger, the frequent need to urinate, and blurred vision.”

“This year’s World Diabetes Day theme aligns with Discovery Health’s approach to tackling diabetes. This important day also brings an all-important opportunity to reinforce that healthy living habits and a healthy weight are key to preventing type 2 diabetes and controlling it when it is diagnosed. To take this further, diabetes management goals are changing. Where reaching and maintaining a healthy blood glucose level has for many years been the focus, we are now looking beyond glucose control – to diabetes remission – a shift in diabetes management, made possible primarily by weight loss.

‘A pandemic of unprecedented magnitude, spiralling out of control’

‘A pandemic of unprecedented magnitude, spiralling out of control’ is how the International Diabetes Federation describes type 2 diabetes. It’s a condition that is among the top ten leading causes of deathin the world. According to the World Health Organization at least 1.5 million deaths are directly attributed to diabetes every year.

In 2021, it was estimated that 6.1% of the global population or 529 million people were living with diabetes and by 2050 this is expected to increase to around 1.31 billion people. In South Africa, 4.2 million people live with diabetes and the direct treatment cost to South Africa’s state healthcare sector alone is almost R20 billion annually. However, more than half (54%) of people living with diabetes in the African Region are undiagnosed.

Type 1 diabetes remains the most prevalent form of diabetes in children. However, in line with the global increase in childhood obesity and physical inactivity, type 2 diabetes mellitus is estimated to occur in one in three (20% to 33%) new diabetes diagnoses in children in 2023.

Within the DHMS member base, the prevalence (the number of people who have a condition at a specific point in time) of diabetes has increased at a rate of 5.9% per annum since 2018.

“Undiagnosed, unmanaged diabetes is life-threatening and leads to multi-organ damage resulting in heart attacks and strokes, kidney disease, blindness, nerve damage, and vascular amputations,” says Dr Nematswerani. This is why screening for early diagnosis and appropriate treatment is essential.

90% of adults living with type 2 diabetes are classified as overweight or obese

1.9 billion or 39% of adults in the world were overweight or obese in 2016. The World Obesity Atlas from the World Obesity Federation reports that by 2035, 51% of the global population or over 4 billion people will live overweight or obese – all in all, over 1.5 billion adults and nearly 400 million children will be living with obesity in 12 years’ time unless significant action is taken.

In South Africa overweight and obesity rates are among the highest globally. The World Obesity Federation also estimates that 37% of local adults (mostly women) and 27% of children (the highest rates on the African continent) will be obese by 2030.

Dr Mabunda says, “In South Africa, 31% of men and 68% of women are overweight or obese. While a wide range of factors contribute to the rising obesity problem, it is largely driven by the availability and consumption of high-calorie and ultra-processed foods, and insufficient physical activity levels. We see the link between increased weight and high blood glucose levels clearly from our Vitality Health Check data – the relative prevalence of Vitality members with high blood glucose levels is 4.2 times higher among those with an out-of-range weight status.”

DHMS member data shows increasing link between diabetes and mental health

“Diabetes management really requires active involvement on the part of the person living with diabetes, to ensure they take their medicine and keep up healthy lifestyle modifications and self-monitoring. Good mental health is key to this,” adds Dr Nematswerani.

Worryingly, global research indicates that people who live with diabetes are up to three times more likely to have a mental illness, than people without diabetes.

Discovery Health Medical Scheme data show that compared to a person living with diabetes but no mental illness, a person living with diabetes and mental illness is:

• 48% more likely to be admitted to hospital
• 14% more likely to have a diabetes-related hospital admission
• 41% more likely to have a long length of stay in hospital
• 45% more likely to have a high-cost admission and;
• At 22% higher risk of death.

A person who has diabetes and mental illness is also 7% less likely to adhere to their diabetes medicine regime.

Diabetes is a complex disease: holistic management is fundamental

There is increasing urgency around supporting people who are at risk of or who are diagnosed with type 2 diabetes to prevent or control and, where possible, bring the condition to remission. Across Discovery Vitality and Discovery Health, there are a range of programmes in support of diabetes prevention and management:

• Through the Discovery Health Disease Prevention Programme, a sophisticated predictive model determines the member’s risk of developing diabetes. With this knowledge and insight, the member can then access an enhance basket of benefits and work with their GP, a Discovery Health coach and a dietitian to actively reduce their risk of developing diabetes.
• The Discovery Health Diabetes Care Programme gives members who are already diagnosed and living with diabetes additional benefits and cover for medicine, consultations, specialists, dietitians, and diabetes educators. Data show that members registered on the Diabetes Care Programme have better health outcomes across the board.
• To assist members to manage their weight and develop healthy eating habits, Discovery Vitality launched the Vitality HealthyWeight Programme earlier this year. Members get on-demand support from a dietitian to guide them in developing healthy eating habits and to reach their weight management goals. Members also get weekly meal plans and shopping lists that can be adjusted by the dietitian based on individual needs

- Additional data on diabetes prevalence across the DHMS member base is included at the end of this media release.

“Vitality members on the Vitality HealthyWeight programme have shown significant improvements in their weight management, with 97% of those who completed three months of the programme losing weight. On average, members on the programme lost 5.2% of their initial weight, with men having lost, on average, 1.9 kg more than women over the same period. This shows that coach-based weight-management programmes can be successful in ensuring healthy weight loss and weight management. It also bodes well for a move to reduce the risk of type 2 diabetes,” says Dr Mabunda.

Discovery Health Medical Scheme members living with diabetes are achieving sustained glucose control

“Diabetes remission is defined as a return of HbA1c to <6.5% following a medical or lifestyle intervention, that persists for at least 3 months without the need for glucose-lowering medicine. An HbA1c test measures average blood sugar levels over three to four months,” says Dr Nematswerani.

Members registered on the Discovery Health Medical Scheme Diabetes Care programme had a 42% higher rate of achieving an HbA1c of <6.5% that persisted for at least 3 months compared to those who are not on the programme.

Dr Nematswerani adds: “When we talk about remission, we don’t mean that the disease goes away entirely, as abnormalities that caused the diabetes to develop are not completely normalised, and one remains at risk of triggering the condition again. Remission means that the person no longer experiences persistent high blood glucose levels. Once in remission, it is very important to maintain regular check-ups to make sure that the diabetes remains in remission. Weight gain, other illnesses, certain medicines, stress or other factors can cause the condition to return. Maintaining a healthy weight is important as excess fat stored in the liver and pancreas can cause insulin to be ineffective in lowering blood sugar levels. People can remain in remission for many years if they maintain a healthy weight, regular physical activity and overall healthy lifestyle.”

Prevention is better than cure

Dr Nematswerani says, “Through education and multidisciplinary support around healthy living that encourages weight loss, people can achieve excellent blood glucose control but also – as new Discovery Health Medical Scheme data is increasingly showing – even achieve type 2 diabetes remission. Considering the impact of diabetes on a person’s life, and the risk of comorbid mental illness, achieving sustained glucose control and a healthy weight mean a range of profound benefits to people’s quality of life.”

“When it comes to type 2 diabetes, knowing your risk is the first step. Health checks, like the Vitality Health Check, include a quick finger prick to test blood glucose levels. Doing these preventative checks is how we know our risk and detect warning signs of diabetes. Then, engaging in healthy lifestyle behaviours like regular physical activity and a healthy diet, as well as finding support in reaching a healthy weight, are essential to preventing or managing one’s risk of diabetes,” says Dr Mabunda.

ENDS/.

Notes to the editor

Diabetes on the rise in the DHMS member base

• The prevalence (the number of people who have a condition at a specific point in time) of diabetes has increased at a rate of 5.9% p.a from 2018 to present. In 2023, there are148 000 Scheme members living with diabetes, reflecting an increase of 103% from 73 000 members with diabetes in 2013.
• 68 000 of the above-mentioned members are members of the Scheme’s Diabetes Care managed care programme.

Diabetes and mental illness – a two-way relationship

• DHMS data show that, compared to a person who has diabetes but no mental illness, a person with diabetes and mental illness is 48% more likely to be admitted to hospital, 14% more likely to have a diabetes-related admission, 41% more likely to have a long length of stay in hospital, 45% more likely to have a high-cost admission and at 22% higher risk of death. A person who has diabetes and mental illness also has a 7% lower likelihood of adherence to their diabetes medicine.
• Furthermore, in 2022 members who had one chronic condition and mental illness cost the Scheme 1.4 times more than members without these conditions. These members also had a 3.5 times higher risk of being admitted to hospital, showing the complexity of their condition and impact on their quality of life.
• DHMS data also show that people under the age of 40 tend to be diagnosed first with diabetes and then a mental health condition, while the reverse is true for people aged 40 or over. This shows the importance of holistic support for diabetes, especially in young people as their risk of mental illness is higher once diabetes has set in.

Type 2 diabetes and remission

• The chances of achieving remission are higher when a person has been diagnosed early into the onset of their condition, that is, before there is too much damage to the insulin-producing cells in the pancreas.
• Importantly, members registered on the DHMS Diabetes Care programme had a 42% higher rate of achieving an HbA1c of <6.5% that persisted for at least 3 months compared to those who are not on the programme, a promising step towards remission.