Every morning for the past 28 years Ihsaan Moola, 62, has gotten out of bed, dressed and injected himself with the first of several daily life-saving insulin jabs before sitting down at the breakfast table.
"The most difficult part of being diabetic is that it cannot be cured. You can only manage it," says Moola, who is a type 1 diabetic.
People living with chronic illnesses such as cancer and diabetes face an increased risk of depression, according to the US National Institute of Mental Health. Research published in 2013 in the Journal of Psychological, Social and Behavioural Dimensions of Cancer showed that up to 24 percent of cancer patients suffer from depression. A 2008 study in the American Journal of Medicine found a prevalence rate of depression about half that among almost 4 200 diabetics surveyed.
For some people with chronic ailments, depression may stem hard lifestyle changes that often follow diagnoses or from illness-related stigma, says psychiatrist Lebogang Zako.
Moola asked not to use his real name.
About 5% of South Africans may be living with diabetes, according to the country's most recent household nutrition survey.
People who are either born with or develop diabetes cannot control the amount of sugar – or glucose – in their blood. In people like Moola who have type 1 diabetes, the body does not produce enough insulin – a hormone that helps the body process sugar. In those with type 2 diabetes, the body can produce enough of this hormone but does not use it effectively, explains the US non-profit Mayo Clinic.
Blood sugar levels can link to moods Those with the chronic illness not only face an increased risk of depression but also a daily battle to control blood sugar levels that can play havoc with moods.
Moola explains: "I feel a swing of emotions during the day. Sometimes I feel angry. Sometimes I feel sad. Sometimes I feel a little miserable, but it's okay – I always bounce back."
Michael Brown is a nurse and clinical consultant at Johannesburg's Centre for Diabetes and Endocrinology. He explains that glucose is the brain's main source of fuel. When a person's blood sugar levels soar, blood thickens. As blood becomes more viscous, it becomes harder for it to deliver glucose to the brain. When the brain doesn't get enough glucose – whether because blood sugar levels are too high or too low – it can lead to behaviour changes. If left unchecked, uncontrolled blood sugar levels can have serious consequences including seizures and loss of consciousness.
Moola and his family say they haven't always understood that a sudden change in his moods may be a signal that something is wrong.
Moola's daughter Fatima remembers one day when a meal was late: "He threw a massive tantrum and started yelling at all of us. It's unlike him to shout like that.
"We eventually tested his blood sugar levels and saw that his sugar levels were low. We rushed to give him something to eat and he was much calmer," she says.
Centre for Diabetes and Endocrinology clinical psychologist Rosemary Flynn says people living with diabetes – and their families – should get as much information as possible about their condition.
"If they know what they are doing, they get less anxious. They will know how to handle it," says Flynn.
People living with diabetes who have undergone diabetes education are more likely to adopt healthy diets, exercise regularly and take their medication, according to a 2013 study in the Journal of Family and Community Medicine. They are also more likely to better control their blood sugar and have decreased symptoms of depression.
Moola goes the gym regularly and enjoys long walks. The avid swimmer says he uses exercise to relax and manage stress.
Fatima also says helping her father manage his diabetes has become a family affair.
"We make sure that he takes tests [his blood sugar] regularly and takes the right dose of insulin," she says.
Flynn suggests that families can support diabetic family members by helping them remember to take their medication.
Research released in 2016 by international patient groups including the International Diabetes Federation found that support from family and friends resulted in lower levels of depression among people living with diabetes.
Moola says: "If you're alone, the illness can be difficult. I am fortunate that I have a good family that supports me."
Have something to say? Tweet or Facebook us on @Bhekisisa_MG
Diet and lack of exercise main reasons for dramatic rise in diabetes
TB and diabetes: Are they linked?
Work at a non-profit media house? Then you know your job is not just reporting anymore.
As deaths mount, take an inside look at the detectives working around the clock to solve the country’s medical mystery.
Until now, the national and provincial health departments have not been able to say where services are provided. Here's how we found them.
Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.