Christine Manga, a diabetes nurse educator, explains the calculation of insulin dosing for fat and protein.

We are social creatures and food plays an enormous role in our lives. Many gatherings and celebrations revolve around food, promoting socialisation and fostering a sense of belonging. These events should be fun and exciting but instead they often present as daunting and challenging if you have diabetes, especially if you need to inject insulin.

Who needs to inject insulin?

Type 1 diabetes is the absolute absence of insulin. Insulin is required to facilitate the movement of glucose from the bloodstream into the cells for energy use and storage. People with long-standing Type 2 diabetes may also have less or no insulin reserves. This will necessitate the need to inject a rapid-acting insulin before eating a meal as well as a long-acting insulin at least once a day.

Carb counting is a commonly taught skill that involves calculating the amount of insulin required to match the amount of carbohydrates eaten at a meal. Your healthcare provider will assist you in working out a carb ratio and insulin sensitivity factor (ISF). This will be used at each meal.

Meals are more than just carbs

Fats and proteins also impact blood glucose levels by delaying the digestion and absorption of carbohydrates, often causing a delayed and prolonged hyperglycaemia (high blood glucose). It can be drawn out for as long as three to five hours post-meal.

Fat causes and worsens insulin resistance which would mean more insulin would be required. A meal that contains 35% or more of it’s total calories is considered a high fat meal. This amount varies in the literature.

There are vast differences in interpersonal and intrapersonal blood glucose responses to fat and protein. There is no uniform response to a meal. These differences can be caused by, but are most definitely not limited to carb ratio, ISF, exercise, weather, duration of diabetes, order in which food is eaten as well as overall health.

To establish how fat or protein affect your glucose, it’s imperative to monitor yourself for patterns. Measurements should be taken three- and five-hours post-meal. It’s possible to monitor with manual finger pricks, but continuous glucose monitoring (CGM) is really helpful in these situations. Pattern detection is far easier.

High fat and protein meals

Examples of high fat and protein meals could include bacon and eggs, burger with avo and chips, salmon with olive oil drizzled on roast vegetables, pizza, creamy sauce pasta, pastries. The list goes on.

It’s often the case that even when carb counting is accurate, a high fat and protein content in the meal will result in under dosing of insulin and a delayed hyperglycaemia. A study using a 50g protein example: 200g cooked steak and 30g carb meal received an extra 30% insulin delivered in a combination bolus. This amount improved post-meal glucose levels without any additional risk of hypoglycaemia. When the amount of insulin was increased to 45%, there was increased hypoglycaemia whereas a 15% increased dose still resulted in post-meal hyperglycaemia.

Whittington Health, followed on the NHS guidelines, suggest counting carbs for the high fat or protein meal and adding 20% extra insulin along with a correction, if necessary. If the meal contains no carbs and more than 50g of protein, count it as 10g of “carbs” and dose according to your carb ratio. If you’re consuming alcohol with the meal, make no adjustments.

Calculating is hard work

In my practice, I tend not to teach insulin bolusing for fat and protein. Carb counting is already an additional step someone with diabetes must contend with pre-meal. Working out the carb content of food can already be challenging. Add in trying to establish the fat or protein content of the meal too and then calculate the extra insulin required. That is hard work and adds to the diabetes burden, possibly causing distress and eventual burnout.

With saying that, there are carb counting apps that make provision for fat and protein. If you choose to follow a low-carb, high-protein, with or without high-fat diet, you will need to work out with your HCP the best insulin ratios to use. There will be a lot of trial and error, but a certain amount of insulin will almost definitely be required, albeit a small amount.

If you’re fortunate enough to be on a sensor-augmented insulin pump, you’ll be better able to negate the effects of fat and protein in the meals. Depending on the pump, there are different features that will accommodate for the extra insulin requirements. Insulin can be given as a dual or square wave bolus which is a bolus given over an extended period. Auto correction from the pump will assist in compensating for the delayed rise in glucose. These are very small bolus amounts delivered by the pump without the user needing to initiate them. The pumps are also able to modulate the basal rate to regulate the blood glucose levels. If you’re manually injecting, you may need to give two boluses to compensate for high fat or protein meals.

Your choice

The choice is entirely up to you, if you would like to take your diabetes management to this level. Many people who don’t bolus for high fat or protein are still extremely well-controlled with an excellent Hba1c only counting for carbs.

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Dr Angela Murphy explains the symptoms and the treatment for both low and high levels of calcium.

What is calcium?

It’s is a mineral necessary for the healthy functioning of bones and teeth. In addition, it’s necessary for normal blood clotting, muscle contraction, nerve function and heart rhythms. Most calcium in the body is stored in bone with only 1% found in blood, muscles, and other tissues.

The body gets calcium from eating foods rich in calcium, particularly dairy products, nuts and seeds and certain vegetables, such as kale. If the diet is low in calcium, then the body will start to extract calcium from bone which can cause bone disorders, such as osteoporosis.

Recommended daily requirements

The table below lists the recommended daily requirements for different age groups.

How are calcium levels affected?

Levels of calcium are controlled by the parathyroid glands, which as the name suggests, lie next to the thyroid gland in the neck. These four, small glands secrete parathyroid hormone (PTH) which acts in several places in the body:

1. Gut – to stimulate uptake of calcium from food by activating vitamin D.
2. Kidneys – to slow down the loss of calcium in the urine.
3. Bone – to stimulate release of calcium from bone into the circulation.

The system should be balanced enough to keep enough calcium available to all the cells in the body, but not remove too much from the bones. When calcium levels are too high or too low, we always look to see what the PTH level is first and from there can decide the cause of the imbalance.

Hypercalcaemia (high blood calcium)

The most common causes are:

• Primary hyperparathyroidism – This usually occurs sporadically, although sometimes there is a family history. In most cases, one of the four parathyroid glands have an adenoma which overproduces PTH. Sometimes the entire gland is enlarged, and this is called hyperplasia. Rarely more than one gland will be overactive. It’s rare for cancer to be a cause.
• Malignancy – Some cancers produce a PTH-like hormone which then increases calcium levels in the blood. Other cancers cause direct damage to bone which releases too much calcium.
• Hormonal disorders –  Such as an overactive thyroid gland or adrenal gland disorders.
• Medications – Can also increase calcium levels. For example: lithium, certain water tablets and excess use of vitamin A and D.

There are less common conditions, such as prolonged illness in ICU, hereditary disorders and inflammatory conditions, which can also cause hypercalcaemia.

Symptoms

A traditional mnemonic categorises the main symptoms of hypercalcaemia: bones, stones, abdominal groans, and psychic moans. This summarises the main clinical features of high calcium levels:

• Bone loss resulting in diseases, such as osteomalacia and a type of osteoporosis;
• Kidney stones and decrease in kidney function;
• Constipation and other gastrointestinal complaints;
• Mood disorders, such as depression, and a general feeling of being unwell.

Treatment

Naturally, this depends on the cause as well as the actual level of calcium. If the levels are very high, the first step is to lower it with medication and intravenous fluids. The definitive treatment for primary hyperparathyroidism is to surgically remove the overactive parathyroid gland. This is a safe procedure in experienced hands with excellent results.

Hypocalcaemia (low blood calcium)

The most common causes are:

• Hypoparathyroidism – Again this can occur sporadically but more commonly as a result of surgical removal of the parathyroid glands, radiation to the neck or a disease process that infiltrates the parathyroid glands.
• Resistance to the action of PTH – This can occur in kidney disease and with certain drugs as well as a condition on its own called pseudohypoparathyroidism. This means that although the PTH level is normal, the body is resistant to its action and behaves as if there is no PTH to keep calcium levels stable.
• Vitamin D deficiency.
• Resistance to the action of vitamin D – This is a rare hereditary condition.

There are other illnesses which can cause a sudden drop in calcium levels, such as acute pancreatitis, but when treated the levels can normalise.

Symptoms

The classic symptom of hypocalcaemia is tetany. This is spontaneous muscle contractions resulting in spasm, especially of the hands or feet. There may also be a tingling sensation around the mouth and in the fingers. If the levels drop too low this may cause seizures. Chronic low calcium levels in children will affect growth and development.

Treatment

If levels are very low and especially if they have dropped suddenly, it might be necessary to give intravenous calcium. The goal of therapy is to maintain levels in the normal range, and to get to the correct dose of supplements may take some time.

It will usually be necessary to have vitamin D supplementation as part of the treatment. An average dose of calcium supplementation for hypocalcaemia is 1.5 – 3g daily. Long-acting vitamin D2 can be given weekly in many cases. Sometimes a shorter-acting vitamin D, such as calcitriol, needs to be used. If there is difficulty restoring levels to normal, you should be referred to a specialist.

Conclusion

For people living below the poverty line, dietary calcium deficiency can occur. Fortification of foodstuffs has helped to lower this risk. For example, a 100g of Pronutro porridge has 530mg of calcium.

Generally, low calcium due to poor absorption or dietary deficiency can be easily corrected. There is no benefit to taking supplements if you have normal calcium levels. High calcium levels must always be investigated and then the cause can be treated.

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Medipost Pharmacy share an easy guide to using medicine safely and how to get the best out of pharmacy care.

Medication is a lifeline for South Africans living with chronic conditions and provides relief from illness and pain, but only when it is used safely and appropriately. Pharmacists are there to guide and advise you on all matters related to your medicine and your health. Make the most of their expertise with these simple tips.

“Medication can do more harm than good if it isn’t used correctly, and so it’s really important that everyone understands the basics of responsible medicine use, and pharmacy teams are ideally positioned to support patients,” says pharmacist Joy Steenkamp of Medipost Pharmacy, South Africa’s first national courier pharmacy.

 What you need to tell your pharmacist

1. All your allergies
2. Your existing health conditions
3. All the medicines you are using, including prescription, over-the-counter and traditional medicines
4. Report any bad reactions to medication
5. If you are pregnant or trying to get pregnant

 What you should ask your pharmacist

1. What is the medication prescribed for?
2. How much and when to take your medicine?
3. Are there side effects to be aware of?
4. Is there anything you need to avoid while taking the medication?
5. Advice for managing symptoms of common or short-term ailments

Five things you should know

1. Keep medicines safely out of harm’s way in a cool, dry place away from sunlight.
2. If antibiotics are prescribed, complete the course.
3. Always check expiry dates and package inserts.
4. Often, child and adult doses vary; be sure not to exceed the recommended dose.
5. If anything to do with medicine is unclear, check with your pharmacist.

Five golden rules of pharmacy

1. Never share your prescribed medication with someone else.
2. Do not stockpile medicines.
3. Medication abuse is dangerous, talk to your pharmacist if you are using more than you should.
4. Don’t throw away or flush medicines; hand in expired or unneeded medications to Medipost’s courier drivers or at any healthcare facility with a pharmacy.
5. You can tell a pharmacist anything without feeling embarrassed. As the most accessible healthcare professionals, they can offer guidance and advice when you need to see a doctor.

“Make sure you understand everything your doctor or pharmacist tells you about how to take your medication, and feel free to ask as many questions as you need to; it’s your health at stake. It can be very helpful to speak to a pharmacy professional in your home language to ensure you get the most out of these interactions,” Steenkamp says.

Apart from the convenience and safety of the free delivery of chronic medications, including treatment for high cholesterol, diabetes, and many other conditions, to any address in South Africa, Medipost Pharmacy also offers all registered patients access to telephonic clinical pharmacy advice in all official South African languages. Self-care medication is also available via the online shop.

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S’thandiwe Magwaza received her Master’s in Biochemistry cum laude for her research on the use of seaweed to treat diabetes and obesity.

S’thandiwe Magwaza’s dissertation titled: Studies on the antioxidative, anti-diabetic and anti-obesogenic potentials of some marine macroalgae or seaweeds collected from the Southern and Western coastlines of South Africa, was supervised by Professor Shahidul Islam (University of KwaZulu-Natal).

She explained that obesity and Type 2 diabetes (T2D) have become significant global health concerns in recent years. “These conditions are associated with a range of serious health complications, including heart disease, stroke, kidney disease and certain types of cancer,” she said. “Understanding their causes, risk factors and management is crucial to improve public health and reduce the burden of chronic diseases.”

The prevalence of obesity and T2D has continued to rise in recent decades and is expected to triple in the next 30 years. They are not only a health problem, but they also impose an economic burden. These conditions are often linked as obesity is a major risk factor for the development of T2D. The pharmacological treatments have side effects and are expensive.

“There is great demand for natural anti-obesity and anti-T2D remedies owing to the fact that they cost less and have fewer to no side effects,’ said S’thandiwe. “A number of seaweeds go to waste although many medicinal plant extracts and their isolated compounds have been scientifically proven to possess anti-obesity and anti-T2D properties.”

23 types of seaweed collected

Her research evaluated the anti-obesity, anti-diabetic and antioxidant potentials of 23 types of seaweed collected on South Africa’s southern and western coastlines. They were evaluated using in vitro and ex vivo experimental models.

Seaweeds have been used to treat various ailments in East Asian countries for centuries. Yet the health benefits of seaweeds from South African coastlines are not well-explored. Seaweeds are rich in bioactive compounds including polysaccharides, polyphenols and peptides, which have demonstrated potential health benefits. Investigating these natural sources for their anti-obesity and anti-diabetic properties can lead to the development of safer and more sustainable therapeutic options.

Thankful for support

S’thandiwe has registered for a PhD and is currently continuing her research under Islam’s supervision. She thanked him for his academic guidance and paid tribute to colleagues at the Biomedical Research Laboratory for their contributions and assistance. She also acknowledged the National Research Foundation for financial support throughout her postgraduate studies.

S’thandiwe thanked her mother, Ntombenhle Ngcobo Magwaza, for her love, support, encouragement and prayers and for the sacrifices she made to ensure she had the opportunities she needed. She paid tribute to her late grandfather who ignited her love for education, noting that it was the one thing no one could ever take from her.

“I always use my breaks to spend time with my family as they are important for my mental and emotional well-being,” said S’thandiwe. “The memories we create together and the emotional connection I have with them serve as a source of comfort during challenging times.”

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