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DIABETES SERIES · ARTICLE 11 OF 17
The long-term complications
What nobody wants to talk about — and how to prevent them.
This is the article most people don't want to read. The doctors don't always want to give it. The patients sometimes don't want to hear it. But knowing what diabetes can do to a body over years is exactly what makes most people take it seriously — and what makes prevention realistic instead of theoretical.
Here's what's true: long-term complications of diabetes are real and they can be devastating. Here's what's also true: every single one of them is preventable, slowable, or treatable when caught early. People who control their blood sugar, blood pressure, and cholesterol, and who attend their annual screening tests, almost never end up with the worst outcomes.
This article walks through the four big complication areas — eyes, kidneys, heart, and nerves — and tells you what to watch for, what tests to ask for, and what to do about each. By the end you'll have a clear map of what to monitor, every year, forever.
Before you read on
This article is honest about what poorly controlled diabetes can do. It's not meant to scare you. It's meant to make abstract risk concrete so that the daily work of managing diabetes feels worth it. If you've already had a complication develop, this is also still useful — most can be slowed dramatically once treatment starts.
The single underlying problem
All long-term diabetic complications come from the same root cause: years of high blood sugar damaging blood vessels and nerves. Different organs are affected because different blood vessels — large in the heart, small in the eyes and kidneys, tiny in the nerves — fail in different ways.
This sounds bleak. It is also clarifying, because it means the same four levers prevent all of them:
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Blood sugar control — HbA1c under 7% (lower if achievable safely)
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Blood pressure — under 140/90, ideally 130/80 for most diabetics
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Cholesterol — LDL under 1.8 mmol/L for high-risk patients (the clinic will set yours)
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Not smoking — quitting is the single biggest improvement most diabetic smokers can make
Get these four right and you have done most of what's possible to keep your eyes, your kidneys, your heart, and your nerves intact for the long run.
Eyes — diabetic retinopathy
The small blood vessels at the back of the eye (the retina) are damaged by high blood sugar over years. They become weak, leak, and sometimes grow new fragile vessels that can bleed inside the eye.
Diabetic retinopathy is the leading cause of preventable blindness in working-age adults globally. About a third of people with diabetes will develop some form of it. The frightening part is that it usually causes NO symptoms in the early stages — by the time vision blurs, real damage has already happened.
What to do
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Annual eye exam. Once a year, every year, by an optometrist or ophthalmologist. They dilate your pupils and check the retina. This catches early changes and is the single most important intervention.
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Free at public clinics under chronic care — ask for a retinal screening referral.
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Treatment if needed. Laser treatment, injections, or surgery — all available in SA. Early treatment usually preserves vision.
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Don't wait for symptoms. By the time you notice anything wrong, you have already lost some sight that may not come back.
Kidneys — diabetic nephropathy
The kidneys filter waste from your blood through tiny vessels. Years of high blood sugar damage these filters. Over time the kidneys leak protein into the urine, then progressively lose function, and eventually fail completely — requiring dialysis or a transplant.
Diabetes is the leading cause of kidney failure requiring dialysis in South Africa. As with the eyes, early kidney damage usually has NO symptoms. The damage is silent until late.
What to do
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Annual urine test for albumin (ACR). A simple urine sample that detects early kidney damage years before anything else. Free at public clinics — ask for it.
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Annual blood test for creatinine and eGFR. Measures how well your kidneys are filtering. Also part of standard chronic care.
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Blood pressure control matters as much as sugar control. High blood pressure accelerates kidney damage dramatically.
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ACE inhibitors or ARBs. These are blood pressure medications that also protect the kidneys, even in diabetics with normal blood pressure. If you're not on one, ask why.
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Limit unnecessary painkillers. Long-term use of NSAIDs (ibuprofen, diclofenac) is hard on the kidneys. Use paracetamol where possible.
Heart and blood vessels
This is the big one. Cardiovascular disease — heart attacks, strokes, narrowed arteries — is the leading cause of death in people with diabetes. The risk of a heart attack in a diabetic is roughly 2 to 4 times that of a non-diabetic of the same age. The risk of a stroke is similar.
Diabetes damages the large blood vessels by accelerating the build-up of cholesterol plaque inside them. Combined with high blood pressure and inflammation, this leads to narrowing, rupture, and the clots that cause heart attacks and strokes.
What to do
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Annual blood pressure check. More often if it's high. Home monitors are affordable (R400–R800) and useful.
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Annual cholesterol panel. Total cholesterol, LDL, HDL, triglycerides. Most diabetics over 40 should be on a statin to lower cardiovascular risk — discuss with your clinic.
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Aspirin (low dose, 75–100 mg) for some. Not for everyone — has bleeding risks. The clinic decides based on your overall risk.
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Stop smoking. If you do nothing else for your heart, do this. Smoking and diabetes together are a particularly dangerous combination.
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Move regularly. 30 minutes of moderate exercise on most days has a bigger effect on cardiovascular risk than most medications.
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Know the heart attack symptoms — chest pain or pressure, sudden shortness of breath, pain radiating into the left arm or jaw, sweating, nausea. Call 10177 or get to a hospital immediately.
Nerves — neuropathy
We covered the peripheral nerves (the ones to the feet) in detail in the foot care article. There's also a second kind: autonomic neuropathy — damage to the nerves that control automatic functions of the body. This can show up as:
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Sudden dizziness when standing (postural hypotension)
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Bloating, nausea, or feeling full quickly after small meals (gastroparesis — slow stomach emptying)
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Frequent urinary infections or incomplete bladder emptying
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Constipation or diarrhoea that doesn't go away
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Erectile dysfunction in men (often the earliest sign of overall vascular disease)
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Difficulty with arousal or lubrication in women
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Sweating abnormally — too much, too little, or in unusual places
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Heart rate that doesn't change normally with activity
Autonomic neuropathy is often missed because it doesn't look like "diabetes". If you have several of the above and have had diabetes for years, mention it specifically at your clinic visit.
The annual screening checklist
If you only remember one thing from this article: this is the list of tests every adult diabetic should have done at least once a year. Copy this. Put it on your fridge. Take it to your clinic.
Test Frequency What it catches HbA1c Every 3–6 months Average blood sugar control over months Blood pressure Every clinic visit Risk for kidneys, eyes, heart, stroke Cholesterol panel (lipids) Every 1–2 years Heart attack and stroke risk Urine albumin (ACR) Annually Early kidney damage Blood creatinine / eGFR Annually Kidney filtering function Retinal eye exam Annually Diabetic retinopathy Foot examination Annually Neuropathy, circulation, ulcer risk Dental check Every 6 months Gum disease (worse in diabetics; raises cardiovascular risk) ECG / heart check As advised — often every 1–3 years over age 40 Silent heart disease Flu vaccine Annually Diabetes makes flu more serious
Most of these tests are free at public clinics
All of the tests above except retinal eye exams and ECG are usually performed at public clinics under chronic care, free of charge. Retinal screening can be referred from the clinic, also free.
If your clinic isn't running these annually, ask. Diabetic chronic care includes annual screening as standard. Some clinics do better than others.
The mental load nobody talks about
Reading this article in one sitting may feel overwhelming. That's normal. Diabetes has a mental weight that other conditions don't quite match — the constant low-level vigilance, the daily decisions about food and movement, the slow drumbeat of "what if" about complications. This is real, and it deserves to be acknowledged.
What helps:
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Knowing the screening tests cover most of the risk. You don't have to worry about every possible outcome every day. The annual tests do the vigilance for you.
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Focusing on the four levers — blood sugar, blood pressure, cholesterol, not smoking — instead of every individual complication.
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Having a doctor or nurse you trust and a regular clinic visit pattern. The relationship matters.
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Talking about the mental side. Depression and diabetes feed each other. The Phila Today Mental Health tab has resources, and clinics can refer you to a counsellor.
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Recognising progress — the small daily acts of self-care that nobody else sees. They are what's keeping you whole.
The bigger picture
The honest truth: diabetes is a long-distance race. Some of what makes the race hard is the running. More of what makes it hard is the knowledge that you can't stop. But the body responds to consistent care over decades, and people who walk this road well live full, long, healthy lives.
The annual tests in this article are how you watch the road ahead. The daily habits in the rest of this series are how you keep walking. Together they are the difference between diabetes that is managed and diabetes that manages you.
The next article in this series steps back from the day-to-day and takes the long view of living well with diabetes — the first year, the fifth year, the tenth year, and how to keep going when the daily work feels endless.
Where to get more help
Diabetes South Africa — diabetessa.org.za · 011 792 9888
Your nearest public clinic — free chronic care including most of the screening tests above
South African Heart and Stroke Foundation — heartfoundation.co.za
Phila Today Diabetes Series — next: living well with diabetes — the long view
Phila Today · Article 11 of 17 in the Diabetes Series