DSA represents Southern Africa Region

Margot Mc Cumisky was elected Vice President of Southern Africa Region, International Diabetes Federation. She tells us how this came about at the 2022 IDF World Diabetes Congress held in Lisbon, Portugal in December.

Diabetes South Africa (DSA) has been a member of the International Diabetes Federation (IDF), based in Belgium, for many years.

Every two years the IDF organises a World Diabetes Congress to which each member country is invited. Margot Mc Cumisky, DSA National Manager, was delegated to attend the IDF World Diabetes Congress 2022 held in Lisbon, Portugal. Lisbon is a beautiful city and Portugal is a lovely country that welcomed all the delegated representing diabetes organisations around the world.

The IDF World Diabetes Congress 2022 was attended by over 4 000 delegates from around the globe, consisting of professors, scientists, doctors and other health professionals, as well as patient organisations like DSA.

It was so interesting to hear the latest information on medication, diabetes devices, treatments and learn from other diabetes organisations and their activities.

Each part of the world is divided into regions and on the first day of the congress each region holds their regional congress. DSA falls under the IDF Africa Region and so all the representatives from all the countries in Africa held their annual regional congress.

At this regional congress, challenges, access to medication, patient outreach and reports on each country and member associations are discussed and many successful projects are adapted as we all learn from each other.

IDF Africa new incumbents

During the regional congress, voting takes place on the new incumbents, for the President of IDF Africa Region, and the President-elect who will take over from the President after two years.

President of Africa Region is Professor Jacko Abodo (Ivory Coast).

President-elect is Sister Elizabeth Denyoh (Ghana).

IDF Africa is divided into four regions: East, West, Central and Southern Africa. The voting then proceeds for the Vice President of each of these four regions. The results of these elections were as follows:

Vice Presidents for regions

Western Africa Region – Dr Ibrahim Nientao (Mali).

Eastern Africa Region –Dr Murthy Pillay (Seychelles).

Central African Region – Dr Davidson Nkwenti (Cameroon)

Southern Africa Region – Margot Mc Cumisky (South Africa)

The Southern Africa Region consists of:

  • Angola
  • Botswana
  • Lesotho
  • Malawi
  • Mozambique
  • Namibia
  • South Africa
  • Eswatini
  • Zambia
  • Zimbabwe
  • Madagascar

Focus and action plan for Africa region

The focus and action plan for the next two years will be:

  • To strengthen existing associations and assist with developing new diabetes associations in countries where there are none.
  • To create a network of health professionals specialising in diabetes in each country, both in public and private sectors for patients to have access to expert treatment.
  • To develop a Diabetes Registry – the first stage will be done in 2023 in French-speaking countries in Africa; followed by English-speaking countries in Africa in 2024.
  • To update and implement guidelines for Type 1 and Type 2 diabetes.
  • Training of peer educators.

Follow-up conference

A follow-up conference was held in Ivory Coast in February 2023 where the implementation of the action plan was discussed, and planning commenced.

Should any of our members have contacts in the Southern African countries with an interest in diabetes, your assistance would be greatly appreciated.

Contact: Margot Mc Cumisky Email: [email protected] 

Cell:  072 345 0086

Did you know?

In 2006 the World Diabetes Congress was hosted in Cape Town and DSA was part of the local organising committee. This congress was attended by 14 000 delegates from around the world and was an exciting time as it was the first World Diabetes Congress to be held in Africa. We did ourselves proud and many people still talk about how well-organised it was and how much they enjoyed attending.

Adrenal fatigue syndrome: myth or menace?

Dr Angela Murphy describes how the term adrenal fatigue syndrome came about and sets the facts straight about it.

What are adrenal glands?

The adrenal glands sit on top of each kidney, measuring 5cm x 31cm and weigh up to 10g. They produce hormones that are involved in the regulation of blood pressure, metabolism, immune function, and the body’s response to stress. These hormones are listed below.

  1. Cortisol is essential for processing carbohydrates, proteins, and fats, and also contributes to blood pressure control. It’s an important stress hormone as it helps to suppress inflammation and increase energy sources available for the body’s fight response. Cortisol levels are controlled by both the hypothalamus in the brain and the pituitary gland.
  2. Adrenalin and noradrenaline are our flight and fight hormones activated at times of stress. They cause an increase in heart rate, blood pressure and metabolism.
  3. Aldosterone is a hormone integral to water balance in the body and thus, blood pressure control.
  4. Androgen steroid hormones are weak male sex hormones that are precursors to either oestrogen which is then made in the ovaries and testosterone which is made in the testes.

Disorders of the adrenal glands

Various conditions can affect the adrenal glands and cause either over production of these hormones or a relative or absolute deficiency.

Overactive adrenal glands

  • Excess of cortisol – Cushing’s Syndrome
  • Excess of aldosterone – Conn’s Syndrome
  • Excess of adrenalin – Pheochromocytoma

Adrenal insufficiency

  • Addison’s disease – primary damage to the adrenal glands.
  • Secondary to pituitary disorders.
  • Congenital adrenal insufficiency – genetic.

Each of these conditions present with suggestive signs and symptoms that would be investigated and then treated appropriately.

Adrenal fatigue syndrome

Adrenal fatigue syndrome was first described by American chiropractor, James Wilson, in 2001. He proposed that the excessive stress of 21st century-living causes a progressive decline in adrenal function.

Dr Wilson lists a collection of symptoms that suggest the condition: fatigue, weakness, body aches, weight loss or gain, depressed mood and cravings are a few. He drew up a questionnaire, which can even be done at home, to assess these symptoms and confirm the diagnosis of adrenal fatigue. He then published a protocol of treatment for this condition consisting of four adrenal supplement formulations that he developed and sold.

Dr Ian Ross, South African endocrinologist and adrenal expert wrote, in 2018, in The South African Medical Journal that the cost of equivalent supplements in our own country is up to R1200 per month.*

There are no confirmed diagnostic tests or evaluations for adrenal fatigue syndrome. No endocrine society has endorsed the term adrenal fatigue syndrome. In addition, no scientific study has proven that patients with symptoms of adrenal fatigue syndrome have biochemically impaired adrenal function.

The Endocrine Society of the USA, among others, has issued a warning that the adrenal fatigue syndrome doesn’t exist. However, the symptoms that people present with do exist and it’s important to diagnose what the cause of these symptoms may be.

The following are conditions which may present with a similar spectrum of symptoms as adrenal fatigue syndrome:

  1. Chronic fatigue syndrome

This complex condition, also known as myalgic encephalomyelitis, is characterised by severe fatigue that is not improved by rest and is significantly worsened by exercise. Associated symptoms such as muscle pains, recurrent infections and poor concentration also occur.

This is a clinical diagnosis made once other possible conditions are excluded, e.g. thyroid disease, primary adrenal insufficiency, anaemia and sleep disorders. In many cases there is also evidence of a mood disorder such as depression or post-traumatic stress disorder.

It’s thought to be caused by a variety of triggers on the background of genetic susceptibility. The most common triggers are infections, particularly viral, and trauma which can be physical or emotional. There has been a significant increase in cases after COVID-19 with many overlap features with long COVID. Chronic fatigue syndrome is treated with a combination of medication, psychotherapy, and lifestyle.

  1. Mood disorder

Depression, anxiety, post-traumatic stress disorder and burnout are all conditions with overlapping symptoms. These can be diagnosed clinically, and the correct management prescribed.

  1. Menopause

In women, many of the symptoms being discussed such as fatigue and weight gain occur at menopause (a time when the ovaries are no longer producing oestrogen). Oestrogen replacement therapy can be extremely effective in treating the symptoms. The choice of therapy must be discussed with your healthcare provider.

  1. Andropause

Men can experience low testosterone levels although this doesn’t occur as definitively as menopause. Risks for low testosterone include obesity and metabolic diseases such as diabetes. Testosterone replacement therapy is an effective option in relieving symptoms in men with biochemically low testosterone levels.

  1. Thyroid disease

Both under and overactive thyroid disease can cause symptoms as described in adrenal fatigue syndrome and should be tested for.

  1. Sleep disorders

The most common one we see is obstructive sleep apnoea. This is diagnosed by doing an overnight sleep study. If present, people are prescribed a CPAP machine which delivers air under increased pressure. It’s sometimes necessary to refer a person to the sleep specialist for a full overnight sleep study.

Management of the symptoms associated with adrenal fatigue syndrome

If a specific condition is found, this must be treated. In most cases, there will be significant benefit adding a healthy lifestyle as well. A healthy lifestyle incorporates:

  • Healthy diet including all food groups and especially fruit and vegetables.
  • Regular exercise – aim for 150 minutes per week.
  • Maintain a healthy weight.
  • Get a good night’s sleep.
  • Stop smoking.
  • Keep alcohol intake to safe values: 2 units daily for a woman; 3 units daily for a man.
  • Stress management – this can be done with medication and/therapy.


As Dr Ian Ross and colleagues wrote in the 2018 article, * “Until there is objective, reproduceable clinical evidence for its diagnosis, adrenal fatigue does not exist, and patients should be appropriately investigated and managed for their symptoms.”

Most of the symptoms ascribed to adrenal fatigue syndrome are non-specific. It is thus, essential for the healthcare provider to take a detailed history, perform a thorough examination and order appropriate laboratory tests. A working diagnosis of the likely cause of the symptoms should always be made. In this way an appropriate treatment plan can be prescribed with the aim of alleviating the symptoms.


*We are tired of ‘adrenal fatigue’ | Ross | South African Medical Journal (samj.org.za)

Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.


Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.

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Influenza vaccination: the great debate

There is always a debate regarding whether you should receive a yearly influenza vaccine. Dr Theresa Coetzer and Monique Marais highlight the facts, myths and why it’s of benefit for people with diabetes.

The biggest myth

Most people have repeatedly heard some people say, “After receiving my influenza vaccination I became so ill; it took weeks to get over it. I’ll never be vaccinated again. It causes infection, it doesn’t prevent it!”

This is a myth, although it’s extremely difficult to convince those who firmly believe this myth. The fact is, the vaccine is made from dead virus material, and doesn’t have the ability to cause active influenza infection. There are other reasons people become ill after vaccination.

Why should you be vaccinated?

Everyone, especially people living with diabetes, can become extremely ill from influenza. Diabetes affects your immune system, as well as causes damage to organs like kidneys, heart, nervous system, etc. Due to this, the risk of severe complications accompanying influenzas are extremely high.

It’s always better to prevent disease than cure it. Complications, such as viral pneumonia, can lead to hospital, and most likely ICU admission.

Who should be vaccinated?

Everybody should be vaccinated yearly against influenza, but especially people with compromised immune systems, like those with diabetes.

Elderly people with comorbidities, such as cardiovascular or renal impairment, are even more at risk for serious complications accompanying influenza infections.

Another group we forget about is young children. Every mother knows that once your child starts nursery school, you’re constantly in your GP’s office with one upper respiratory tract infection after another.

The elderly, and the population with diabetes can easily contract influenza this way. Everybody in the family thus needs to be vaccinated to allow herd immunity to develop. Your family and your community will certainly reap the benefits of something as simple, as a yearly flu shot.

When should you get your shot?

It’s recommended that you get the newest flu vaccine yearly as soon as it becomes available; normally this is early autumn in South Africa.

Because viruses mutate, and new viruses constantly appear, the vaccine is adapted yearly to cover the three or four most virulent strains. This is the reason everyone needs a yearly vaccine, and not just a once-off.

The benefit of receiving it yearly, is that you maintain immunity to certain viruses that don’t form part of that year’s vaccine.

Advantages of vaccination

The vaccine doesn’t make you immune to influenza, you might still become infected, especially if it’s from a virus that doesn’t form part of that year’s vaccine, but by having some immunity, the severity of an influenza infection will be reduced, as well as possible complications like pneumonia.

You can’t always prevent contracting an infection, but with excellent control of diabetes, target organ damage can be prevented, and this leads to better immunity and other health benefits. Patients with diabetes need to be proactive in controlling their disease and complications that can accompany serious illness, like influenza.

Possible side effects

The vaccine will stimulate your immune system to form antibodies. It takes about two weeks, and during this time you can still be infected and become ill from influenza.

During the period of forming antibodies, you can have side effects. The most common side effects are tenderness around the injection site, and then symptoms like fever, headache, general body pains and nausea.

Allergic reactions are uncommon, but possible. If you’ve serious allergies, discuss them with your GP before receiving the vaccine.

Pregnant women can get vaccinated but discuss it with your gynaecologist to be certain. Antibodies can be transferred to the foetus, as well through breastfeeding, and this is a great benefit to your tiny bundle of joy.

The COVID-19 pandemic has taught us all valuable lessons. Vaccines work; the amazing worldwide vaccination programme allowed us to return to our normal way of living.

One very crucial fact we can’t ever forget is: prevent getting affected. Vaccines are effective and is strongly advised but remember the wonderful habits we learned with COVID: sanitise your hands and wear a mask if you feel you need protection.

Knowledge is power. Make informed decisions, based on clinical and scientific information to keep yourself and your loved ones safe.




Monique Marais is a registered social worker at Care@Midstream sub-acute, specialising in physical rehabilitation for the past 11 years. She has a passion for the medical field and assisting people to understand and manage their diagnoses and the impact on their bio-psychosocial well-being.


Monique Marais is a registered social worker at Care@Midstream Sub Acute, specialising in physical rehabilitation for the past 11 years. She has a passion for the medical field and assisting people to understand and manage their diagnoses and the impact on their bio-psychosocial well-being.



Dr Theresa Coetzer is a general practitioner at the ClaytonCare Group, specialising in the treatment of medical complex patients in the physical rehabilitation field. She has a passion for people and ensuring the best possible medical outcome for her patients.

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Influenza vaccinations: the great debate

DSA News Autumn 2023

– DSA Port Elizabeth News –

Aveng Trident Steel Wellness Day

Although no Diabetes Wellness meetings were held during December and January, DSA Port Elizabeth branch was invited to attend the Long Service Awards Ceremony and Annual Wellness Day at Aveng Trident Steel PE branch on 2 December 2022.

Thank you aQuellé

We thank aQuellé for sponsoring DSA memberships for new members. aQuellé supplied the bags, bottles of water and an information pamphlet, as well as paying the membership fees. Other items in the bag included: FOR A glucometers, mohair socks from Cape Mohair, Diabetes Focus A to Z booklets plus other literature, and special savings offer from SpecSavers.

First Diabetes Wellness meeting for 2023

The first Diabetes Wellness meeting for this year was held on the evening of 8 February. Lisa Luckman, a biokineticist, encouraged us to enjoy a healthy lifestyle in her presentation: Great ways to create a healthy lifestyle in 2023.

We started in the soft light of candles and lanterns until load shedding ended at 8pm. Then we had to endure the harsh lights again, but we also had the benefit of the many ceiling fans.

Top chronic diseases in SA

Do you know what the top chronic diseases are in SA? Diabetes is one of them.

What are chronic diseases?

A chronic diseases are defined broadly as conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both. They are long-term illnesses caused by a combination of genetic, physiological, environmental, and behavioural factors

Chronic diseases, also known as non-communicable diseases, are the leading cause of death and disability worldwide, accounting for nearly 60% of all deaths and 43% of the global disease burden.

Although chronic diseases are frequently associated with older age groups, evidence suggests that thousands of South Africans are dying of chronic diseases before the age of 70.

Top chronic diseases in SA 

Stroke and heart disease

The sheer number of heart disease or stroke fatalities is a growing concern in SA. According to the Heart & Stroke Foundation, 215 people die from heart disease or strokes daily. Every hour, five people have heart attacks, and 10 people have strokes. Because there is a lack of awareness about cardiovascular disease, many people go undiagnosed and untreated until it is too late.


One in every three adults (13 million) in South Africa has impaired fasting glucose, putting them at high risk of developing Type 2 diabetes. Diabetes is the country’s second deadliest disease, according to Statistics South Africa’s 2021 report on mortality and causes of death.

It has claimed more lives than HIV, hypertension, and other forms of heart disease combined. It’s a leading cause of blindness, kidney failure, heart attacks, stroke, and amputation of lower limbs.


Osteoarthritis is the most common type of arthritis in South Africa, with a prevalence rate of 55.1% in urban areas and between 29.5% and 82.7% in adults over 65 years of age in rural areas.

As many patients are unsure how to manage their symptoms, arthritis coexists with other chronic conditions. This disease is surprisingly common among children, affecting one to four out of every 1000.


Cancer care is expected to cost $240 billion (R4160 billion) by 2030, according to the most recent Centers for Disease Control and Prevention (CDC) and National Cancer Institute estimates, due to healthcare inflation over the previous decades.

Despite declining cancer rates, the CDC predicts that cancer will remain one of the leading causes of death in SA. It’s estimated that nearly 110 000 new cancer cases will be diagnosed in SA by 2020, with over 56 000 cancer-related deaths accounting for one-quarter of all premature non-communicable disease-related mortality.

The most effective cancer prevention measures continue to be early screenings, raising awareness about preventative techniques, and developing strategic partnerships.


Obesity statistics in SA are concerning, with approximately 31% of men and 68% of women obese. Being overweight and obesity can lead to various lifestyle diseases, including diabetes and heart disease.

Obesity is a major issue in adults and children, with more than 13% of South African children aged 6-14 years classified as overweight or obese.

Education, promoting access to healthier foods, and providing preventive care to paediatric patients can help maintain a healthy weight.

Alzheimer’s disease 

According to the most recent World Alzheimer’s Report, SA has 4.4 million people over the age of 60 living with the disease. Around 187,000 of these people have dementia.

Alzheimer’s disease isn’t a normal part of ageing. Although most people with Alzheimer’s are 65 and older, people younger than 65 can also develop the disease. It’s the most common cause of dementia that worsens over time. In most cases, the symptoms develop gradually and become severe enough to interfere with daily activities.


More than 500 000 people in SA have epilepsy. Seizures caused by epilepsy can sometimes result in death. People with epilepsy may also have poor mental health or other impairments that are difficult to detect.


Asthma affects more than 20% of children and 10-15% of adults in SA. It’s not uncommon for those suffering from the illness to be hospitalised during an attack, which can significantly reduce their quality of life.

High blood pressure

High blood pressure, also known as hypertension, affects more than one in every three adults in SA. Because there are rarely any symptoms or visible signs that blood pressure is high, it’s referred to as a silent killer.

As a result, more than half of people with high blood pressure are unaware of their condition. Symptoms such as headaches, visual disturbances, nose bleeds, nausea, vomiting, facial flushing, and sleepiness may sometimes occur, typically with extremely high blood pressure. It would be best if you didn’t wait for symptoms to appear. High blood pressure becomes more common with age, but anyone, regardless of age, gender, fitness level, or lifestyle, can develop it.


In SA, the overall HIV prevalence rate is estimated to be around 13.7%. In 2021, the total number of people living with HIV was expected to be approximately 8.2 million. HIV infection affects an estimated 19.5% of adults aged 15 to 49 years.


In South Africa, tuberculosis is a significant public health concern. Every year, approximately 450,000 people contract the disease, with 270,000 also infected with HIV.

TB kills approximately 89,000 people per year, or 10 people every hour. Effective treatments are available, and the country has made significant progress in combating the disease, but much more is required to bring it under control.

This article is attributed to Affinity Health.

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Call for policy changes to prevent SA childhood obesity

The Healthy Living Alliance (HEALA) calls for urgent policy changes to prevent SA childhood obesity.

Childhood obesity in SA

Approximately 13% of South Africa’s children under five years are overweight, more than double the global average.1 Being overweight and developing obesity in early childhood increases the risk for adult obesity, as well as associated conditions like high cholesterol, diabetes and high blood pressure. All of these conditions are increasingly prevalent in South Africa.1

Childhood obesity is a serious medical condition that affects children and teens. It’s particularly troubling because the extra kilos often start children on the path to lifelong health problems. Childhood obesity can also lead to poor self-esteem and depression.2

The main cause of overweight and obesity among children is the consumption of high-calorie diets; those that are rich in salt, sugar and fats.1 This is also influenced by other factors such as household poverty coupled with the high cost of healthy foods.1

South African children’s fast-food consumption rates are high.3 In a 17-country study completed in 2014, researchers found that fast-food consumption among South African children and adolescents was more frequent than in high-income countries such as Japan and Belgium.3

“Highly processed and unhealthy foods have become increasingly accessible and affordable over the last three decades, leading to a global increase in weight issues and obesity, especially in the poorest and most vulnerable communities and households,” says Nzama Mbalati, Programmes Manager at HEALA.

Sugar consumption

One of the major factors associated with obesity is sugar consumption. South Africans are estimated to consume up to 24 teaspoons of sugar per day, double the daily WHO recommendation.4

South Africa passed a Health Promotion Levy (HPL) on sugary beverages in 2018.5 Commonly known as sugar tax, it has led to considerable reductions in the purchase and consumption of taxable drinks, proving that legislation can support consumers to reduce intake of unhealthy foods and beverages.5

“Currently, at least 85 countries have sugar-sweetened beverages (SSB) taxation,” says Mbalati. “Data from countries like the UK and Mexico indicates that SSB taxes successfully reduce sugar consumption. In SA, people are buying 28% fewer sugary drinks since the government implemented the HPL in 2018. In addition, the levy has slashed the South African beverage sector’s use of sugar by a third. The combination of the two has cut sugar intake in the country by nearly a third. It is now time for the sugar tax on drinks, currently at 10% of the cost per litre, to be doubled and this needs to happen soon.”

Mbalati stresses that this is critical to address the country’s raging diabetes epidemic and the high rates of obesity that fuel it. “South Africans are addicted to sugar. With more than a quarter of the population living with obesity, we are among the top 20% of the most obese nations in the world. More than 4,5 million people have diabetes, with diabetes being the second-largest cause of death after tuberculosis.”

Mbalati adds that sugary drinks should be drastically reduced in children’s diets. “Even 100% fruit juice with no added sugar contains a lot of sugar with none of the fibre you would find in a piece of fruit to help fill you up. Encourage kids to drink mostly water and plain milk. Get them to eat whole fruit, like an apple, instead of drinking apple juice.”

Visit whatsinourfood.org.za for more information.

Instagram: instagram.com/betterlabels_za

Facebook: facebook.com/betterlabelsza


  1. Statistics on children in South Africa: Overnutrition in children, Sambu, W. Children’s Institute. University of Cape Town. [Nov 2019]. Available from:http://childrencount.uct.ac.za/indicator.php?domain=4&indicator=96
  2. Childhood obesity. Mayo Foundation for Medical Education and Research (MFMER). [Dec 2022]. Available from:https://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/syc-20354827
  3. South African Child Gauge 2020: Food and nutrition security. May, J.; Witten, C.; Lake L. Children’s Institute. University of Cape Town. [2020]. Available from:http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/ChildGauge_2020_screen_final.pdf
  4. McCreedy, N.; Shung-King, M.; Weimann, A.; Tatah, L.; Mapa-Tassou, C.; Muzenda, T.; Govia, I.; Were, V.; Oni, T. Reducing Sugar Intake in South Africa: Learnings from A Multilevel Policy Analysis on Diet and Noncommunicable Disease Prevention. Int. J. Environ. Res. Public Health 2022, 19, 11828. Available from: https://doi.org/10.3390/ijerph191811828
  5. Stacey, N; Edoka, I; Hofman, K; Swart, EC; Popkin, B; Shu Wen, N. Changes in beverage purchases following the announcement and implementation of South Africa’s Health Promotion Levy: an observational study. The Lancet. 5, 4, E200-E208. [Apr 2021]. Available from:https://www.thelancet.com/action/showPdf?pii=S2542-5196%2820%2930304-1
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Weight loss: more than just eating less and being more active

Dr Paula Diab sheds light on the physiological mechanism of weight loss and gain then looks at the methodologies that can assist in achieving and maintaining the desired weight.

Did you make any New Year’s resolutions for planned weight loss, go on diet, spend more time in the gym or start some new type of exercise? Have you kept up with any of those goals as yet?

Don’t feel alone or despondent about these goals. In this fast-paced, instant-gratification world in which we live, such goals are extremely common. However, the rewards aren’t as easy to achieve as we think they are.

Obesity as a chronic disease

Obesity has recently been recognised by the international healthcare community as a chronic disease. What this means is that the mechanisms that cause obesity are persistent and long-lasting and various complications may be associated with the condition as well.

The European Medicines Agency states that “Obesity is recognised as a chronic clinical condition that usually requires long-term therapy to induce and maintain weight loss and is considered to be the result of complex interaction of genetic, metabolic, environmental and behavioural factors, which are associated with increases in both morbidity and mortality.”

The World Health Organization has recognised obesity as a threat to both developed and developing countries and estimates that over 650 million people worldwide are affected by it.

The Canadian Medical Association has declared “obesity to be a chronic medical disease requiring enhanced research, treatment and prevention efforts.”

The bottom line is that treating obesity is more complicated than cutting out sweets and going to gym more often.

What is obesity?

Many people and healthcare institutions consider a body mass index (BMI), a simple height to weight ratio, as the only indicator of being over or underweight. In addition, it’s suggested that all types of people from all races and ethnic backgrounds be subject to the same parameters. Some exceptions have been made but generally a BMI of > 25 is considered overweight and > 30 is obese.

This is also changing. I’m not a big follower of action movies but my teenage son tells me that Dwayne Johnson (aka The Rock) is 1.96m tall and weighs 118kg. That gives him a BMI of 34; very soundly in the obese category. I’ll certainly be last in the queue of people to go up to him and tell him he’s overweight.

More recently, we have started looking at a multitude of other factors to determine if someone is overweight and how this may or may not affect their health. Some of the factors we consider are:

  • Medical co-morbidities – cardiac disease, arthritis, fertility problems, diabetes, etc
  • Mental concerns – depression, social isolation, etc.
  • Functional ability – can the person continue their desired daily activities without limitation?

These are all important indicators that will guide as to how we should approach the management of obesity. Few would argue that The Rock has any limitations on his functional abilities.

Complications of obesity

Does this mean that we can ignore a higher BMI and allow people to choose their desired weight as they please? Not really. Research indicates that people with a higher BMI are definitely prone to developing a range of complications and that obesity has a significant impact on life expectancy. People with a BMI over 40 have a predicted only 50% chance of reaching the age of 70 compared to those with a BMI < 30 who have an 80% chance.

Complications range from other metabolic diseases, such as diabetes, which has a significant impact on other health concerns in itself, to cardiovascular disease and some types of cancers.

Gout, arthritis and bone disease also become more prevalent due to the mechanical strain on joints and muscles and mental health complications, such as depression, also are more frequent.

Weight loss improves complications

Whilst this may sound like a very negative situation, the reality is even a modest weight loss will have an enormous effect on reducing these complications.  

What causes obesity?

It’s probably fair to say that most people think that weight gain is due to an imbalance between energy intake and energy expenditure. People who are overweight, either eat too many calories or do too little activity. Losing weight therefore requires more activity or fewer calories. This is not true.

It has now been scientifically proven that weight gain or loss is far more complex than this and that the main organ responsible for controlling weight is our brain.Genetics play a vital role in regulating this control; if your family is overweight, it’s very likely that you have similar genes that will dictate how your body responds. Other organs in the body such as the pancreas, gut and adipose tissue (fat tissue) also influence your metabolism and how you process energy in the body.

Restricting energy intake (eating less) is also not an effective means of weight loss as hormones, such as leptin, are downregulated as energy restriction occurs. Low leptin levels cause the body to conserve energy and trigger a response in the brain that you are hungry and need to eat. This is not a will-power issue but a genuine lack of energy in the body which causes weight to regain as your body adapts to the feeling of hunger and desire to eat.

The role of the brain in controlling appetite

Until recently, the impact of the brain in appetite has been largely overlooked. Homeostatic eating is eating for hunger. This is what we generally don’t do. It is, however, what most animals do. They hunt when they are hungry and eat until they have gained enough calories to survive.

Hedonic eating

Hedonic eating is eating for pleasure and is under control of the mesolimbic system. This is the eating that happens at Christmas lunch or at a wedding or when we eat out at a restaurant with friends. It’s mediated by feelings of wanting or liking to eat and not by satiety or hunger.

A want-to-eat is mediated by dopamine, a hormone implicated in reward-behaviour system. The more we eat, the more we reward our brain and drive future such behaviours. Liking-to-eat is associated with pleasure derived from eating and is mediated through opioid and cannabinoid receptors. No one would dream of hosting a celebration and serving just a small amount of food to allow your guests to survive and combat starvation. We like tasting different foods, we like socialising while we eat, we like food that tastes good.

We have the privilege of being able to indulge in hedonic eating and not just eat when we are hungry. It’s the executive functioning in the pre-frontal cortex of our brains that decides when we are hungry. Over years of over-riding the need to eat and the want to eat, our brains develop alternate pathways.

In addition, each time we gain weight, our brains use that as a new set-point, a new normal to which it governs our weight regain. Many of us will relate to the experience of going on a diet, eating fewer calories but as soon as you go into a maintenance phase again, you regain the weight to where you were initially.

How do medications work?

Some older weight loss preparations have a more short-term effect and aim to speed up metabolism; these generally work very well in the short-term but have little effect on the underlying problem.

Others act on energy wastage and bind fat in the gut to reduce calories absorbed. Again, this can work well in the short-term but aside from some negative side effects, do very little to address the pathways in the brain.

Newer formulations of medications to manage weight have recently been developed and licenced for use and are much more effective at addressing the chronic underlying pathology that results in weight gain.

What we need is a drug that acts on the pathways in the brain to reset the weight set-point and override the feelings of hunger and desire to eat as well as improve metabolism in the gut, pancreas and other metabolic organs.

By reducing gastric emptying, you feel fuller for a longer period of time thus decreasing the desire to eat. Within the liver, metabolism is also affected reducing glucose production and enhancing glucose sensitivity.

Such drugs also have a positive effect on cardiac function, but the most significant effect is the action directly on the brain which results in decreased food intake, improved satiety and sustained weight loss.

Patient feedback

There has been great success using these drugs with my patients and some of the comments talk directly to the mechanisms in which they work. Comments relating to how their focus shifts away from food and they can get on with normal daily activities without being fixated about their next meal or how little they should be eating.

Other comments relating to the ability to sit at a table and eat what they feel they need to eat rather than what they want to eat and actually feel full and satisfied at the same time. The medication also has a significant effect on combatting the cravings that people feel in between meals and the extra snacks that we have just because they taste nice.


Shifting from a BMI-centric approach of treatment where we are purely trying to target a number to a more complication-centric focus where the multiple co-morbidities associated with obesity are addresses as well as the often unseen mental complications will certainly result in better outcomes in managing weight and obesity.

Counselling, self-monitoring, physical activity and diet are most certainly vital aspects of weight management achieved through interaction with a holistic multi-disciplinary team. This includes dietitians to address the obvious aspects of diet and a doctor skilled in obesity management to know which drugs and possible surgical options suit each patient as well as multiple other practitioners as individual patient needs dictate.

Our healthcare system is perhaps not ideally suited to deliver obesity management in such a way, but it will be a great leap forward if we can shift our focus from thinking that weight loss is a quick-fix that requires more activity and fewer calories to one of understanding the chronic nature and multi-faceted cause of weight gain.

Accurate and effective pharmacological treatment is the future of weight management and treating obesity as a disease and not a lack of will power and poor decision-making will go a long way to helping those who need medication to access it.

Dr Paula Diab


Dr Paula Diab is a diabetologist at Atrium Lifestyle Centre and is an extra-ordinary lecturer, Dept of Family Medicine, University of Pretoria.

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Can gout be connected to diabetes?

Dr Louise Johnson explains what triggers a gout attack and explains how it may be connected to diabetes.

What is gout?

Gout is a systemic disease that results from the deposition of urate crystals in tissue, such as the big toe and other joints.

In normal conditions, the urate crystals are passed into the urine. In certain circumstances, there is abnormality of urate handling. There are two categories:

  1. Increased production
  • Cancer
  • Diet consistent with too much purines that cause urate crystals, such as red meat (beef, pork, lamb), seafood and beer.
  1. Decreased clearance
  • Kidney failure
  • Diuretics (medication use to make you pass more urine).

The gout attack

Deposition of urate crystals in the joint cavity triggers a gout attack. The affected joint is red, swollen and very tender. It resolves within hours to days. A drug (colchicine) will limit inflammation and symptoms. This can usually be obtained from the pharmacy as a gout cocktail.

It’s important to know that gout can become a chronic disease. It’s estimated that 85% of people who have a first attack will have one again within three years.

Chronic gout

This is the result from recurrent acute attacks and causes chronic inflammation in the joint with cartilage damage and tophi formation.

This is the result from recurrent acute attacks and causes chronic inflammation in the joint with cartilage damage and tophi formation.

The impact of systemic disease on uric acid

Gout seems to affect osteoarthritis joints more often. High blood pressure is a known risk factor for gout. Diabetes is also a risk factor for hyperuricemia (urate build-up in the blood) and gout.

The gout-diabetes link

People with Type 2 diabetes are more likely to develop hyperuricemia and people with gout and high uric acid may be more likely to develop diabetes. Not everyone with hyperuricemia will get gout but your chances go up as the uric acid levels rise.

In a 2010 study in The American Journal of Medicine, thousands of adults and their children were examined. The researchers found that those with higher uric acid levels were more likely to get Type 2 diabetes.

A 2014 study in the Annals of Rheumatic Diseases found that the gout-diabetes connection was especially strong in women. Researchers found that women with gout were 71% more likely to get diabetes than women without it.

Other factors that also play a role


Almost 90% of people with Type 2 diabetes are overweight or obese. People who are obese are four times more likely to get gout than a person of normal weight. Carrying extra kilograms slow down your kidneys’ ability to remove uric acid.


About 80% of people with diabetes also have hypertension (high blood pressure). This raises uric acid levels and is also linked to insulin resistance. Gout and diabetes are also linked to kidney disease and heart disease.


If you are older than 45 years, you have an increased risk of diabetes and gout especially if you have metabolic syndrome features.

Metabolic syndrome according to the ATP 111 criteria

  1. Increased waist circumference. More than 80cm in a female and more than 94cm in a male.
  2. High blood pressure.
  3. Abnormal blood lipids: low HDL (good cholesterol) and increased triglycerides (blood fat).
  4. Abnormal blood glucose.

Insulin resistance

High uric acid doesn’t only cause inflammation, it can also trigger insulin resistance. Insulin resistance is when your body doesn’t respond well to insulin, causing too much blood glucose to circulate in the bloodstream.

What triggers gout?

  1. Heavy alcohol uses especially beer and hard liquor.
  2. Foods high in purine, such as red meat, liver and seafood.
  3. Sugary cold drinks, such as sodas, fruit juice, and candy.
  4. Certain drugs that are used to decrease swelling of feet called diuretics.
  5. Fasting and dehydration.
  6. High doses of vitamin A and niacin.


There are two categories:

  • Uricosuric agents helps the body to pass more uric acid.
  • Xanthine oxidase inhibitors help the body produce less uric acid.

Managing an acute attack

  1. Colchicine taken within 12 hours of the onset of the flare has been shown to be effective. Remember that colchicine can cause diarrhoea, nausea and vomiting if the dosage is too high.
  2. Non-steroidal anti-inflammatory drugs; these are analgesics such as Voltaren or Brufen. Remember not to take aspirin since this can make the pain worse.
  3. Corticosteroids can give fast relief given as a tablet or injection. Remember that steroids will temporary push up blood glucose.

Managing gout and diabetes

Lifestyle changes is important for both conditions.

Watch what you eat

Diet is a key to managing both conditions well. In addition to your diabetes friendly diet, avoid certain foods and add others.

  • Cut out or limit red meat and seafood including mussels, anchovies and sardines.
  • Add dairy products like skim milk and low-fat yoghurt which may protect against gout.

Get moving

Regular exercise helps control blood glucose and can help with losing weight. This will help with reducing uric acid levels.

Stay hydrated

Plenty of water can help flush out uric acid and keep your kidneys working well. A rule of thumb is 250ml (a glass) of water for every 10kg. Remember to drink more when it is very hot, or you are exercising.

Control other health problems

High blood pressure, kidney disease and obesity raise the uric acid levels and can bring on a gout flare.

Make sure you see your doctor regularly for a treatment plan and uric acid levels.

Dr Louise Johnson


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.

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The link between sleep disturbances and diabetes

Dr Louise Johnson lists several sleep disturbances that may affect people living with diabetes and the treatment thereof.

It’s estimated that one in two people with diabetes have sleep disturbances due to unstable blood glucose and accompanying diabetes related symptoms. High and low blood glucose levels during the night can lead to insomnia and fatigue the next day. As with many chronic conditions, feelings of depression or stress about the disease itself may keep you awake at night.

Sleep disturbances in diabetes

  1. Insomnia (too little or no sleep)
  2. Hypersomnia (too much sleep)
  3. Sleep apnoea
  4. Restless leg syndrome
  5. Peripheral neuropathy


This can be due to high or low blood glucose levels. With hyperglycaemia, the kidneys overcompensate by causing more frequent passing of urine at night to try and get rid of blood glucose. You may also be excessively thirsty.

In the case of hypoglycaemia, the body’s alarm system adrenaline is triggered causing hunger, palpitations, sweating and shivering. You may also have severe nightmares with low blood glucose. These conditions will make you tired and irritated the next day due to poor quality of sleep.

Sleep deprivation raises the hormone ghrelin (hunger hormone) and decreases levels of leptin (hormone that makes us feel full). To compensate for lower energy levels, people who sleep poorly may be more likely to seek relief in foods that raise blood glucose and put them at risk of obesity, which is a risk factor for diabetes.


Too much sleep may be due to extreme high blood glucose or can also be a sign of depression. One quarter of people with diabetes report sleeping more than eight hours per night which puts them at higher risk for elevated blood glucose.

Studies have also found that later or irregular sleeping schedules are correlated with higher blood glucose even in non-diabetic people. One of the reasons is that irregular sleeping schedules are more likely to follow an erratic diet.

Adults with Type 2 diabetes who experience disturbed sleep or frequent night-time awakenings may also be less likely to follow other standards for diabetes self-care such as getting enough exercise and closely monitoring blood glucose.

In addition to its immediate effects on blood glucose, poor sleep can take a long-term toll on individuals with Type 2 diabetes. Those who resort to sleep medication or having trouble staying asleep are more likely to report feeling serious psychological distress. There is also tentative evidence to suggest that people with diabetes who don’t get enough sleep may be at higher risk of cognitive decline later in life.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a sleep disorder in which a person momentarily stops breathing at recurring intervals throughout the night. In most cases the person isn’t aware this is happening, though a bed partner may observe snoring and gasping. These lapses in breathing cause micro-arousals (very brief awakenings without knowing it) that interfere with the natural progression of the sleep stages and impair quality of sleep.

OSA typically occurs in people who are overweight or obese as they have a thicker neck circumference that interferes with the airway. The condition can be treated with weight loss and a continuous positive airway pressure (CPAP) device that keeps the airway open to restore normal breathing and reduce interruptions to sleep. This better sleep pattern also aids in losing weight more easily with a diet. Should you experience daytime fatigue or night time snoring, speak to your doctor for a sleep laboratory evaluation.

The connection between sleep apnoea and diabetes

Though sleep apnoea doesn’t directly cause diabetes, it’s a risk factor for Type 2 diabetes and has been shown to increase insulin resistance, even in non-diabetic and non-overweight people.

The American Diabetes Association estimates that up to one in four people with Type 2 diabetes also suffers from OSA, and a further quarter of Type 2 diabetes suffer from another sleep-related breathing disorder.

Both OSA and Type 2 diabetes are more common in people who are overweight and obese. However, OSA appears to affect insulin resistance and glucose control even after controlling obesity. Not only does OSA cause sleep fragmentation that interferes with slow-wave sleep, but it also periodically cuts off the body’s oxygen supply. Together these effects lead to insulin resistance and impaired glucose metabolism.

In many studies, short-term sleep apnoea treatment appears to improve blood glucose levels while long-term CPAP treatment improves blood glucose and insulin resistance.

Restless leg syndrome

Approximately one in five people with diabetes have restless leg syndrome (RLS), marked by tingling or other irritating sensations in the legs that can interfere with getting to sleep.

This sensation causes an irresistible urge to move the legs. Diabetes is a common cause of restless legs syndrome but also remember to ask your doctor to check your iron, since iron deficiency and kidney failure are also main causes of restless legs. Other body parts such as upper extremities can also be involved.

Females suffer from RLS twice as much as their male counterparts across all different populations and ages. There is evidence linking an increased risk for RLS in patients with diabetes. Many people with diabetes and RLS also suffer from peripheral neuropathy.

Peripheral neuropathy

Painful feet at night is a prominent symptom of peripheral neuropathy. In diabetes, this is caused by nerve damage. The feet can also feel numb, burning or tingling. Other causes can be thyroid disease, liver disease or vitamin B12 deficiency. Always let your doctor examine your feet properly to distinguish the correct cause and treatment.

How can people with diabetes cope with sleep disturbances?

Careful management of blood glucose is of the utmost importance. If blood glucose is up and down despite a good diet and exercise and medication plan, consider the use of a sensor to help warn you about low and high blood glucose. There are a variety of continuous glucose monitors (CGM) on the market.

If you have sleep apnoea, use your CPAP mask regularly. Peripheral neuropathy and restless leg syndrome have specific mediation that your doctor will prescribe.

Practise good sleep hygiene

  • Keep a regular bedtime schedule.
  • Keep your bedroom dark, cool and quiet.
  • Avoid stimulants such a caffeine, nicotine and alcohol before bedtime.
  • Don’t exercise too close to bedtime as this may stimulate the body and cause low blood glucose.
  • Learn relaxation and breathing techniques.
  • Listen to relaxation CDs of nature sounds or water.
  • Avoid or minimise napping during the day.
  • Get out of bed and do something in another room when you can’t sleep. Go back to bed when you feel drowsy.
  • Use the bed only for sleeping or sexual activity. Don’t lie in bed watching TV.
  • Try cognitive behavioural therapy as first-line for insomnia.

The significance of good sleep can’t be overemphasised when it comes to chronic medical conditions like diabetes. Poor sleep quality, apart from its usual effect of daytime sleepiness, has ramifications that affect every aspect of life. The pertinent ones are exacerbations of seizures, short-term memory deficits, long-term cognitive effects and headache. These when combine to already worsened quality of life in patients with chronic diseases, can have several deleterious consequences in an individual’s life. Don’t lie awake counting sheep, speak to your doctor or sleep physician.

Dr Louise Johnson


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.

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