Experts have revealed that many (especially) lean people are not seeking screening for diabetes despite the government’s having increased programmes aimed at creating awareness about Non – Communicable Diseases (NCDs).
Dr Kauthrah Ntabadde, an Epidemiologist whose research focuses on population cardiometabolic health in African populations told URN that diabetes is still largely associated with weight by members of the public creating an illusion that thinness equals safety. As a result, many lean people do not seek screening.
“Diabetes is not a single uniform disease,” Dr Ntabadde said. “It develops through different pathways and can present in different ways. We are seeing a growing number of people with diabetes who are lean or non-obese, yet many of our approaches to finding them are still based on assumptions that no longer match reality. That creates a massive blind spot.”
Ntabadde’s revelations speak to what other clinicians were observing during the International Diabetes Day. Clinicians in Uganda and the World Health Organization pointed out that the disease dynamics have changed and is no longer following familiar patterns including the raise in gestational diabetes.
Also, early last year, the International Diabetes Federation formally recognized Type 5 diabetes as a distinct form linked to chronic undernutrition disproportionately affecting lean young adults in low- and middle-income countries.
Ntabadde says that recognition doesn’t mean most diabetes in Uganda is Type 5 but it does reinforce the broader point that body size alone is not a reliable gatekeeper for testing.
Generally, testing for NCDs remains low irrespective of one’s body size. According to results of Uganda’s 2023 STEPS survey which is the country’s latest and most comprehensive national assessment of key NCD risk factors among adults aged 18 to 69, 86.7% of the respondents said they had never had their blood glucose measured and 97.6% reported they had never had their cholesterol measured.
The consequences show up in what the survey found when it measured people’s blood sugar during the assessment. About half of adults with raised blood sugar were only discovered because the survey tested them. 48% were unaware that they are living with diabetes.
The epidemiologist offers an explanation as to why people are not getting screened even as awareness messages are now all over the place. She mentions a mix of reasons including the fact that government screening programmes are prioritizing those who look visibly sick, are older or heavier and are therefore considered high risk.
Another challenge Ntabadde tells lies in the performance of the tests themselves as many of the tools used to screen for diabetes do not perform equally across individuals or populations.
“One commonly used test HbA1c estimates average blood sugar levels over time and is often favored because it does not require fasting. But because it relies on blood characteristics, its accuracy can be affected by anemia and other blood disorders conditions that are widespread in Uganda”.
The implication is not that HbA1c has no role, Dr. Ntabadde cautioned, but that a one-size-fits-all approach to diagnosis may quietly miss people, particularly in settings where confirmatory testing is uncommon.
The most reliable diagnostic tool, the oral glucose tolerance test (OGTT), is far less familiar to most Ugandans, she says. The test is logistically demanding, requires fasting and multiple blood draws over two hours, and is therefore rarely used outside of pregnancy care. As a result, many people are never assessed using the gold-standard test.
Recognizing these challenges, researchers have been working to improve diabetes detection. The International Diabetes Federation has backed a shift toward a simplified one-hour post-load glucose test, proposed as a more practical alternative to the traditional two-hour OGTT. The approach aims to simplify detection and reach more people.
But findings from a 2024 study co-authored by Dr. Ntabadde suggest that the solution may not be so straightforward. In the first study to evaluate the proposed one-hour glucose threshold in an African population, the researchers found that while the recommended one-hour test performed reasonably well among individuals with obesity, it missed a substantial proportion of diabetes cases among people without obesity. In lean participants, sensitivity dropped to 58 percent, meaning many cases would go undetected.
The findings highlight a troubling paradox: efforts to simplify diabetes detection may inadvertently widen diagnostic gaps. The faster test was most likely to miss precisely the group already least likely to be screened and the very group that is increasingly affected by diabetes in Africa, including Uganda.
“Late diagnosis doesn’t happen by accident,” Dr. Ntabadde said. “It reflects a series of gaps along the way limited awareness that keeps people from seeking care even when they feel well, missed screening opportunities, and limitations of some of the tests we rely on.”
