Zoné Oberholzer – the beauty living with Type 1 diabetes

Modelling, insulin pumps, make-up and studying. This is all in the life of Zoné Oberholzer, a Type 1 diabetes patient and a Miss Supranational SA 2019 finalist.


Zoné Oberholzer (21) lives in Pretoria, Gauteng. She is an Education (BEd) student at Aros University.

The young Pretoria beauty recently celebrated her 21stbirthday which came at an apt time as she just finished her first year June exams. We caught up with the  model to find out how she has handled living with Type 1 diabetes for 17 years.

When were you diagnosed?

In September 2002. I was four years old. My nursery school teacher mentioned to my mom that I was no longer playing outside and that I was constantly thirsty. She suggested that we see a doctor, where upon I was diagnosed.

I spent a week in hospital where my blood glucose was stabilised, and my parents were educated about Type 1 diabetes. The doctor said the most likely cause was the chickenpox virus which I had contracted nine months earlier.

I started using a pump (Medtronic Minimed Paradigm) at age six. My mother decided it would be easier for me to be on pump therapy before I started school. This helped my parents to regulate my blood glucose levels.

They educated the teachers in using it. We, however, quickly learnt that it would be best for me to handle my own pump. This forced me from a very young age to know my pump and also calculate carbohydrates. Although, it was very difficult to start off with, it helped me to manage my condition from an early age and to take responsibility.

The insulin pump only operates on short-acting insulin (NovaRapid). I think it makes life easier to not have to use a long-acting insulin as well.

When did you start modelling?

As soon as I was diagnosed, my mother decided to boost my self-confidence by enrolling me to do a modelling course. Since then it has been an absolute passion. Not only has it motivated me to look after myself, but it has inspired me to use it as a platform to promote diabetes awareness.

Did modelling boost your confidence as your mom hoped?

Modelling definitely boosted my confidence. But, it was a learning process throughout all the years to eventually bear the fruit. It definitely takes the correct attitude to use the experiences I learned from modelling for a positive growth experience. It stays crucial to seek your identity in Christ and not in modelling.

Why did you enter Miss Supranational SA 2019?

I entered as I saw it as an opportunity and platform to make a difference. Especially, among the diabetic community.

Miss Supranational South Africa 2019 focuses primarily on social upliftment. It creates a platform for finalists and winners to achieve their goals within the pageant, entertainment and business industries.

I am so grateful to be a finalist and thankful for the opportunity. The winner will be announced on 27 July at the Arto Theatre.

Have you been in any other contests?

Yes. Besides some smaller contests, I am currently a title holder (Apprentesses Charity 1st Princess) for Apprentesses SA. I was also a finalist for Top Model South Africa.

Do you proudly wear your insulin pump during modelling competitions?

In the past I would hide my pump as I was ashamed. I saw diabetes as my identity. This led me to hide myself from the world, but I realised that diabetes is only a part of me. A part of me that I should embrace and be proud of. This only happened after school. 

It is my goal to wear my insulin pump with pride at Miss Supranational SA. It’s not always easy as pageant dresses don’t always cater for an insulin pump. But, I will definitely wear it if the costumes allows.

Has it been easy to manage your diabetes?

No. It hasn’t been easy. Nonetheless, I’m grateful for the lessons learnt through my diabetes journey. Every day has its highs and lows. One just has to learn how to deal with it and not run away from it.

I would definitely not exchange living with diabetes for an easier life, because the lessons I’ve learned and keep on learning are far too valuable. The hardships of this condition empower me to empower those around me with positivity.

What are the highs of having diabetes?

There’s a valuable lesson that diabetes teaches every day. From a lighter viewpoint, you will live a healthier life than the average person out there. This is because you must be sensitive to what you eat, what you do, how you do things, and where you do things.

What are the lows of having diabetes?

Personally, the low is that no matter how healthy and cautious you live, there is always the risk of unexpected blood glucose drops and highs.

Do you follow any any special diet?

I’m not on a special diet, but I do follow a balanced healthy diet. I eat according to my blood glucose levels. I give my body what it needs. Not what it wants.

Do you make use of sweeteners?

My mother raised me to be a healthy child living with diabetes. She taught me from an early stage that sweeteners aren’t necessary to live a happy full life.

What helps you the most to manage your diabetes?

My support system, my family, boyfriend and, most importantly, God! If it wasn’t for Him, I wouldn’t have made it this far. He turned my misery into a ministry.

Tell us how puberty affected your blood glucose

Puberty took my blood glucose levels on a roller coaster. My menstruation also affected my blood glucose levels. I usually struggle with a higher blood glucose level during menstruation.

We wish Zoné all the best for the finals of Miss Supranational SA 2019.

 

Photos by Kayleigh Kruger

Zoné Oberholzer - the beauty of living with Type 1 diabetes

MEET OUR EDITOR


Laurelle Williams is the Editor at Word for Word Media. She graduated from AFDA with a Bachelor of Arts Honours degree in Live Performance. She has a love for storytelling and sharing emotions through the power of words. Her aim is to educate, encourage and most of all show there is always hope. Feel free to email Laurelle on editor@diabetesfocus.co.za


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Type 1.5 diabetes – a new diagnosis?

Dr Angela Murphy tells us about Type 1.5 diabetes, commonly known as latent autoimmune diabetes.


Mrs JM came to see me about her new diagnosis of Type 1.5 diabetes. She was concerned that she had never heard of this before and that it may represent a more dangerous type of diabetes. She specifically wanted to know if she was receiving the correct treatment. To be able to explain this diagnosis, let us go back to the very beginning.

Back to the beginning

Diabetes mellitus, a condition where blood glocose is high, has been described for thousands of years. It was initially diagnosed by testing for the sweet (mellitus) taste of urine.

Over time it became clear that not all diabetes is the same and so began attempts to classify the various types. This classification has changed over the years and we now categorise diabetes according to the cause of the diabetes. The four main types are:

  • Type 1

In this type, there is significant destruction of the insulin producing beta cells of the pancreas. This is usually due to an autoimmune process that attacks these cells but may occur without any sign of autoantibodies. The latter variant has a very strong family history and is more common in African and Asian populations.

  • Type 2

This is the most common form of diabetes occurring in 90-95% of cases. Usually there is a background of insulin resistance and then progressive loss in insulin secretion from the beta cells.

  • Type 3

This group has over several major subtypes with over 40 individual causes described. The group includes the maturity onset diabetes of the young (MODY) conditions which are single gene mutations; pancreatic diseases such as cystic fibrosis; endocrine disorders; side effects of drugs, such as HIV treatment or other rare genetic conditions.

  • Type 4

By definition, this is hyperglycaemia (high blood glucose) first detected in the second or third trimester of pregnancy. This type is better known as gestational diabetes.

LADA

As you can see, there is no Type 1.5 diabetes. The more accepted term for this type of diabetes is latent autoimmune diabetes in adults (LADA). LADA is a condition that occurs in adults between the ages of 30-50 years. Like Type 1 diabetes, there is autoimmune damage to the pancreatic beta cells. However, this seems to be at a much slower rate than in the young, typical Type 1 diabetes patient. Hence, the term latent.

Why is LADA called Type 1.5 diabetes?

LADA has features from both Type 1 and Type 2 diabetes, so it seems reasonable to call it Type 1.5. However, the cause of LADA is autoimmune beta cell destruction. So, for that reason it must be considered as a subtype of Type 1 diabetes.

We should always consider a diagnosis of LADA in a normal weight patient who has reasonable glucose control, using lifestyle interventions and/or oral medication only. It would be reasonable to test for LADA in such a patient.

LADA/Type 1.5 diabetes symptoms

Initially, patients may experience non-specific fatigue, decrease in concentration and hunger pangs after eating. More typical symptoms, such as weight loss, thirst and blurred vision, develop gradually over months, sometimes even years. Patients are often of normal weight and usually there is no family history of diabetes. They may have another autoimmune condition, such as thyroiditis, rheumatoid arthritis or coeliac disease. The patient is advised on a healthy lifestyle and usually started on oral medication to control glucose, which seems to help for a period. Ultimately, there will always come a point when insulin needs to be initiated.

Confirmation tests for LADA

The only way LADA can be confirmed is to do specific tests to look for the antibodies causing the damage, specifically the glutamic acid decarboxylase (GAD) antibody. A C-peptide level test can also be done to measure how much insulin the pancreas is still producing.

These are not routinely tested and it can be argued that doing these tests, does not necessarily change management. If the patient is having regular check-ups, including HbA1c measurement and testing glucose regularly at home, any deterioration in the diabetes will be detected. The decision to initiate insulin can then be made timeously.

However, we should consider the advantages of doing the antibody testing and establishing if LADA is present as seen below.

Protecting beta cell function

Some of the oral medications available to treat high blood glucose work by stimulating the beta cells of the pancreas to increase their insulin production.

In LADA, this may have the negative effect of speeding up the deterioration of the beta cell and shortening the latent period: patients would need to start insulin sooner.

Metformin is the best oral diabetic medication to begin with as it has no pancreatic action. Rather, metformin decreases the production of glucose in the liver.

Preserving beta cell function

There is evidence that early insulin treatment may assist the beta cells so that they can continue producing insulin for longer periods. A Japanese study looked at 4000 patients with LADA and found that those treated with early insulin took longer to be fully dependent on insulin compared to those patients on oral medications.

Prevention of ketoacidosis

Ketones are formed by the body when fat is used for fuel. The body does this when there is not enough insulin to move glucose out of the blood stream and into the working cells of the body. Unfortunately, these ketones cause the body to become acidotic which is very dangerous.

Patients with LADA could be made aware that a persistent increase in their blood glucose might be heralding the time to start insulin. In this way, there would be less delay and thus, less chance of developing ketones.

Table 1 – Comparison of Type 1 and Type 2 diabetes

DIABETES ADULT ONSET AUTOIMMUNE DIABETES TYPE 2
Type 1 Latent Autoimmune
Autoantibodies YES YES NO NO
Insulin required at diagnosis YES NO NO VARIABLE

MEET OUR EXPERT


Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence as well as a specialist with the Centre for Diabetes Excellence (CDE) network.


Healthier hearts in Type 2 diabetes

Dr Angela Murphy educates us about new drugs that treat Type 2 diabetes and decrease the risk of heart disease.


I asked several of my patients what concerns them most about having diabetes. The answers were fairly consistent: high sugar levels, losing vision, amputations, kidney failure and needing dialysis, and dying early.

However, cardiovascular disease (CVD) which consists of heart attacks, heart failure and stroke is the cause of complications and death in two-thirds of patients with Type 2 diabetes. It would make sense to have treatment for diabetes that not only decreased the blood sugar but also the risk of heart disease.

In 2008, the Federal Drug Administration (FDA) in the USA stipulated that all new diabetic agents would need to prove that they do not increase the risk of CVD. This was in the wake of a medication (Rosiglitazone – insulin sensitiser) that had to be withdrawn due to adverse cardiac effects. Only Pioglitazone remains available from that group.  

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The first of the new medications to market – the gliptins or DPP1V inhibitors – showed they were safe but did not improve cardiac outcomes. However, two new agents have, remarkably, done just that: empagliflozin (Jardiance) and liraglutide (Victoza).

1.Empagliflozin

This is a sodium glucose transport receptor (SGLT)-2 inhibitor. It acts by stopping the reabsorption of glucose in the kidney. Excess glucose is excreted in the urine which results in the lowering of blood glucose levels. This is accompanied by an estimated loss of 280kcal/day which contributes to a decrease in weight. There is also fluid and sodium losses resulting in blood pressure lowering and improvement in heart function.

The excellent results from the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients–Removing Excess Glucose (EMPA-REG OUTCOME) trial, allowed the FDA to add another indication for treatment with Empagliflozin.  Empagliflozin is now registered:

  1. as an adjunct to diet and exercise to improve glycaemic control in adults with Type 2 diabetes mellitus.
  2. to reduce the risk of cardiovascular death in adult patients with Type 2 diabetes mellitus and established CVD.

In this ground-breaking trial, over 7000 patients with Type 2 diabetes were shown to have had a 38% relative risk reduction (RRR) in cardiovascular death with empagliflozin compared with placebo. There was also a statistical reduction in hospitalisation for heart failure, as well as a drop in all causes of death.

CANVAS programme

There are two other drugs in the SGLT-2 inhibitor class, viz. dapagliflozin (Forxiga) and canagliflozin (Invokana). The recent CANagliflozin CardioVascular Assessment Study (CANVAS) programme also reported a significant reduction in cardiovascular disease and hospitalisations for heart failure.

Over 10 000 patients with Type 2 diabetes were enrolled in the study with a third of the patients not yet having documented heart disease but they had to have two or more risk factors (hypertension, hyperlipidaemia or obesity).

This is exciting to know that the protection is also for patients who have not developed heart disease.

A concern with the use of Invokana was the reported increase in amputations, mainly of the toes but some leg amputations too. Patients with diabetic foot problems should probably not receive Invokana.

CVD-REAL study

It is possible that the SGLT-2 inhibitors as a class will be cardioprotective. The Comparative Effectiveness of Cardiovascular Outcomes in New Users of Sodium-Glucose Cotransporter-2 Inhibitors (CVD-REAL) study shows just that.

This is a study that looked at 154 528 patients who received a SGLT-2 inhibitor from their own doctor for the first time. The results were compared with other classes of glucose-lowering drugs. Again, there was a significant improvement in hospitalisation for heart failure and reduction in all cause of deaths.

Only 13% of the patients had established cardiovascular disease which implies a benefit for the broader Type 2 diabetes population. In the USA, canagliflozin was the drug most used whereas in Europe it was dapagliflozin. This supports the idea of a class effect.

2.Liraglutide

This is the second diabetic drug to receive cardiovascular approval from the FDA. Liraglutide is a glucagon like peptide-1 (GLP-1) agonist.

GLP-1 is a hormone released in the gut in response to food. GLP-1 then stimulates the pancreas to produce insulin. In Type 2 diabetes, this system is sluggish so a great deal of research has focussed on restoring this important system.

Liraglutide is a synthetic version of GLP-1 and when given (via subcutaneous injection), it raises the GLP-1 levels to above normal. In addition to the glucose lowering effects from stimulating the pancreas, liraglutide slows down gastric emptying, dampens the appetite centre and protects the heart muscle from damage in the event of a heart attack.

LEADER trial

The Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results—A Long Term Evaluation (LEADER) trial showed a 13% reduction in the combined endpoint of heart attack, stroke and cardiovascular death compared with placebo.

The official FDA approved package leaflet now reads that liraglutide is indicated:

  • as an adjunct to diet and exercise to improve glycaemic control in adults with Type 2 diabetes mellitus.
  • as an adjunct to standard treatment of cardiovascular risk factors to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal heart attack, or non-fatal stroke) in adults with Type 2 diabetes mellitus and high cardiovascular risk.

Current label indications

It is important to note that at this time the FDA label indications for these two drugs, Jardiance and Victoza, is for those people with diabetes and current heart disease.

The results of the CANVAS trials, as well as other ongoing trials, will allow the FDA to consider indications in the future for these medications to help reduce heart complications in those people with diabetes who have risk factors for but no known cardiovascular disease.

Should a Type 2 diabetes patient change his/her medications?

It is always important to review a prescription, especially with patients with diabetes. If sugar control is poor, if more cardiovascular risk factors have been identified, or if a patient has had a heart attack, stroke or been hospitalised for heart failure, it would be very valuable to consider changing or adding these new classes of medications.

Availability

Liraglutide, empagliflozin and dapagliflozin are available in South Africa. However, they are not available in the public sector and medical aids may not always fund them. Hopefully, as evidence continues to build of the importance of the extra benefits of these glucose lowering medications, they will become more accessible for all patients with Type 2 diabetes.

MEET OUR EXPERT


Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence as well as a specialist with the Centre for Diabetes Excellence (CDE) network.


Reflections of a Type 1 diabetic: diagnosed during WW2


Nadine Lang says living with Type 1 diabetes for 74 years has not been problematic. She reflects back to the time she was diagnosed and tells her tale.


Nadine Lang (79) – a widow – lives in Summerstrand, Port Elizabeth and has two daughters and a granddaughter. She moved to South Africa from Britain in 1964.


1944

I was diagnosed one week before my 6th birthday. The onset was very quick; I was constantly drinking, tripping off to the toilet and bed wetting. I landed up in the local children’s hospital and a few days later, all the children, except me, were enjoying my birthday cake. Naturally, my parents were in shock but quickly recovered with the wonderful help and encouragement they received from the hospital staff.

Insulin options

It was only 22 years after the discovery of insulin and there was little choice: only the long-acting Protamine Zinc and short-acting insulin, I think called Soluble. Because I was so young, it was thought better (and kinder) to only have one injection a day, so I was put on Protamine Zinc.

After I left hospital, I used to go every fortnight as an outpatient. The Protamine Zinc-alone regimen proved ineffective, so it was complemented with Soluble. Eventually, the Protamine Zinc was discontinued and thereafter I was only on Soluble twice a day.

Waiting game

I had to wait 20 minutes to half an hour in those days after having my injection before I could eat. This was to allow the insulin to start to work before the food had chance to raise my sugar level. As I became more stable and my mother more confident in coping, my outpatient visits occurred less frequently. They became monthly, then every six weeks and finally every six months, unless a problem cropped up.

I continued to use Soluble twice a day with occasional adjustments of dosage as I grew up until the mid 80s. In fact, I must have been almost the last person to use Soluble as I refused to change until it ceased to be manufactured. I considered myself quite stable on it and had no wish to bother to change.

Changing insulin

From the mid 80s, I still had two injections a day for a long while with my doctors trying different alternatives and dosages. Eventually, around the turn of the century, I changed to Levemir twice a day and NovoRapid three times a day, until recently when my diabetes began to give problems. My sugar readings have always yo-yoed but were getting out of hand. Currently, my doctor and I are trying Ryzodeg twice a day and NovoRapid at lunchtime.

Diabetes old syringe.

Glass syringes

Initially, injections were a hassle. How much easier it is today! Back then, there were no pumps, pens or even disposable syringes. Only glass syringes, which had to be sterilised by boiling in water and/or be kept in spirits. Needles were longer and thicker by today’s standards. Mine were often re-sharpened when they got blunt as we were too poor to buy new ones.

Sugar test by urine sample

Another problem was testing sugar levels. We had no blood testing with a glucometer. It was urine testing with a test tube, a spirit lamp and Fehling’s or Benedict’s solution. Once mixed together and heated, the results merely showed whether there was no sugar (no colour change); green (a little or 1+); yellow (more or 2+); or red (far too much or 3+).

Later, it was easier by dropping a pill in the test tube which contained a sample of my urine. Then it became a paper strip which just had to be held in the urine flow. Urine testing was never very accurate but we managed.

If one was feeling hypoglycaemic (having a low), it was useless to test to ‘prove’ one was indeed having a low as the urine could be ‘stale’. Comparing those urine test readings with today’s blood tests with glucometer readings, one realises just how inaccurate they were.

I must admit, because testing was such a hassle, from my early teens I never tested unless I was going to the doctor or if I was pregnant. I relied on how I felt. This was until glucometers and the new insulins arrived.

Weighing what you eat

Because testing results were so limited, diets were rigid. Everything had to be weighed. It was 1944, in wartime Britain with food rationing which persisted for several years afterwards. Though, diabetes patients were allowed extra meat, cheese and butter in place of sugar and sweets.

There was little choice and apart from diabetic apricot jam, which came in a jar not unlike the old small anchovette jars. There were no alternatives for many years, such as tins of ‘lite’ or sugar-free versions of fruit, custard, biscuits, soup, sweets and cool drinks, etc.

Finding a good paediatrician

When I went to kiddies parties, I was not allowed any sweet things the other children had. Instead my mother would make me blue jelly made with gelatine and colouring. When I was about nine, I was lucky to get a new paediatrician. He explained as he had four children himself, he knew all too well that children broke rules, and it was better to break the rules of rigid dieting and times of eating and learn how to avoid problems that could ensue. Which I did.

His reasoning has stood me in good stead and I have enjoyed everything that life has offered me. My diabetes has not prevented me from doing anything. At school I was treated like everyone else. Only once, in primary school, was it a problem when teachers were hesitant to take responsibility for me on a day trip out of town. Thankfully, my mother came so I enjoyed the outing.

No diabetologists

In the early days, there was no such speciality as a diabetologist. You either saw a GP or specialist physician. I was under the care of a diabetologist for several years.

Over the years, I have seen several other medical experts, such as podiatrists and dietitians, etc. There is always something new to be learned. For instance, I find it fascinating that there always seems to be a newer insulin on the market, which is ‘better’ than the others. I must admit, I do not always follow the changes, particularly if I am stable. It is both wasteful and expensive if the new is ineffective, since insulin usually comes in batches of 5 pens. At times I was left with some I couldn’t use.

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Diabetic pen pal

At 16, I stayed with my diabetic pen pal in Holland for five weeks. I also went on the first three overseas trips, organised by the British Diabetic Association; twice to Switzerland then to Austria. At varsity, I participated in several extramural activities, where I met my husband, Cyril – a South African. We both became dental surgeons and spent many years together in private practice. I have been fortunate to have travelled extensively, enjoyed a variety of hobbies, been involved in several community and charitable organisations and studied further.

Starting a family as a Type 1 diabetic

After finishing varisty, Cyril and I migrated to South Africa, finding I was pregnant with our first child. When I was pregnant, urine testing and Soluble insulin were still common practise. I would test meticulously and watched my diet, though I had given up weighing my food years before. There were no dietitians in town and I relied on past diets, experience and my specialist physician and gynaecologist. My daughters have not inherited diabetes, and as far as can ascertain, I am the only one of my many cousins who has it (I am an only child).

Type 2 diabetic husband

However, I am ashamed to admit that I failed to recognise the symptoms when my husband developed Type 2 in his seventies. Though he complained of a dry mouth, I was more concerned with his sudden and dramatic loss of weight. When we were given the diagnosis by the doctor, I burst out laughing both with the relief that it was not cancer and at my stupidity. My husband was on insulin for a couple of weeks, then moved to tablets for the rest of his life. He only retired at 83 when he had a successful quadruple bypass heart operation. He lived very well afterwards until his sudden death of natural causes, a month short of 88.

Can’t picture a life not as a Type 1 diabetic

I really cannot imagine my life without diabetes. Starting so young, I have little recollection of life before it arrived. My experiences, when things were more difficult, taught me to be more self-reliant; to be pro-active and not reactive; and not to take risks.

I am well aware of how infections and relatively minor illnesses can upset my diabetes control. Thus, I always seek medical advice sooner than later and have flu vaccinations and the like. But, with that said, I don’t worry about all the other diseases that diabetes may lead to because they can affect the normal population too.

Fear of an amputation

However, I am petrified of having an amputation. I only buy shoes that I have fitted properly in the shop. Though, I once bought a pair of shoes with had a label inside, just over the toes, which I could neither feel nor see. The next day, my big toes, on both feet, were septic. I sought a doctor immediately. I lost the toenails a couple of days later. The doctor and my podiatrist admitted how lucky I was not to have needed surgery which they had both anticipated.

Personal records

Since the mid 80s, I have kept a record of my tests, insulin taken and food eaten. I find it useful when things go haywire to see why, by turning a few pages back to find similar circumstances and compare. Also, I am never without sweets, chocolate or biscuits within reach, in case of a low.

Past vs Present

I read the labelling on foods in supermarkets these days and know the contents are listed in order from highest percentage to least. These labels weren’t always listed in the past. Also, one must be wary of ‘lite’ now that our government is promoting less consumption of sugar. Some cool drinks are ‘lite’ with no sugar, but others are ‘lite’ in the sense they that they contain less than the normal product but far more than a diabetic should have.

There is definitely an element of luck with my surviving so long. When you get to my age, you’ve lost many friends along the way. I’m lucky. My only handicap at the moment is that I am very hard of hearing and getting slower with age.

Article written by Nadine Lang.

Type 2 diabetes and HIV


Considering World Aids Day, Dr Alessandra Prioreschi examines the connection between Type 2 diabetes and HIV.


Increase of lifestyle diseases in HIV patients

Advances in treatment of HIV have resulted in HIV patients being able to live longer lives, largely due to controlling their disease using combination antiretroviral therapies (cARTs). This has resulted in people with HIV experiencing increases of lifestyle diseases. These include hypertension, cancers, metabolic disease and Type 2 diabetes.

These non-communicable diseases (NCDs) occur due to the normal aging process. However, the presence of HIV and drug therapy used to treat HIV are associated with increased risk of developing NCDs. Thereby, resulting in people with HIV having multiple risk factors for developing an NCD, such as Type 2 diabetes1.

Increase of Type 2 diabetes in Africa

Type 2 diabetes is becoming increasingly common in Africa. This is due to the rapid transition to a ‘Westernised lifestyle’ that has occurred over the last few years. Although the reasons are not fully clear, recent studies internationally have associated diabetes with HIV infection and with cART1-3.

Systematic review

The Developmental Pathways for Health Research Unit (University of the Witwatersrand, Faculty of Health Science) therefore conducted a systematic review and meta-analysis of the literature. This is the most rigorous scientific method to review published literature to determine the overall effects found from multiple studies.

The aim was to determine whether HIV infected patients in Africa were more likely to have Type 2 diabetes than non-infected individuals. We also wanted to determine whether cART treated patients were more likely to have Type 2 diabetes than non-treated patients.

After screening for eligibility, 21 articles were found to meet the search criteria and were included in the analysis.

Findings

The results showed no statistically significant association between HIV infection or cART treatment with Type 2 diabetes prevalence. These findings are contrary to international studies in Europe and North America, which showed a higher prevalence of diabetes in HIV infected compared to uninfected participants4,particularly when treated with cART1-3.

Therefore, from the limited data available in Africa, it does not seem as if the risk of Type 2 diabetes is higher in populations infected with HIV than in a normal healthy ageing African population.

However, we did find that the number of new cases of Type 2 diabetes that occur in HIV infected cART treated African patients was higher than what has been shown internationally. Therefore, it does not seem that patients with HIV in Africa are presenting with Type 2 diabetes more frequently than a normal aging population in Africa. However, the number of cases of Type 2 diabetes is higher than rates reported internationally for HIV infected patients.

Possible reasoning

It is possible that this finding is in part due to African populations being more susceptible to diabetes, regardless of HIV status. This could be due to ‘Westernisation’, which is happening rapidly in many African countries, resulting in changes in lifestyle and metabolism. In Africa, there is an added risk for infants born during periods of Westernisation to develop metabolic disorders later in life, due to metabolic changes occurring during pregnancy.

In fact, in this systematic review, a substantial proportion of participants infected with HIV were overweight or obese and thereby predisposed to diabetes. This presents a different picture to the undernourished HIV infected individual previously associated with Africa.

Importance of screening

In this new context, higher diabetes risk may just be an effect of lifestyle rather than due to HIV disease or treatment. Therefore, although this review did not show a higher risk of Type 2 diabetes in HIV infected individuals compared to uninfected individuals, it does support the importance of screening for diabetes in African populations infected with HIV, where diabetes incidence appears to be high in general.

Furthermore, these findings reinforce the importance of managing and screening for metabolic diseases, such as diabetes, as part of routine clinical care of patients infected with HIV to support continuity of care5.

Limitations of review

It is important to note that there were some limitations; namely the small number of studies available to analyse and the small number of participants included in these studies.

Over and above that, all the studies available for this analysis were observational. So, we were unable to determine how things may change over time. However, this meta-analysis shows that currently HIV infection and cART do not seem to predispose patients in Africa to Type 2 diabetes. However, high rates of Type 2 diabetes warrant focus on screening and preventative programmes for HIV infected people living in Africa.

MEET OUR EXPERT

HIV
Dr Prioreschi is a researcher with a background in exercise physiology. She has a special interest in lifestyle behaviours, particularly physical activity and sedentary behaviours, which can be used to decrease obesity and metabolic disease; as well as treat some chronic diseases. She has a keen interest in examining these behaviours throughout the life course, but particularly in the first two years of life.

References:

  1. Samaras K. The burden of diabetes and hyperlipidemia in treated HIV infection and approaches for cardiometabolic care. Curr HIV/AIDS Rep. 2012;9(3):206-17.
  2. Hadigan C, Kattakuzhy S. Diabetes mellitus type 2 and abnormal glucose metabolism in the setting of human immunodeficiency virus. Endocrinol Metab Clin North Am. 2014;43(3):685-96.
  3. Paik IJ, Kotler DP. The prevalence and pathogenesis of diabetes mellitus in treated HIV-infection. Best Pract Res Clin Endocrinol Metab. 2011;25(3):469-78.
  4. Galli L, Salpietro S, Pellicciotta G, Galliani A, Piatti P, Hasson H, et al. Risk of type 2 diabetes among HIV-infected and healthy subjects in Italy. Eur J Epidemiol. 2012;27(8):657-65.
  5. Rabkin M, Melaku Z, Bruce K, Reja A, Koler A, Tadesse Y, et al. Strengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland. J Trop Med. 2012;2012:137460.