Management of Type 2 Diabetes in Adults at Primary Care Level

Objectives

Improve the length and quality of life of people in South Africa by preventing or delaying type 2 diabetes, promoting early diagnosis, achieving effective long-term management, and reducing complications, disability and premature mortality.[1]The guideline adopts a whole-of-government and whole-of-society response to obesity and diabetes, rather than limiting action to individual patient care.[2][3]

• Prevent type 2 diabetes through healthy eating, regular physical activity, weight reduction and targeted support for people with impaired fasting glucose or impaired glucose tolerance.[1][4][5]
• Detect diabetes early through risk-based screening in health-care settings, prioritising adults with overweight or obesity and other risk factors, and avoiding unsupported population-wide screening.[6]
• Provide comprehensive care spanning diagnosis, lifestyle modification, pharmacological treatment, self-management, emergency care, management of co-morbidities, and prevention and treatment of microvascular and macrovascular complications.[1][7][8]
• Individualise glycaemic targets while using glycated haemoglobin below 7% as the primary target for most people with type 2 diabetes.[9]
• Reduce cardiovascular risk through active management of smoking, obesity, hypertension, dyslipidaemia and metabolic syndrome, treating diabetes as a coronary artery disease risk equivalent.[10][11]
• Prevent or delay kidney disease, retinopathy, foot ulceration and amputation through systematic screening, risk-factor control, education, early referral and timely specialist treatment.[12][13][14][15]
• Address the needs of priority groups, including older people, pregnant women, people living with Human Immunodeficiency Virus, people receiving tuberculosis treatment, high-risk ethnic groups and people who choose to fast.[16][17][18][19][20][21]
• Empower people with diabetes, families and caregivers through structured education, supported self-management, culturally appropriate nutrition advice, physical activity and psychosocial support.[1][22][23][24]

Implementation

Deliver care principally through strengthened primary health care, supported by referral hospitals and specialist services, multidisciplinary teams, patient registers, recall systems, regular audit and coordinated action across government departments, civil society and communities.[3][25][26][27]The National Department of Health developed the guideline with the Society for Endocrinology, Metabolism and Diabetes for South Africa, its Steering Committee and an Advisory Committee.[22]

• Engage Agriculture, Trade and Industry, Sport and Recreation, Basic Education, Health, non-governmental organisations and communities in diabetes prevention and control.[2][3]
• Equip primary-care clinics with trained staff, private consultation and education space, calibrated equipment, protocols, medicines and consumables, patient registers, recall systems, education materials and referral pathways.[25]
• Organise regular clinic visits according to need, with nurses undertaking core checks before medical review and with quarterly review of chronic patients’ blood pressure, blood glucose, weight and glycated haemoglobin results.[27]
• Confirm diagnosis through formal laboratory testing, repeating the same test on another day when hyperglycaemia is asymptomatic or uncertain, rather than starting therapy on point-of-care results alone.[28][6]
• Apply stepwise glycaemic management using lifelong lifestyle modification and metformin, adding a sulphonylurea where control remains inadequate and progressing to insulin with structured education, glucose monitoring and specialist referral when needed.[29][30][31]
• Provide comprehensive initial, three- to six-monthly and annual assessments covering clinical history, complications, lifestyle, psychosocial factors, physical examination, biochemical testing, treatment review and education.[32]
• Maintain reliable access to oral antidiabetic medicines, insulin, syringes, disposables, glucometers and sufficient test strips, particularly for people using insulin.[33][34]
• Use multidisciplinary referral and back-referral arrangements for severe metabolic emergencies, renal disease, sight-threatening retinopathy, diabetic foot disease, pregnancy, complex cases and rehabilitation needs.[35][36][14][16][21]
• Deliver structured, interactive education from diagnosis onwards through trained educators, individual or small-group sessions, and involvement of families and caregivers; small-group education is identified as the most cost-effective option.[22]
• Support adherence by tailoring prescribing to daily routines, identifying social, economic, behavioural and treatment-related barriers, simplifying regimens where possible, and using reminders, motivational interviewing and treatment-support programmes.[37][38]
• Audit clinic performance through measures such as the proportions of patients reaching glycaemic, blood-pressure and lipid targets and receiving designated processes of care, including glycated haemoglobin testing, foot examinations and retinopathy assessment.[25]
• Develop core process and outcome indicators and data-collection tools for collaborative tuberculosis and diabetes activities; beyond clinical monitoring and audit, a consolidated reporting framework, surveillance system, accountability body and budget are not specified.[21][3][33]

Monitoring & Evaluation

Monitoring is primarily organised through routine clinical review, risk-based screening, patient registers, recall systems, service audit and record review, rather than through a single national performance framework.[25][26][27]The guideline links these mechanisms to improved glycaemic control, complication prevention and service quality, but does not set a consolidated reporting schedule, surveillance architecture, numerical programme targets or named accountability body.[3][33][39][40]

• Monitor diabetes care through regular clinic visits, with review every 3–6 months until treatment goals are achieved, annual comprehensive review, and more frequent assessment when abnormalities are present.[32]
• Use clinical indicators including glycated haemoglobin, fasting or pre-prandial glucose, blood pressure, lipids, weight, waist circumference, body mass index, foot status, injection sites and self-monitoring technique.[41][9]
• Audit the proportions of patients achieving glycaemic, blood-pressure and lipid targets and receiving essential processes of care, including blood-pressure measurement, glycated haemoglobin testing, foot examination and retinopathy assessment.[25]
• Review randomly selected records and report the percentage in which all required care procedures have been completed.[25]
• Maintain patient registers with recall systems, conduct regular service audits, and assess the effectiveness of diabetes services, patient coping skills, records and medical histories.[33][25]
• Monitor chronic patients quarterly through documented blood pressure, blood glucose, weight and glycated haemoglobin results, and reassess interventions where necessary.[27]
• Confirm diagnosis using formal laboratory tests, repeating the same test on another day for asymptomatic or uncertain hyperglycaemia before treatment begins.[28][6]
• Screen people at elevated risk for type 2 diabetes in healthcare settings, repeat screening every three years after normal results, and test more frequently for impaired fasting glucose, impaired glucose tolerance or multiple risk factors.[6]
• Monitor renal disease through annual urine albumin-to-creatinine ratio and estimated glomerular filtration rate testing when results are normal, with repeat testing within three months when albuminuria is abnormal or estimated glomerular filtration rate is below 60 millilitres per minute.[36]
• Screen for retinopathy at diagnosis and at specified intervals, undertake foot-risk categorisation and schedule foot reviews from annual to every 1–3 months according to neuropathy, peripheral artery disease, deformity, ulceration or amputation history.[13][42]
• Monitor lipids annually when satisfactory, repeat testing after three months when unsatisfactory, and measure serum lipids every three months while titrating lipid-lowering therapy.[11][43]
• Assess adherence regularly through self-report, visual analogue scales, pill identification and pill counts; investigate adherence and adverse effects when clinical outcomes are unsatisfactory.[37][38][44]
• Monitor self-management safety through glucose testing schedules for insulin users, illness management, hypoglycaemia review and structured follow-up.[34][35]
• Develop a core set of process and outcome indicators and data-collection tools for collaborative tuberculosis and diabetes activities, while monitoring treatment side-effects, interactions and hyperglycaemia.[21]
• Audit diabetes education programmes regularly and assess their effect on outcomes, alongside psychological and emotional assessment.[22]

Costing & Financing

The guideline identifies substantial operational resource needs, including trained staff, functioning and calibrated equipment, laboratory testing, medicines, insulin, syringes, consumables, glucometers, test strips, patient records, education materials, referral services and specialist care.[25][34][27]It does not provide a budget, costing methodology, funding allocation, financing source, resource-mobilisation plan, quantified funding gap or broader economic assumptions.[1][43][45]

• Ensure uninterrupted availability of oral anti-diabetic agents, insulin, syringes, disposables and other required medicines.[33][25]
• Provide glucometers and sufficient test strips for people receiving insulin, and additional strips where required for safe driving, illness management or fasting.[31][34][39]
• Resource clinics with trained personnel, private consultation and education space, calibrated equipment, screening and referral protocols, patient registers, recall systems and education materials.[25][27]
• Allocate sufficient time and resources for structured diabetes education; small-group education is identified as the most cost-effective delivery option.[22]
• Recognise that diabetic foot problems increase health-care costs and that retinal photography is cost-effective and feasible in primary care.[14]
• Consider affordability, long-term safety, effectiveness and additional health benefits in preventive therapy; metformin is characterised as relatively safe and low cost.[5]
• Note that access to dieticians, tertiary-level weight-management pharmacotherapy or bariatric surgery, eye care, podiatry, vascular services, rehabilitation aids and specialist referral is required, but no associated costs are specified.[13][23][21]
• Recognise that some medicines referred to in the diabetes and HIV guidance are not available at primary-care level, without specifying the financing implications.[20]