Diabetes in rural South Africa--an assessment of care and complications.

OBJECTIVES: To describe the diabetic population under care of the public health sector in a district in rural KwaZulu-Natal, to assess the nature of their care, their glycaemic control and the extent of their complications. SUBJECTS AND METHODS: Two hundred and fifty-three diabetic patients consecutively attending clinics for review were interviewed and examined, and where available a 12-month retrospective review of clinical records was performed. Random blood glucose, haemoglobin A1c (HbA1c) and urine albumin/creatinine ratio were assayed.
RESULTS: Acceptable glycaemic control (HbA1c < 2% above normal population range) was found in only 15.7% of subjects (95% confidence interval (CI): 11.4-20.8%). Mean HbA1c was 11.3%. The prevalence of hypertension (blood pressure > or = 160/95 mmHg and/or prescribed antihypertensive medication) was 65.4% (CI: 59.0-71.1%). Of 129 patients who were prescribed antihypertensives, 14.0% (CI: 8.5-21.2%) were normotensive (< 140/90 mmHg). Severe obesity was present in 36.5% (CI: 30.4-42.9%). Rates of attendance for review and compliance with diabetic medications were high. Blood glucose monitoring was not regularly performed and medications were rarely modified. Complications were common and mostly undiagnosed. Retinopathy of any grade was found in 40.3% of patients (CI: 33.2-50.9%) and was severe enough to warrant laser photocoagulation in 11.1% (CI: 8.5-21.2%). Microalbuminuria was found in 46.4% (CI: 40.0-53.0%) and foot abnormalities attributable to diabetes in 6.0% (CI: 3.4-9.7%).
CONCLUSIONS: Care and control of diabetes in this rural community is suboptimal. There is a need for primary care staff to focus on modifying prescriptions in the face of poor blood glucose control and/or uncontrolled hypertension. Additional training and support for nursing staff and education for patients will be central to achieving this level of intervention.