The University of Pretoria (UP) Tshwane Insulin Programme (TIP) has completed a five-year project in the Tshwane district, successfully and safely reducing the blood glucose (blood sugar) levels of more than 300 patients.

“If blood glucose levels are not well controlled, complications such as blindness, kidney failure and amputations may result,” explains Professor Paul Rheeder, Director of the UP Diabetes Research Centre, which initiated TIP. “These levels are measured by means of the haemoglobin A1c [HbA1c] blood test; the goal of glucose treatment is to get the HbA1c of a patient living with type 2 diabetes – who has been started on tablets, not insulin – to below 7% to 8%.”

On average, the HbA1c of TIP patients was reduced from 12% to 8%, thus greatly lowering their risk for hospitalisation and the long-term complications associated with diabetes.

Type 2 diabetes is a global challenge. According to the International Diabetes Federation, at least 11% of adults in South Africa are affected; that equates to more than 4 million people.

“For comprehensive diabetes management, glucose (blood sugar), cholesterol and blood pressure need to be lowered through a combination of a healthy lifestyle and medication,” Prof Rheeder says. “After five to 10 years on tablets, many patients need to add insulin injections to their treatment to lower the blood sugar sufficiently. It is worth noting that newer injectable non-insulin drugs are not affordable in the public health sector.”

However, insulin initiation is not always easy, he adds. Many patients are reluctant to have injections administered and so healthcare workers delay their use; also, glucose meters and strips are often unavailable, and both patients and healthcare workers lack the confidence or skill to make use of these devices.

Changing treatment options for people living with diabetes

This was the situation that TIP – which was funded by the Eli Lilly and Company as part of the Lilly Global Health Partnerships – began to address five years ago. Working in Tshwane’s primary care clinics, TIP healthcare workers set out to change the treatment options for people living with diabetes. This was a partnership between the national Department of Health, the City of Tshwane, and the nurses, doctors, facility managers and community healthcare workers at the clinics.

“Qualified fieldworkers, including nurses and clinical associates, visited local clinics and identified individuals who needed insulin,” Prof Rheeder says. “They then instructed patients on how to use insulin and glucose meters. Patients were visited at home, often with community healthcare worker teams. Diabetes education was also provided during home visits. The results of these visits were that patients became better skilled at injection techniques and glucose testing, and felt more confident about carrying them out. ”

Reliable glucose testing allows a doctor or nurse to increase or decrease the insulin dose accurately. Unlike tablets, where a fixed number are taken a day, insulin dosage varies from person to person.

“If possible, this dose must be corrected more often than once a month or every three months – this is what makes home visits so vital,” Prof Rheeder says. “Using a telehealth app called Vula, fieldworkers could communicate blood glucose levels with clinic doctors, who could recommend adjusting the insulin dose between clinic visits. This mobile service was also carried out during clinic visits if the doctor was not on site.”

Patients were assisted for 14 weeks, after which, the clinic continued its usual care. To increase their knowledge and skill about insulin use, doctors and nurses attended training workshops on comprehensive diabetes care.

The main insulin study was conducted between 2021 and the middle of 2023, and was preceded by a pilot study. According to Prof Rheeder, the team managed to get a final HbA1c among 78% of the people on the programme and reduced their HbA1c from 12% to 8%. Low blood glucose values were detected among 21% of participants during home or clinic visits, but most did not have associated symptoms and none were serious.

“Through their efforts and with the aid of innovative techniques, the TIP team overcame the barriers associated with an under-resourced public system to help patients improve their glucose control,” he says. “We hope that the lessons learnt will be taken up in the public healthcare sector and that more people will benefit from earlier insulin use.”