Category: 2017 Spring – Diabetes Focus

heart awareness month

Power up for Heart Awareness Month

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The Heart and Stroke Foundation South Africa (HSFSA) is powering up this September for Heart Awareness Month (HAM). They aim to reach the global goal of reducing premature deaths from cardiovascular disease (CVD) by 25% by the year 2025.

Why a whole month for Heart Awareness Month?

Heart disease is the world’s number one killer, claiming nearly 17 million lives every year. Although the incidence of heart disease has steadily declined in high-income countries, the burden on middle and low-income countries has never been greater.

In South Africa, the burden of heart disease and stroke follows HIV and AIDS; 1 in every 5 deaths are caused by heart diseases and strokes, totalling nearly 82 000 lives lost annually.

Contributing factors

Despite advances in medical care, contributing factors, such as high blood pressure (hypertension), obesity, a poor diet, lack of exercise and pollution, are all on the rise. Tobacco use has decreased, but 37% of men and 7% of women in SA are still regular smokers, tripling their risk of heart disease.

Heart disease in SA is further exacerbated by inequality. While high blood pressure is common across socio-economic groups, awareness and appropriate treatment is much lower among people living in poverty. Making healthier choices to eat better, stop smoking or to get active are far less achievable for South Africans trapped in poverty.

Is South Africa ready for 25 by 25?

The World Health Organisation has set nine global targets to address lifestyle-related diseases. One of these goals is a 25% reduction in premature heart disease and a 25% reduction in blood pressure by 2025. Can this be achieved within the South African context?

Over the last 25 years, neither heart disease nor blood pressure levels have improved in SA. In fact, given that more people are overweight and have high blood pressure now than ever before, SA may even see an increase in heart disease as obesity and hypertension are known contributors to cardiovascular (CVD) disease.

How to reduce the burden of heart disease

To reduce the burden of heart disease, we need to encourage lifestyle changes in SA. This starts with encouraging South Africans to eat nutritious food, drink less alcohol, exercise more, manage day-to-day stress and give up tobacco smoking.

Early detection and diagnosis of CVD, treatment of hypertension, raised cholesterol (especially bad cholesterol-LDL), and managing diabetes can further help to prevent the onset of heart disease. Together, these factors can prevent up to 80% of all heart diseases, before the age of 70 years, if the individuals affected adopt healthy behaviours.

Heart Awareness Month is earmarked by the HSFSA every year to encourage South Africans to re-evaluate their heart health and to start adopting healthy behaviours to take back control and Power Their Lives.

Getting to the hearts of young people in SA

The damage inside blood vessels that leads to most heart disease already starts in childhood. Healthy lifestyles in childhood therefore has a direct positive effect on heart health, but even more importantly, it often creates a blueprint for lifestyle choices made in adulthood.

Ten percent of boys and 22% of girls, between the ages of 10 and 14 years, are overweight. One South African study found girls who were obese between the ages of 4 and 8, were 40 times more likely to be obese when they finished high school. Numerous primary school children eat unhealthy foods on a daily basis, and don’t participate in enough physical activity.

Skip Smart for your Heart Schools Programme

To start Heart Awareness Month, the HSFSA is raising awareness among young South Africans of the importance of keeping their hearts healthy. The HSFSA selected 13 schools, nationally, to participate in the Skip Smart for your Heart Schools Programme between August and September 2017.

The Skip Smart for your Heart Schools Programme aims to inform primary school children about the importance of their heart and brain health and what they can do to take care of these vital organs by eating smart, breathing fresh air, avoiding tobacco smoke and being physically active.

Exercise with Hearty

Children will be further encouraged by Hearty to exercise. The HSFSA mascot will visit the schools, and the children will be given a free skipping rope. His presentation teaches five simple exercise moves that we can all use daily.

Finally, the HSFSA will showcase a performance from a professional skipper to captivate the learners with extraordinary tricks and skills, using a mere skipping rope, thus making moving more a cool and aspirational thing to do.

Moreover, the staff at the 13 selected schools will have a Health Risk Assessment conducted by health promotions officers and nurse practitioners.

Caring for adult hearts – get tested for free

Less than 50% of South African adults living with high blood pressure are unaware of their condition. The prevalence of hypertension is said to be around 45% among adults.

Similarly, many people who are pre-diabetic and have raised cholesterol are unaware, and as a result do not improve their lifestyles nor gain access to medication.

Blood pressure should be checked at least annually for all adults, and blood glucose annually when overweight. Many people unaware of the dangers of hypertension prefer to postpone a medical check or, simply, cannot afford to get tested.

Professor Pamela Naidoo, CEO of the HSFSA, urges all South Africans to have a Health Risk Assessment (which includes checking their blood pressure, blood glucose, cholesterol levels and weight) done free during Heart Awareness Month at all Dischem Pharmacies. Prof Naidoo expresses her gratitude to Dischem Pharmacies for partnering with the HSFSA to raise awareness of CVD and to mobilise communities to know their diagnosis and get treatment when necessary.

Build-up to World Heart Day (WHD)

The HSFSA’s build-up to WHD (29 September), during Heart Awareness Month, will focus on lifestyle factors which have a major impact on one’s risk for developing heart disease. Each week there will be a focus on important risk factors. These focus areas are detailed below:

  1. Your body does not want the extra salt: To encourage the reduction of extra salt for your heart health, a Salt Reduction Campaign will run from 1 – 8 September, funded by the National Lotteries Fund (NLC) and supported by the Department of Health (DOH).
  2. Keep it light: bring obesity down: Emphasising how physical activity and healthy eating go hand in hand, we need to evaluate what we eat and portion control. Healthy eating should not be a ‘diet’ but rather a lifestyle. The importance of physical activity in conjunction with eating well, how much exercise is enough, and simple ways to incorporate this into everyday life are imperative.
  3. You can do it: This unappealing habit (smoking) can be conquered, HSFSA can help with smoking cessation and dispel any myths and misconceptions associated with tobacco smoking. Tobacco smoking is one of the biggest drivers of CVD.
  4. Power up on WHD – The HSFSA, together with key staff at UCT’s Faculty of Medicine and Health Sciences, will be involved in activities aligned with the World Heart Federation’s mission and vision to bring to South Africa’s attention that we can work together to reduce the burden of heart disease.

The HSFSA will light up iconic landmarks on WHD as they drive the global goal of reducing premature deaths from CVD by 25% by the year 2025. They will explore risk factor reduction and influencing the behavioural and uptake of health risk assessments.

heart awareness month

#CheckyourPower 

This year, HSFSA have once again partnered with Dischem Pharmacies who will make available free testing in their stores across South Africa – please call 08601 (HEART) 43278 for more information. Free health risk assessments offered at Dischem, during September and October, will include blood pressure, blood glucose and cholesterol levels, and body mass index. 

diabetes sex hormones

Sex hormones and diabetes

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People living with diabetes should consider the use of either female or male hormones during their lifetime to improve quality of life, however, many factors need to be considered. Dr Louise Johnson walks us through these factors, explaining diabetes and sex hormones.

Women and sex hormones

In the reproductive years, a female should consider contraception methods (sex hormones) to prevent unplanned pregnancies. The risk of unplanned pregnancies has a possibility of miscarriage and foetal abnormalities if the HbA1c (average 3-month glucose value) is not at a normal or near normal value. The HbA1c should be 6 to 6,5% to promote developing a healthy baby.

The menstrual cycle

During a 28-day cycle, there are two different hormones, oestrogen and progestogen, at play that prepare the ovaries to produce an egg, which can then be fertilised should it encounter sperm.

The cycle starts off with the follicle of the ovary secreting oestrogen so that the endometrium (inside of the uterus lining) increases rapidly in thickness, from the 5th to the 14th day of the menstrual cycle. This is where blood vessels grow in preparation of a possible egg cell. This is called the proliferative phase.

On day 14, ovulation occurs and the egg cell is secreted from the ovaries. The blood vessels are then on its thickest, under the influence of oestrogen. Should there be no implantation of a fertilised egg cell and sperm, the hormonal support begins to be withdrawn. This causes the inner layer of the uterus to be necrotic, and then bleeding of the inner wall occurs, known as menstruation.

After the bleeding, the endometrium becomes ready again for the proliferative phase, which is the preparation of the lining for possible implantation, which will occur after day 14 in the secretory phase. The secretory phase is constant at 14 days. The variation in the menstrual days is due to the thickness of the layer that formed in the proliferative phase3.

diabetes sex hormonesOral contraceptives

There are two types of contraceptives – local and systemic contraceptives.

Local contraceptive

  • An intrauterine device (IUD) is placed inside the womb and can prevent pregnancies. This is a Copper T and does not release sex hormones.
  • The intrauterine system (IUS) is placed inside the womb and secretes low-doses of levonorgesterol hormone to prevent pregnancy.
  • Implantable contraceptive in arm. It releases a steady dose of progestogen to prevent pregnancy.

Systemic contraceptives

  • Progestogen-only tablets or depot injection every eight to 12 weeks. This is usually the safest systemic combination for women: living with diabetes, who smoke, suffer with migraines, are overweight, or have other medical conditions.
  • Combination therapy of oestrogen and progestogen.

Choosing the correct method

In deciding which would be the correct method for you, your doctor should take into consideration that it should not interfere with your carbohydrate metabolism or with your lipid profile. The method should not increase long-term microvascular and macrovascular complications.

In a review of literature, it was found that there is currently no one method that is superior to another. The methods should be discussed with the female diabetic patient, where all the pros and cons of each method are understood7.

It’s important to remember that only condoms can protect against STDs. Other methods can protect against pregnancy only.

Contraceptives that are more than 99% effective, if used correctly:

  • Contraceptive implant – lasts up to three years.
  • IUS system – lasts up to five years.
  • IUD – lasts up to five to 10 years.
  • Female sterilisation – permanent.
  • Male sterilisation or vasectomy – permanent.

Contraceptives that are more than 99% effective, if always used correctly but generally less than 95% effective with typical use:

  • Contraceptive injection – important to renew strictly every eight to 12 weeks, depending on the type.
  • Combination pill – take every day for three weeks out of four weeks. Can skip the red or placebo tablets, if menstruation is wanted to be avoided.
  • Progesterone-only pill – take every day.
  • Contraceptive patch – renewed each week for three weeks in every month.
  • Vaginal ring – renewed once a month.

Contraceptives that are 92 to 96% effective, if used correctly:

  • Female condom (every time you have sex).
  • Diaphragm with spermicide (every time you have sex).
  • Cap with spermicide (every time you have sex).

Factors to consider

  • How soon do you want to fall pregnant and is your HbA1c level at target?
  • How conscientious are you in taking medication or applications regularly? Do you remember to take tablets on a daily basis? This is vital with the contraceptive pill, since it is not effective if not taken regularly.
  • Do you want to menstruate every month or would you prefer a method that takes that away, or alter it causing lighter or sometimes heavier bleeding?
  • Do you smoke? Diabetic patients should not be smoking due to the increased vascular risk of atherosclerosis (calcification of blood vessels) of small and large vessels disease, such as eye-, feet-, kidney-, brain- and heart blood vessel damage.
  • If you are currently smoking and are over 35 years of age, the combination pill will not be suitable to use due to the possible increase in vascular disease. If you prefer a pill, the progestogen-only pill would be an option, or the IUD, IUS, or contraceptive injection.
  • Are you overweight? The contraceptive method that can cause a slight increase in weight is the contraceptive injection, if used for more than two years.
  • Do you have additional medical conditions, such as breast cancer? If yes, you are not suitable to use combination hormonal therapy. Other methods, such as IUD, are suitable.
  • Do you suffer from migraines? If so, you should be careful when using contraceptives, since it can aggravate this condition. You should use the IUD, IUS, progestogen-only pill, contraceptive injection or implantation. Stay clear from oestrogen preparations.

diabetes sex hormonesHormonal replacement therapy (HRT) in menopause

Usually around 50 years of age, women reach menopause when their ovaries stop producing sex hormones. The symptoms of menopause may differ between women. Some have profuse sweating, palpitations, moodiness, tiredness and insomnia, while others have very little symptoms.

The natural menopause can be divided into three stages:

  • Perimenopause – this is the time between the start of the symptoms and up to one year after the final menstruation.
  • Menopause is confirmed 12 months after the last menstrual cycle.
  • Post-menopause is the years after the menopause.

The replacement of female sex hormones should be carefully evaluated in each person since there are risks associated with this. There are two types of HRT:

  • Oestrogen-only therapy (ET): oestrogen is the hormone that provides the most menopausal symptom relief. ET is prescribed for women without a uterus (womb) due to a hysterectomy.
  • Oestrogen plus progestogen therapy (EPT): the progestogen is added to the oestrogen therapy to protect the uterus against endometrial cancer (womb cancer) from oestrogen alone.

Diabetic women and HRT

The diabetic women with symptoms severe enough to require systematic hormones should be started on the lowest effective dose for the shortest amount of time.

The benefit-risk ratio is favourable for women who initiate HRT close to menopause (ages 50-59 years) but the benefits becomes riskier with time from menopause and advancing age.

Women with early menopause (before 40 years of age) without a family history of breast cancer can take HRT until the typical age of menopause at 51.

Your doctor will evaluate your risks and possible benefits since there is no ‘one size fits all’ therapy.

Benefits of HRT

Improvement of symptoms of hot flashes, vaginal dryness, night sweats, and bone loss which can lead to osteoporosis. These benefits can lead to improved sleep, sexual relations and quality of life.

Risks of HRT

The importance of low-hormonal dosage for a short period of time cannot be reiterated enough. In the Women’s Health Initiative (WHI), done in 2002, an evaluation was done on the side effects of HRT. It was shown that there was an increased risk of breast cancer. Also, an increased risk of blood clots in the veins were shown, known as deep venous thrombosis (DVT) and pulmonary embolism (PE). The risks were higher in women older than 60 years of age.

Women who still have their uterus, should be prescribed a combination of oestrogen and progestogen to protect against uterine cancer.

Remember, there are other options available to help with hot flashes and moodiness other than sex hormones. Certain antidepressants, such as Venlafaxine and Clonidine, can help with vascular symptoms of hot flashes.

Men and sex hormones

diabetes sex hormones

Sexual dysfunction in Type 2 diabetes

The most common presentation of Type 2 diabetes with sexual dysfunction is erectile dysfunction (ED), also called impotence.

ED is defined as the inability to sustain adequate penile erection for satisfactory sexual activity. It is common in adult men with Type 2 diabetes (50-75%). This has a negative impact on quality of life. ED has been described in up to a third of newly diagnosed men with diabetes1.

Low testosterone levels in men have been shown to predict insulin resistance and the future development of Type 2 diabetes5. In studies, it was found that hypogonadism (diminished functional activity of testes) in Type 2 diabetic men may be as high as 33%2.

Additional risk factors for ED include:

  • Duration of diabetes
  • Increasing age
  • Poor glycaemic control
  • Cigarette smoking
  • Hypertension
  • High cholesterol
  • Cardiovascular disease

ED in diabetic men

ED occurs 10-15 years earlier in men with diabetes. It is more severe and less responsive to oral drugs than in non-diabetic subjects.

It is important to tell your doctor if you suffer from ED since it is associated with an earlier risk for cardiovascular disease. The risk for cardiovascular disease, such as heart attacks, is 20% higher in low-testosterone groups.

In the Copenhagen City Heart Study, it was shown that a low testosterone level could increase the risk of stroke with 34%, compared with normal testosterone individuals6.

Screening with an effort ECG will help to identify the high-risk individual. The first line of treatment for ED is addressing the risk factors effectively. The first therapeutic option would be to start with a PDE5 inhibitor (Viagra, Cialis, Levitra). A specialist should be consulted for second line therapy, should the patient not respond to these tablets.

Testosterone replacement

It is important to measure testosterone in all adult Type 2 diabetic men since up to 40% will have low levels4. It is also important to measure these levels in all patients presenting with ED.

A change in hormonal state is not unique to women. In men, it is called andropause; men will suffer with irritation, aggression, depression, hair loss and, sometimes even, loss in muscle mass.

Hypogonadism or andropause is present when there are symptoms, such as impaired cognitive and sexual functioning, associated depression and low testosterone levels. It is of importance to remember that the testosterone levels should be tested between 7am and 11am, after an overnight fast.

Testosterone therapy is approved for treatment if these factors are present. A trial therapy of three to 12 months is of importance to fully access response.

Types of testosterone replacement

  • Tablets (testosterone undecanoate) three to four capsules daily.
  • Intramuscular injection every six to 10 weeks. The interval will depend on the response to medication and testosterone levels.

Monitoring of testosterone treatment

It is important to monitor a few parameters after three, six and 12 months of starting therapy. These parameters are:

  • Serum testosterone level towards the end of the testosterone interval.
  • PSA (prostate specific antigen).
  • Haematocrit (red blood cell count).
  • Regular examination of the prostate.

The evaluation of the prostate, before and during treatment, is important because of concerns that exist between prostate cancer and testosterone therapy.

The importance of measuring the haematocrit is that testosterone can increase the haematocrit in some individuals and they then have an increase risk in cardiovascular events. The haematocrit should stay below 54%. If treatment is needed and this value continues to be above 54% then the person should have regularly phlebotomies (donating of blood for medical purposes).

References:

  1. Al-Hunayan A, Al-Mutar M, Kehinde EO et. al. (2007) ‘ The prevalence and predictors of erectile dysfunction in men with newly diagnosed type 2 diabetes mellitus.’ BJU Int ,99 p130-3
  2. Dhindsa S, Prabhakar S, Sethi M et. al. (2004) ‘ Frequent occurrence of hypogonatrophic hypogonadism in type 2 diabetes.’ J of Clin Endocrinol Metab, 89 p5462-5468
  3. Ganong WF (1993) ‘ Review of medical physiology’ 16th edition, a Lange medical book, San Francisco
  4. Hackett G (2015) ‘Should PDE5Is be prescribed routinely for all men with newly diagnosed type 2 diabetes?’ Br J Diabetes Vasc Dis, 15 (4) p184-186
  5. Haffner SM, Shaten J, Stern MP (1996) ‘ Low levels of sex hormone binding globulin and testosterone predict the development of non-insulin dependent diabetes mellitus in men.’ Am J of Epidemiology, 143 p889-897
  6. Holmboe SA, Jensen TK, Linneberg A et. al. (2016) ‘ Low testosterone: a risk marker rather than a risk factor Type 2 diabetes.’ JCEM , 101 p69-78
  7. Visser J, Snel M, Van Vlier HAAM. Hormonal versus non-hormonal contraceptives in women with diabetes mellitus type 1 and 2. Cochrane Database Syst Rev. 2013;3:CD003990. doi: 10.1002/14651858.CD003990.pub4.

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Johnson
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.
dry eye

Dry eye associated with diabetes

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Eye Care Awareness Month runs from 21 September to 18 October. In light of this, Dr Chrissie Cockinos explains why dry eye is so common in people living with diabetes.

Diabetes has a number of associated eye conditions: ocular muscle palsies, blepharitis, dry eye, corneal ulceration, changes in refraction, early cataracts and retinal disease.

Sadly, diabetes is becoming more common than ever before. The World Health Organisation (WHO) predicts that there will be 370 million diabetes patients by the year 2030. This is double the number of people living with diabetes registered in 2000.

Why is dry eye common in diabetes patients?

Some studies report dry eye in more than 50% of diabetic patients. People with dry experience discomfort, grittiness, sensitivity to light, redness and a foreign body sensation of the eyes. Sometimes vision becomes blurry. One of the most common causes of dry eye disease is blepharitis (infection and/or inflammation of the eyelids). This is very common in diabetic patients.

Causes of dry eye in people living with diabetes

Hyperglycaemia and insulin resistance can result in neuropathy. The corneal nerves can be affected by long-term diabetes and this may, via the trigeminal nerve and facial nerves, affect the way the lacrimal gland produces tears. This may result in dry eye.

Neurotrophic (insensitive) corneas often result from diabetes. This nerve damage interrupts normal tear development pathways.

Insulin also has a role in tear production.

Inflammation releases certain chemicals, called cytokines, in the body. These chemicals can also damage tear producing cells in the conjunctiva and lacrimal gland.

Sequelae of dry eye

Apart from the frustration of suffering from dry eye, people living with diabetes have a higher incidence of corneal ulceration. This is due to the lack of protection to the eye by a normal tear film, increased blepharitis incidence (a source of bacteria) and insensitivity of the cornea.

Treating your dry eye

  • Topical treatment
  1. Eyelid hygiene to clear blepharitis. A good eyelid cleanser, preferably with tea tree is advisable.
  2. Topical lubricant eye drops and lubricant ointments at night.
  3. Visit your eye doctor annually.
  4. The inflammation of your eyes may require additional treatment and extra measures with cortisone eye drops or ointments.
  5. You may even require lacrimal plugs to be inserted.
  • General
  1. Check your HbA1c and blood pressure regularly via your doctor.
  2. Follow a good diet consisting of protein, vegetables, especially leafy greens, and oily fish like salmon and mackerel.
  3. Exercise regularly. Walk 20 minutes daily.
  4. Take Omega 3 supplements.

MEET OUR EXPERT - Dr Chrissie Cockinos

Dr Chrissie Cockinos (B.Sc (Hons) MBChB (Pret) MMed (Ophth) (Wits)) is an ophthalmologist in Sandton, Gauteng. She completed a masters dissertation in corneal ulceration. She has a special interest in laser eye surgery; cataract microincision, using monofocal and multifocal intraocular lenses; medical retina (diabetes and macular degeneration); surgical retina (retinal detachment and macula surgery) and glaucoma.
exercise feet

Put your sole at ease: exercise feet

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Anette Thompson, a podiatrist, tells us how to exercise feet to improve blood circulation, especially if you have diabetes.

An immense amount of recent research has reinforced the fact that exercise is essential for those who live with diabetes – at whatever stage you are – pre-diabetic; diabetic on diet + exercise only; diabetic on diet + exercise + tablets; diabetic on diet + exercise + tablets +/or insulin. This makes sense because we know that exercise helps ‘switch on’ insulin receptors in those with Type 2 diabetes, therefore is useful in lowering blood sugar levels.

There are also benefits of regular exercise of the feet, such as improved blood circulation. Blood contains oxygen, nutrients and repair cells so it’s vital that increased blood supply reaches each cell in the body, especially nerves and other structures in the feet, which are furthest away from the heart.

SA research

As part of Louise Stirk (a South African podiatrist) master’s degree, she studied the effects of an eight-week endurance exercise programme on blood sugar control and peripheral sensory neuropathy in people with Type 2 diabetes.

Her study was conducted on eight previously inactive diabetic volunteers, aged 34 to 47 years. They completed an eight-week endurance exercise intervention of moderate intensity. They started the exercise programme at the same time as two control groups. The first control group, aged 45 and 46 years, continued with a sedentary (inactive) lifestyle and the second active control, aged 40 years, continued with a prior exercise programme.

All participants were requested to maintain their usual diet. The moderate exercise for the previously inactive group consisted of a 30-minute cycling regime, during which the heart rate fluctuated between 60-80% of age-predicted maximum, repeated three times per week.

She measured the effects of this endurance exercise programme on diabetic peripheral neuropathy (DPN) and possible associations between exercise-induced changes in resting heart rate, blood pressure, body mass index, waist circumference, % body fat, six objective neurological measures of diabetic peripheral neuropathy, and eight subjective ratings of symptoms of foot discomfort. She also measured changes in HbA1c, plasma brain neurotrophic factor and serum adiponectin concentrations in all 11 participants.

The only significant change (p>0.05) in the passive (non-exercising) controls was an increase in subjective ratings of foot discomfort, while no significant change (p>0.05) was observed in the active control.

The eight-week endurance exercise programme was not combined with dietary intervention so it did not improve HbA1c levels, but it did result in significant improvements (p<0.05) in the average resting heart rate, systolic blood pressure, and patellar and ankle reflexes in the group of eight people.

Common reasons for not exercising

The most common reasons as to why diabetic patients don’t exercise on a regular basis is: their feet or legs hurt, they don’t know what shoes to wear, they don’t know how to exercise, they feel it isn’t safe to walk outside or they can’t afford a gym membership.

1. Feet or legs hurt
You may have an imbalance of the feet due to the effects of diabetes on soft tissue, or because of incorrect footwear or other biomechanical reasons of which you may be unaware. Feet should never hurt – this is a sign that something is amiss.

A podiatrist will conduct a full clinical biomechanical examination or you may choose to go to a biokineticist for a full-body assessment if other parts of your body also hurt when you exercise. Take your exercise shoes as well as your usual shoes with you to be assessed.

If imbalances or bony protrusions are present in the feet or ankles, a podiatrist will then take an impression of your feet in plaster of Paris or orthopaedic foam to fabricate custom foot orthoses, which fit into your shoes.

These can re-align your feet to make muscles work in balance with each other, offload sore spots or high pressure areas, and make you comfortable in your shoes once more.

Custom inserts, made by a podiatrist, can be moved between pairs of shoes and, even sandals, with a piece of adhesive Velcro affixed underneath to prevent sliding.

Do custom shoe inserts really work? 

In July 2005, James Wrobel, Adam Fleischer, Ryan Crews, et al., reported in the Journal of the American Podiatric Medical Association on examining the outcomes of custom foot orthoses on patients with plantar heel pain.

These researchers randomised 77 patients with plantar fasciitis to one of three groups in a double-blind fashion (custom foot orthoses, prefabricated orthoses, and a sham). Using objective and subjective outcome measures, they found a 5,6-fold increase in physical activity and improved outcome measures with the custom foot orthoses in comparison with the other methods at three months.

2. How to exercise feet

The second largest pump mechanism of blood in the body (after the heart) is that of the calf muscle ‘pump’. When the calf muscles contract, they push up against the big blood vessels deep in the leg.

exercise feetAny exercise that helps the calf muscles to contract is a good exercise for lower limb blood circulation. Walking is excellent – choose a flexible pair of shoes that grip the back of your heels, and grip over the top of your foot with adjustable fastening.

If you have never exercised, start with a 5-minute walk then turn around and go back and you’ll have completed 10 minutes. The next day, increase by 5 minutes. The day after, increase by 5 minutes, or stay at the same number of minutes for a few days until you feel you can add on more minutes.

Motivating tip: If you are new to exercising, do not measure distance when walking as it will only discourage you, only measure by time spent. As you become fitter, you’ll naturally increase your distances. Work up to 30 minutes of exercise every second day, then eventually 30 minutes every day.

3. What shoes to wear

You need flexible flat soled shoes/takkies that have a good grip on your feet, either in the form of: laces up the foot or sturdy Velcro straps up the foot. No open back shoes. If you want to walk in hiking sandals, wear a pair of socks together with the hiking sandals to prevent chafing or blisters. Other types of fashion sandals are not suitable.

Make sure the shoes are wide enough for your feet. The easy way to check this, is to remove the innersole from the takkie and stand on top of it as if your foot was in the shoe. If your foot width spills over the sides, the shoe is too narrow for you and should be avoided.

New Balance and Asics now have sports shoes available in wider fittings, called 2E and 4E.

Be aware that your foot volume naturally increases by 7% after four hours of standing or walking, so allow for foot expansion when fitting.

exercise feetMake sure the shoe is flexible – you should be able to bend it back from the ball of the foot with one finger. If it is not flexible enough, the calf muscles can’t work to their full capacity because the foot can’t bend easily at the ball of the foot.

4. Can’t afford gym or scared to walk outside?

Here are simple ways to exercise feet in your own home:

Sitting: Sit up on a chair with your feet flat on ground and knees bent to 90 degrees. Keeping your toes on the ground, lift the heels off the ground then put them down. Increase the number of repetitions until the calf muscles feel tired, then stop.

The next day, try to increase beyond the previous day’s number of repetitions by 1, the day after by 2, the day after that by 3. That way you will gradually build up to being able to do 300 repetitions while watching TV, or sitting in the office, or waiting at an appointment.

Standing: You can do calf raises holding onto the back of a chair, or the supermarket trolley, or while waiting for the kettle to boil or the photocopy machine to do its work.

On your bed: If the weather isn’t good, you can still lie on your bed and do exercises pointing your toes away from you and then pointing them towards you. Do at least 100 repetitions or until your calf muscles ache. If you persist with the exercise each day, it will become easier to do and the aches ease up as you improve your blood circulation.

MEET OUR EXPERT - Anette Thompson

Anette Thompson
Anette Thompson (M Tech Podiatry (UJ) B Tech Podiatry (SA)) is the clinical director at Anette Thompson & Associates, Incorporated, a multi podiatrist practice in KwaZulu-Natal. Tel: 031 201 9907. They run a member service for Diabetes SA members at their Musgrave consulting rooms as a service to the community.
diabetes nurse educator

A day in the life of a diabetes nurse educator

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Christine Manga, a diabetes nurse educator (DNE), explains what her job entails and shares some of the challenges faced as well as the pluses.

I am a diabetes nurse educator. I use this title without much thought. My mistake, not everyone knows what DNE stands for, let alone what we do. So, let me explain what a diabetes nurse educator is, why we are necessary, and what an average day routine consists of.

Part of a team

DNE is an acronym for diabetes nurse educator. A DNE is a healthcare professional who possesses comprehensive knowledge, skills and experience in diabetes management. We work as part of a diabetes management team, along with doctors, podiatrists, dietitians and ophthalmologists. Patients tend to spend more time with their diabetes nurse educator than any other of the team members.

Role

Our role, as DNEs, is to assist patients to effectively manage their own diabetes. We strive to do this through education, coaching and support. Being non-judgemental is of paramount importance.

Because diabetes is a chronic condition – patients have to live with it 24/7 365 – it’s not surprising that managing diabetes effectively requires a lot of time and effort. Patients are required to take various medications at multiple times in the day. These may be tablets or injectables. Regular structured glucose testing is recommended. Constantly being aware of what they’re eating is tiring. It is therefore imperative that DNEs equip these patients with the tools and coping mechanisms to master self-management. We know that each patient is unique, hence we tailor a management plan around this.

First consultation

During the first consultation, a DNE does a thorough history taking. From this information, we can assess diabetes duration, comorbidities, medication, diet, lifestyle, and patient motivation level.

Working within the South African guidelines for diabetes management and taking into account the patient’s preferences and habits, together we can formulate a management plan.

General information is given to all patients. This includes explaining what diabetes is. Many patients are not aware of what diabetes is and the serious complications that can occur without good control. A lot of time is spent correcting misconceptions. We explain the various targets that they should be aiming for.

Basic dietary information including meal planning, portion sizes and timing of meals are explored. Small changes to these choices can result in improved glucose control. Educating patients on blood glucose testing technique, injection technique, needle and site rotation is key to good management.

Explaining how the medication works in the body, what side effects to expect, and what medication may need to be used in the future seems to have improved medication compliance in my patients. Highlighting the importance of exercise and quitting smoking is vital to incorporate.

This generic information is given to all patients. Without the basics, one cannot easily progress.

SMART goals

In future consultations, DNEs coach patients on how to set a Specific, Measurable, Attainable, Realistic and Time-based (SMART) goals. Once the patient has set goals, we sit together and discuss how he/she can attain these goals. These goals are much more than just achieving a good blood glucose reading.

It’s the patient who needs to formulate a plan; a DNE will assist or give potential options that he/she may not have been aware of. By coming up with the solutions themselves, it empowers them and builds self-confidence. It encourages self-management, which is what we are aiming for.

Daily routine

A routine day consists of consultations, checking and responding to patient emails and, in most cases, managing an emergency hotline. Remember, diabetes doesn’t go away after office hours.

Though, saying a day is routine is not very accurate. No two patients ever present in the same way. So, although saying a consultation is routine is true, the content will never be routine. The patient may be in a bad space – unrelated to diabetes – resulting in 90% of the consultation being spent on that issue.

A DNE needs to be flexible. A consultation should have structure, but the content should be led by the patient. Our agenda may not meet the patient’s needs. We need to be attentive to where the patient is leading us.

Pros and cons

As with every profession, there are both rewarding and challenging moments. The most challenging issues being language differences, financial constraints, and a general resistance (from patients) to change.

These changes include lifestyle modification, increasing, changing or adding medication. Resistance is also common when initiating insulin. Financial constraints affect the choice of medication, the amount of testing strips that a patient can use as well as food that can be purchased. All of these have an effect on the way the patient responds to the recommendations.

On the up side, I love being the first person to interact with a newly diagnosed patient. Being able to allay the fear these patients feel is extremely rewarding. Many people are scared when they have been diagnosed with diabetes. They also fear being judged.

As time goes on and my patients come for follow-up appointments, it is wonderful to see how many of them have embraced the diagnosis, worked through and with it. Their self-esteem appears to blossom.

Sadly, this is unfortunately not the case with all patients. At the end of the day, we are all human. Helping one person might not change the world, but it could change the world for one person.

MEET OUR EXPERT - Christine Manga

Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.
Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.
sleep timing

Early to bed, early to rise: sleep timing and your health

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Paula Pienaar explains why sleep timing is important to your health, adding that the time you go to sleep and wake up plays a large role in whether you increase your risk of obesity and Type 2 diabetes.

Traditional lifestyle-related risk factors, such as overeating, poor nutritional choices and physical inactivity, have long been blamed for the alarming global increase in obesity, diabetes and cardiovascular disease. In recent years, it has become evident that sleep habits (sleep timing) also contribute significantly to one’s health risk status. In fact, did you know that the time you go to sleep and wake up plays a large role in whether you increase your risk of obesity and Type 2 diabetes?1-3

Sleep timing is crucial

Studies on how sleep timing affect health have shown that late bedtimes, combined with sleep deprivation (often due to waking up early enough for work) results in increased caloric intake in the late evening hours, as well as increased appetite for foods that are calorie-dense. In addition, later bedtimes seem to have become more frequent in the general population and is associated with an increased prevalence of Type 2 diabetes as well as poorer glucose control in diabetic patients.1,3

The circadian rhythm influences sleeping, eating, heart rate, blood pressure, body temperature, the levels of certain hormones, and the immune system.

Tick-tock our body clock: our circadian rhythms

The time you go to sleep and the time you wake up, or your sleep-wake cycle, is referred to as your circadian rhythm.

This internal body clock is a 24-hour internal timer that functions by cycling between sleepiness and alertness at regular intervals throughout the day.

The pattern of feeling energised and tired at usual times is an example of your circadian rhythm at play.

For most adults, the biggest energy dip occurs between 2:00 am and 4:00 am, when we are meant to be sleeping, and 1:00 pm and 3:00 pm, usually after lunch. These circadian dips are especially prominent in those who are sleep-deprived.

Did you know?

After midday, body temperature drops slightly which prompts the release of melatonin. Although this effect is at a smaller scale compared to nighttime, we often experience it as a ‘post-lunch’ energy dip occurring between 2pm and 4pm.

Social jet-lag

Today’s society has created an illuminated environment that alters the natural light-dark cycle needed to regulate the circadian rhythm. Big cities with 24-hour light exposure, workplaces with bright artificial lighting, and neon lights adorning places of entertainment are all examples of how we are constantly exposed to unnatural lighting during the time when our body needs to wind down.

Additionally, our lifestyle choices may also create a body clock that is out of sync with the environment. For example, our natural rhythm is affected by being awake when we are meant to be sleeping; sleeping for long periods during the day; and even having erratic meal times.

When we intend on ‘catching-up’ on sleep during weekends, or days off from work, we expose ourselves to the same health ramifications, as now we are trying to change our sleep timing once again. This mismatch in sleep time is called ‘social jet-lag’ and affects most of us at some stage in our lives, whether it is due to travel, social engagements or work demands.

Consequences of a disrupted body clock

The sleep disruption and deprivation resulting from irregular sleep times and increased night-time light exposure have shown to disrupt metabolic and hormonal processes.2,4,5

The body responds by:

  • Increasing hunger hormones, which may lead to weight gain and obesity.
  • Suppressing the release of sleep-inducing hormones, making it more difficult to fall asleep.
  • Creates an immune response, which lowers your immune status.
  • Increases stress hormones, which have shown to lead to hypertension and cardiovascular disease.
  • Disrupts insulin action, which favours fat accumulation.

The good news is that by adjusting your sleep routine to follow the environments natural light-dark cycle, you can support your body clock in restoring your health.

Managing sleep timing

The following tips have shown to help improve circadian function and sleep disruption:

  • Ensure adequate exposure to daylight: exposure to sunlight during the day and darkness at night helps to maintain a healthy sleep-wake cycle. This is especially important for people who spend most of their time indoors.
  • Stick to a healthy sleep and wake time routine: try to consistently make your way to bed when it gets dark, and wake up to natural light instead of hitting the snooze button.
  • Ensure the bedroom is dark, quiet and comfortable: cosy temperature; no television, mobile phones and bright lamps (see next tip below); and pets that wake you up should be kept out of the bedroom. The mattress and pillows should also be comfortable. It may be helpful to use blackout curtains, ear plugs, and eye shades.
  • Refrain from screen time at least an hour before going to bed: the blue light from certain televisions, mobile phones and tablet devices suppress the release of sleep-inducing melatonin. It may be useful to use blue-blocking glasses and apps to filter short-wavelength emissions from electronic devices. You can download such an app from https://justgetflux.com/ .
  • Avoid napping during the day, but if the need is very high, limit it to before 03:00 pm and for no longer than 30 minutes. You do not want to end up with a late bedtime and sleep deprivation the following day.
  • Get regular physical activity: moderate activity, such as brisk walking, has shown to help improve sleep quality. If you are a morning-type person, use that to your advantage and get natural morning light during your outdoor sessions.
  • Go camping! A weekend dose of nature’s light-dark cycle has shown to restore a disrupted circadian rhythm.

Shift workers and individuals who travel regularly across time zones are most vulnerable to circadian rhythm disruption and would benefit greatly from sleep-timing support. If having tried these tips, but you still are out of sync, or struggle with excessive daytime sleepiness, it is best to seek help from a sleep health professional.

References:

  1. Knutson, Kristen L., et al. “Association Between Sleep Timing, Obesity, Diabetes: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Cohort Study.” Sleep 40.4 (2017).
  2. Baron KG, Reid KJ, Kern AS, Zee PC. Role of sleep timing in caloric intake and BMI. Obesity (Silver Spring). 2011; 19(7): 1374–1381.
  3. Merikanto, Ilona, et al. “Associations of chronotype and sleep with cardiovascular diseases and type 2 diabetes.” Chronobiology international 30.4 (2013): 470-477.
  4. McHill, A. W., and K. P. Wright. “Role of sleep and circadian disruption on energy expenditure and in metabolic predisposition to human obesity and metabolic disease.” Obesity Reviews 18.S1 (2017): 15-24.
  5. Sharma, Arpita, Shashank Tiwari, and Muniyandi Singaravel. “Circadian rhythm disruption: health consequences.” Biological rhythm research 47.2 (2016): 191-213.
  6. Potter, Gregory DM, et al. “Circadian rhythm and sleep disruption: causes, metabolic consequences, and countermeasures.” Endocrine reviews 37.6 (2016): 584-608.

MEET OUR EXPERT - Paula Pienaar

Paula R. Pienaar
Paula R. Pienaar (BSc (Med)(Hons) Exercise Science (Biokinetics)), MSc (Med) Exercise Science) is the scientific advisor to EOH Workplace Health and Wellness, and a PhD candidate at the University of Cape Town. Her scientific research relates to sleep health and managing daytime fatigue to improve workplace productivity and lower the risk of chronic disease. Her thesis will identify the link between sleep and cardiometabolic diseases (Type 2 diabetes and cardiovascular disease) in South African employees. She aims to design a tailored sleep and fatigue management workplace health intervention to improve employee health risk profiles and enhance work productivity. Contact her at paula.pienaar@eoh.co.za
resilience

An opportunity to develop resilience

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Rosemary Flynn enlightens us as to why having diabetes is an opportunity to develop resilience.

When you have a medical problem, you usually go to a doctor to have the problem solved. With diabetes, the doctor cannot ‘solve’ the problem. He/she can give you medication and advice on living with diabetes to keep you going, but because there is no cure, taking care of diabetes falls to you.

Good diabetes control depends on a healthy psychological environment. You have diabetes, but the family has diabetes too, whether it is a marriage or partnership, with or without children, grandparents or extended family. Research has shown that families play a key role in how well people with diabetes adjust to their condition, integrate it into their lives, and manage it well.

But as far as you are concerned, you need a good attitude towards your diabetes and you need to develop resilience. Resilience is an important part of the process of learning to adapt to life with a chronic condition.

What is resilience?

It is the courage to come back after a stressful situation has arisen. It is the capacity to respond positively to adverse situations. It is the ability to learn from your experiences and a capacity to be adaptable.

You can develop resilience when you have diabetes. If you already have some resilience because you have had to deal with many other stressful events, it will become even better as you deal with the daily management of diabetes and you will be stronger for it.

There are many opportunities for personal growth, higher emotional intelligence and maturity because you have diabetes.

Things you can learn from diabetes:

  • You can learn to think – when your blood glucose levels surprise you, you have to think about what gave you a higher or lower level than you expected.
  • You can learn to handle the unpredictability of those blood fluctuations.
  • You can learn perseverance through thick and thin.
  • You can develop more empathy and compassion for others who are going through stressful situations.
  • You can develop a greater sense of purpose and meaning.
  • You can develop a greater appreciation of life itself, as you work on controlling your diabetes to keep your body as healthy as possible for as long as possible.

There are negative things that you have to deal with when you have diabetes, but if you choose to tackle your diabetes with effort and energy and strive to succeed, you can live with a sense of purpose and commitment to life which will make you feel positive and fulfilled.

MEET OUR EXPERT - Rosemary Flynn

Rosemary Flynn
Rosemary Flynn is a clinical psychologist at the Centre for Diabetes in Johannesburg. She has worked with children, families and adults with diabetes for 24 years, enabling them to overcome their anxieties about their condition and to deal with the difficult events in their lives.
cde club app

CDE Club App launched

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The first free information and support app for people with diabetes has been launched by the Centre for Diabetes and Endocrinology (CDE). Hamish van Wyk, registered dietitian and diabetes educator from CDE, tells us more.

The most important person in the management of diabetes is the person living with diabetes. For this reason, the CDE launched its CDE Club App to assist people with diabetes by providing valuable information, a tool to track progress, and even earn rewards.

“The majority of diabetes care is self-administered. For example, people with diabetes have to decide when to take their medication, what goes onto their plate on a daily basis, and whether or not they will exercise. It has been suggested that a person with diabetes should know more about diabetes than the average general practitioner. This can be overwhelming. The aim of the CDE Club App is to step in and empower people with diabetes so they can meet their daily self-management demands,” Hamish explains.

cde appDiscover

Discover is the first section of the CDE Club App. Here people with diabetes can access educational articles, videos and recipes, all designed to help gain a better understanding of their health. The content is developed by some of the leading healthcare providers in diabetes in South Africa. Very importantly, the app asks the user clinically relevant questions in an attempt to better understand the user’s health status. Based on these questions, the app can suggest educational content specific to the user.

“Our experience tells us that the majority of people with diabetes have many questions about their condition and don’t have the answers. The intention of the app is not to take over the role of a diabetes nurse, educator or dietitian, it provides information to support the user’s education journey and it acts as a point of reference. It offers answers to questions, such as: Why do I have diabetes?, What is an HbA1c?, Will I ever need insulin in addition to my pills?, How many times a day should I check my blood glucose levels? and so on,” says Hamish.

cde appAct

The second section of the app is Act. “Knowledge alone is often not enough to change behaviour. So, paired with each article is an achievable action to provide the user with the next step forward. Basically, it provides a way to put what they’ve learned into action,” he says.

Based on the questionnaires the user has answered and the articles that they read, the app provides suggested actions, which pop up as notifications. For example, the app can remind the user to drink more water, or to take lunch to work. Users can also track their workouts and steps, among other things. Users that register on the CDE Diabetes Management Programme can view their online health record with clinical feedback. “This is incredibly important, as ultimately, the suggested actions ideally need to translate into improved clinical outcomes, such as lower blood pressure.”

cde appShare

To assist in the maintenance of changed behaviour, the next section of the app, Share, encourages users to view and share their successes with friends and supporters. “It is so important that people living with diabetes are encouraged and supported on their journey. Lifestyle changes are hard to implement alone. The true beauty of changing one’s health comes through two-way support. I believe that if we had a community that encourages and supports healthy living, we would not be experiencing the current ‘global tsunami’ ofcde app Type 2 diabetes,” says Hamish.

Rewards

The CDE Club App will have a list of rewards that are redeemable at no cost. As users read articles, complete actions, and achieve clinical targets, they will earn ‘badges’. By accumulating badges, users are rewarded with coupons for discounted prices on various brands.

“Short-term rewards keep people motivated, which will ultimately lead to lifestyle changes and improved health. This rewards section of the app aims to give users a sense of achievement and keep them motivated.” Best of all, these rewards are free!

Hamish says this app is a first of its kind and believes it will make a difference in the lives of people living with diabetes. “Diabetes can be managed and people with diabetes can live rich and fulfilling lives. The CDE Club App is a brilliant support tool,” he concludes.

How to download the app

To download the CDE Club App scan the QR code on the website http://www.cdediabetes.co.za/home/diabetes/join-cde-club/about-cde-club.html or search “CDE Club” App on either Google Play Store or the iTunes Store.

MEET OUR EXPERT - Hamish van Wyk

Hamish van Wyk, registered dietitian and diabetes educator from CDE.
flash glucose monitoring system

The first flash glucose monitoring system now in SA

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The world’s first flash glucose monitoring system, which requires only a scan rather than a traditional finger prick to test blood glucose, is now available in South Africa.

The ability to get a glucose reading with a quick, painless scan has ushered in a new era of bloodless, simple and calibration-free visualisation of glycemic control – the flash glucose monitoring system.

The unique technology replaces blood glucose meters, while giving patients many of the benefits of continuous glucose monitoring (CGM), including real-time glucose values, trend information and comprehensive reports.

The flash glucose monitoring system

This new system includes a flexible filament sensor, which is inserted 5 mm under the skin. The filament is connected to a small, round disc and held in place on the skin with medical adhesive. The sensor remains inserted for 14 days. One hour after application to the upper arm, it begins reading blood glucose levels and continues to do so for up to 14 days.

The hi-tech monitor, first introduced in Europe, has provided unparalleled levels of data so necessary in the management of diabetes and has revolutionised the way people with Type 1 diabetes can manage their glucose levels.

Controlling glucose levels is a prerequisite for treating diabetes. Traditional testing with blood from a fingertip is recommended 4 to 8 times a day.

What the expert says

Dr Larry Distiller, an endocrinologist, says when the technology was first introduced in Europe, a voluntary pilot project was initiated. More than 50 000 people participated in the pilot, between 2014 and 2016, yielding 409 million data points. The analysed data provided invaluable insights into glucose monitoring.

In comparison, the new flash glucose monitoring system allows users to scan and check their blood glucose at any time without any limit. Practically, pilot project participants scanned on average up to 16 times per day. Research found that those who scanned the most had the best control of their blood glucose.

In addition to always being available and providing immediate personal monitoring, the reader data can be downloaded and analysed using specific software. This produces detailed and informative visual outputs on daily glycaemic trends and variability and highlights statistical risks of hypoglycaemia and hyperglycaemia according to the time of day.

Looking into the future

In time, patients will also be able to scan the sensor using their cell phone. Distiller says this new technology is approved for dosing insulin, except in three cases when a finger stick is recommended: when hypoglycaemic, when glucose is changing rapidly, or when symptoms don’t match the system’s readings.

MEET OUR EXPERT - Prof Larry Disteller

Prof Larry Disteller is an endocrinologist.