At her inaugural lecture titled ‘Bridging Gaps: Tackling Diabetes and Maternal Health in South Africa,’ Professor Sumaiya Adam, a leading specialist in maternal and fetal medicine from the University of Pretoria’s Department of Obstetrics and Gynaecology, delivered crucial insights into one of South Africa's most pressing public health challenges: gestational diabetes mellitus (GDM) and its impact on maternal health.

The inaugural lecture, which was delivered on 29 October 2024 at UP’s Senate Hall, Hatfield Campus, shone the light on both the challenges posed by diabetes during pregnancy and innovative, evidence-based solutions that can address this growing problem.

“GDM occurs when insulin resistance develops exclusively during pregnancy due to hormonal changes and usually resolves postpartum. While glucose tolerance returns to normal after delivery, women with GDM still face an elevated risk of type 2 diabetes later in life,” Prof Adam explained.

The prevalence of GDM in South Africa, as her research revealed, is alarmingly high.

One of Prof Adam’s studies conducted in Johannesburg in 2018 found that over 25% of the 554 women studied had gestational diabetes. Major risk factors included elevated BMI (Body Mass Index) and history of a previous baby weighing more than 4kg. Biomarkers such as fasting insulin (levels used to assess insulin sensitivity) and adiponectin, a protein hormone that among other functions helps regulate insulin sensitivity and inflammation, were also associated with an increased risk of GDM.

According to the 2021 International Diabetes Federation (IDF) Diabetes Atlas, 10.5% of the global adult population is currently living with diabetes, with nearly half unaware of their condition. By 2045, it's projected that 1 in 8 adults — equivalent to 783 million people — will be living with diabetes, a 46% increase from current figures.

South Africa holds the highest prevalence of diabetes in Africa, with an estimated 4.3 million people affected, according to the IDF. Since 2019, diabetes has tragically become the leading cause of death in the country.

“The global rise in diabetes, particularly type 2 diabetes (T2DM), is a growing public health concern, driven by lifestyle changes, urbanisation, and increasing obesity rates. Over 90% of those with diabetes have T2DM, a condition strongly linked to these lifestyle factors. This surge is also reflected in rising cases of diabetes in pregnancy, where the physiological stresses of pregnancy often reveal underlying metabolic conditions,” said Prof Adam.

Challenges in diagnosis and management

A key issue highlighted in Prof Adam’s lecture is the lack of a unified approach to screening and diagnosing GDM in South Africa. Currently, multiple diagnostic criteria are used and this leads to discrepancies in care and health outcomes.

“Different diagnostic tools yield different results, which means that the prevalence of GDM can vary significantly depending on the method used,” she explained.

This variability in diagnosis not only complicates patient care but also adds to the financial strain on the public health system. The oral glucose tolerance test (OGTT), commonly used to diagnose GDM, is resource-intensive and adds to the workload of healthcare providers.

Prof Adam’s research proposes a clinical prediction model aimed at reducing the number of unnecessary OGTTs. “If we can streamline our diagnostic processes, we can reduce the burden on our healthcare workers and allow for more efficient resource allocation,” she said.

To do this, Prof Adam said there needs to be greater collaboration across the different spheres of healthcare. She pointed out that diabetes in pregnancy is not an isolated condition, but one that intersects with primary healthcare, non-communicable diseases (NCDs) prevention, and broader maternal and child health initiatives.

“We must move away from working in silos. A more collaborative healthcare model is crucial to managing gestational diabetes effectively, especially in a resource-limited environment like ours,” she said.

Prof Adam called for a holistic, life-course approach to diabetes care. She stressed the importance of using pregnancy as an opportunity not only to manage GDM but also to identify women at risk for future diabetes and other NCDs. This would not only enable early intervention and continuous support, but also benefit both mothers and their children, creating a positive cycle of health outcomes that extends beyond the pregnancy.

Solutions through inclusivity, research and innovation

Prof Adam drew from her research – with both local and international collaborators – on biomarkers and their association with GDM to highlight the promising strides being made in diabetes research.

"Our research has demonstrated that these biomarkers, when combined with clinical risk factors, can enhance our ability to predict which women are most at risk for developing GDM. This early detection could dramatically improve outcomes for both mother and child," she said.

Prof Adam’s collaborations with the South African Medical Research Council (SAMRC) and the University of Pretoria have also led to the exploration of novel tools like DNA methylation and microRNA signatures, which could further enhance screening and diagnosis.

“Our work on epigenetics and biomarkers has been pivotal in identifying unique markers that, when combined with clinical correlations, have the potential to advance precision and personalised medicine. Much of this type of research has been conducted in the Global North, so conducting studies in African populations is critical to ensure that treatments are relevant and applicable across diverse groups, including those living with HIV”.

“Our findings could lead to breakthroughs in understanding diabetes within the African context, ultimately contributing to more personalised healthcare solutions that consider genetic, environmental, and lifestyle factors unique to these populations,” she said.

Prof Adam emphasised the need for policy-level changes and improved integration of care across South Africa’s healthcare system. She called on healthcare professionals, researchers, and policymakers to work together to reduce the burden of GDM on the country’s health system and improve health outcomes for mothers and children, in pregnancy and in the long-term.

“Our ultimate goal must be to create a more inclusive, collaborative healthcare system where high-risk women are identified early, treated effectively, and supported throughout their healthcare journey.”