Autumn 2021 Treatment Archives

A telegram to Dr Robert Lawrence: “I’ve got insulin – it works – come back quick.”

In May 1923, Dr Robert Lawrence was in Florence, Italy, far from his family home in Scotland, preparing to die from Type 1 diabetes. A telegram from his colleague urged him to return to London and on 31 May 1923, Lawrence received his first injection of insulin. His life was saved! Lawrence went on to become a leading diabetologist and help found the British Diabetes Association. He lived almost 50 productive years thanks to insulin.

Present day

Yet today, insulin is frequently not seen as life-saving but rather as a harbinger of the end of the road. People with Type 1 diabetes require insulin injections from diagnosis as they lose the ability to secrete insulin from the beta-cells in the pancreas.

In Type 2 diabetes, insulin deficiency only develops after several years. A healthy lifestyle, as well as oral medications, is prescribed to bring glucose levels under control. It’s important to remember that diabetes is, by nature, a progressive disease.

Initial treatments aim to improve insulin sensitivity and improve endogenous insulin secretion. At some point, the insulin secreting cells of the pancreas struggle to keep up with demands and start to shut down. When glucose control can’t be achieved with the body’s own insulin then it’s time to start insulin injections.

Incredibly, sometimes this seems to trigger a partial recovery of some beta-cells. It turns out that they had not died, merely gone on strike as the work became too hard. When reinforcements arrive in the form of an insulin injection, they decide to return to work. This is the reason people with diabetes often manage with just one injection daily, in combination with their tablets, for many years.

How does insulin work?

Insulin is needed to open the glucose channel into the cell so that glucose from the blood can enter the cell. If there is not enough insulin, or the cell resists the action of the insulin, blood glucose levels will rise.

In the 1920s, insulin was derived from animals and only lasted in the body for several hours. In the 1950s, modifications were made to allow the insulin to be absorbed more slowly into the body. Over the next decades more advances where made with the introduction of human insulin, insulin analogues, improved delivery devices (pens and pumps) and non-injectable insulin (not available in SA). However, the precept of the purpose of insulin has not changed: it functions to move glucose from the blood into the cells where glucose is used to produce energy.

Patients often ask me how the morning blood glucose can be high when they have not eaten for 10 hours. Glucose enters the body directly from food and from stored glucose in the liver and muscle, particularly the liver. In the fasting state, such as being asleep overnight, the liver not only releases stored glucose but also manufactures glucose. One of the earliest features of insulin resistance occurs when the production of glucose in the liver is not kept in check, resulting in a rise in fasting glucose. At this point people with diabetes may be advised to start a night-time insulin.

Insulins available in SA

With such a plethora of insulins on the market, it’s no wonder insulin use can seem overwhelming and confusing. To better understand how the different insulins are used, I will explain the various insulin regimens that people with diabetes may be started on.

BASAL INSULIN

Regular insulins: Humulin N; Protophane; Biosulin N

Analogue Insulins: Basaglar; Levemir; Lantus and Optisulin; Tresiba; Toujeo

Most people with diabetes who are initiated on insulin will start with one daily injection, usually at bedtime. The efficacy of this insulin is determined by the fasting blood glucose reading: i.e. the blood glucose measured on waking in the morning before eating or drinking. If this fasting blood glucose is not at the target range (see Table 2 for your target range as per our South African guidelines), then the evening insulin is adjusted accordingly. The important points about bedtime insulin dose adjustment are:

Adjustments are NOT made according to the bedtime glucose
Adjustments are made according to the average fasting blood glucose values over a 3-7-day period (your HCP will determine this time frame).

Thus, adjustments are not made up and down daily. Rather they are based on the trend of the averages. Sometimes, the HCP may suggest using the basal insulin twice daily if they feel it would benefit daytime control. The titration of the morning dose will then be determined by the evening glucose reading, as explained below in the Pre-Mix Insulins.

TABLE 2: Target range (2017 SEMDSA GUIDELINES)

	HbA1c	FBG (mmol/L)	PPG (mmol/L)
YOUNG	<6.5%	4-7	<8
MOST	<7,0%	4-7	<10
ELDERLY	<7,5%	4-7	<12

TWICE DAILY PRE-MIX INSULIN

Regular insulins: Actraphane; Humulin 30/70; Insuman; Biosulin 30/70

Analogue insulins: NovoMix 30; Humalog Mix 25; Humalog Mix 50; Ryzodeg

When good glucose control can’t be maintained throughout the day with tablets alone, then insulin must be given to allow glucose absorption from meals. Pre-mix insulin consists of a mixture of short and intermediate insulin in the same pen. Some important points to remember:

This insulin will replace the basal insulin.
It’s essential to remember that a pre-mix insulin must be given BEFORE meals. I have often come across patients switched from basal to premix insulin and continued to give the evening insulin dose before bedtime, i.e. several hours after supper. This is extremely dangerous as the short-acting component can cause low blood glucose during the night.
Adjusting the dose of pre-mix insulin can seem quite complex. As with basal insulin, this must be done according to trends and not according the reading on hand.
The dose of morning insulin is determined by how well the glucose readings are controlled during the day, so we look at the pre-dinner reading to decide.
The dose of the evening insulin is determined by the control of glucose overnight, so we use the morning reading to decide (similar to titrating basal insulin).

Insulin diary log

I ask my patients to keep a diary and send it in every week so that I can help with these dose adjustments until we have reached the target glucose levels.

BASAL BOLUS INSULIN

Basal insulins as described above.

Bolus insulins:

Short-acting regular insulins: Humulin R; Actrapid; Biosulin R

Rapid-acting analogue insulins: Humalog; NovoRapid; Apidra

This regimen aims to mimic the normal function of the pancreas: intermediate or long-acting insulin provides the background insulin needed and then short-acting insulin is given before each meal (but not with snacks).

This short-acting insulin can be adjusted at every injection according to the pre-meal glucose reading and food being eaten. People with diabetes on this regimen are often taught carbohydrate counting. This is a method of quantifying how much carbohydrate is in a meal.

The HCP works out a ratio of insulin dose per carbohydrate portion and this is calculated at each meal. In addition, high glucose readings need to be corrected, so people with diabetes are taught a correction formula to bring the blood glucose back to an average of 6mmol/l (see calculation below). This sounds much more complicated than it is.

With some practice, people with diabetes can use this skilfully. It’s mainly used in Type 1 diabetes but is appropriate for anyone using a basal bolus regimen.

CALCULATION OF A BOLUS INSULIN DOSE

Pre-meal dose of insulin = food dose + correction dose, where

Food dose = (total carbohydrate portion) ÷ carbohydrate insulin ratio

Correction dose = (blood glucose – 6) ÷ sensitivity factor

The carbohydrate insulin ratio and sensitivity factor will be provided by the healthcare provider.

Constant communication with doctor

At my practice, we would not expect patients with diabetes to adjust their own insulins in those first weeks. They are asked to send readings in regularly, weekly to begin. We often revert to recording the readings the old-fashioned way with a diabetic diary as seen above and the patient can email or text that to me or the diabetic nurse educator (DNE). Some patients are using newer glucometers with Apps that can be uploaded and sent in.

HbA1c readings

Overall diabetes control is assessed with an HbA1c measurement every three to six months. HbA1c is a complex of glucose attached to haemoglobin in the red blood cell. This allows us to see what the average glucose is over the previous three months and gives a more comprehensive idea of control compared to the glucometer.

If the HbA1c and glucometer readings don’t correlate, then we must look at where in the day the blood glucose is increasing. To do this, patients will be asked to do 360’ testing or seven-point profile testing. For three days, they must test before and two hours after each meal as well as before going to bed (seven readings). This can help decide the next step in insulin management.

Getting the best response from insulin therapy

Up to this point, emphasis has been made on the choice of insulin and finding the correct dose. However, it’s important to remember the following when aiming to get the best response from insulin therapy:

Timing of the insulin injection
1. Basal insulin should be given at the same time every day. There is only a leeway of an hour either way.
2. Pre-mix insulin should be given 30 minutes BEFORE breakfast and dinner.
3. Bolus insulin should be given 15-30 minutes BEFORE each meal. No insulin will work in time if given at or after the meal.
Changing of needles used to inject insulin should be done every THIRD injection. If looked at under a microscope after three injections, the needle has a barb on it and can cause significant trauma to the skin and subcutaneous tissue.
Rotation of sites is essential. Repeatedly using the same site will result in a condition called lipohypertrophy, the accumulation of fat at the injection site causing a lump.

If your healthcare provider suggests it’s time to start insulin, do not see this as a negative in your diabetes journey but as a tool to continue in good health in your life journey.

MEET THE EXPERT

Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence and has a busy diabetes practice.

Dr Louise Johnson gives us a breakdown of the insulin pump therapy available in South Africa.

Diabetes is rapidly becoming a major health epidemic in most regions of the world. All Type 1 diabetes patients and a significant number of Type 2 diabetes patients require the use of insulin for controlling blood glucose.

There are several varieties of insulin and many different injection regimes that can be used. Despite the availability of insulin vials and pens, the acceptability for patients and the glucose readings that are obtained with single or multiple injections regimens is not to the desired level.

This is where insulin pump therapy also known as continuous subcutaneous insulin infusion (CSII) comes in.

Continuous subcutaneous insulin infusion

Insulin pumps were introduced half a century ago. They utilise short- or rapid-acting insulin types only. This minimises variability of administration and reduces the chances of glucose fluctuations. Pump therapy has progressed to the level of mimicking physiological demands.

Pumps are programmed to deliver basal or background insulin. This is usually the same as the previous long-acting insulin. Basal insulin delivery happens automatically. It delivers a programmable dosage per hour every 24 hours; it’s tailored according to the glucose profile of the person.

The insulin requirements may be affected by a person’s physiology, exercise, work schedule, concomitant medications, and illness.

Most patients utilise multiple basal rates over a 24-hour period. There are some that only uses one rate. Most pumps have the capability of programming basal rates that can be used in special situations as a temporary basal rate. Your physician will determine all this.

There is also a bolus function. This is calculated according to the carbohydrate ratio used for carb counting. The person should administer the correct amount of total carbohydrates consumed to the pump and it will then automatically calculate the exact number of insulin and deliver it. This will be administered over minutes to a few hours. Insulin boluses cover meals and correct high blood glucose levels.

How is insulin delivered?

This happens via a plastic cannula connected to the pump on the one side and a single subcutaneous site with a connection on the other side.

The subcutaneous site is the same as a person would inject insulin in the fat tissue on the abdomen. The site needs to be changed every three to four days to prevent infection or inflammation.

Only rapid-acting insulin can be put into a pump. Usually the analogues work best (Novorapid, Humalog and Apidra).

Advantages

Programmable insulin delivery allows closer match with physiologic needs.
Uses only short- or rapid-acting insulin. This minimises peaks and absorption related variability.
Use one injection site every three to four days. This reduces variation in absorption and treatment burden from multiple injections.
Reduction in glucose variability and improve glucose control.
Decrease the risk of severe hypoglycaemia
Improved quality of life and treatment satisfaction.

Type 1 ideal candidate

The ideal candidate for initiation of pump therapy is a motivated patient who is knowledgeable in the important aspects of diabetes self-care and desires better glucose control.

The patient should be familiar with carbohydrate counting and have knowledge about pump technology.

However, a pump is neither a cure for diabetes nor does it function autonomously without intervention or input.

Patients should be clear about the fact that the pump is a highly-specialised gadget. It requires constant interaction from the wearer.

It’s important to regular monitor blood glucose and communicates with a professional pump team. This will predict long-term success.

Indications for insulin pump therapy

Suboptimal glucose control despite multiple daily injections. You do not reach your target HbA1c.
Frequent or unpredictable hypoglycaemia and hypoglycaemia unawareness.
Dawn phenomenon. That is the early rising of blood glucose between 2am and 8am.
An active lifestyle with strenuous physical activities.
Children and young adults who typically desire fewer restrictions and more flexibility.
Growth spurt of adolescents.
Preconception planning and pregnancy
The presence of gastroparesis. (Abnormal slow movement of food from stomach to the rest of the bowel).
Hectic lifestyle with frequent travel between time zones.
Shift work.
Need for flexibility in the amount and timing of meals.
Patients that are sensitive to insulin and need very small dosages.
Type 2 diabetes patients with increased insulin requirements.

Types of pumps in South Africa

We currently have three different companies with have a variety of pumps. Each have its own pros and cons. It’s important that your medical team is familiar with your pump. Medical aids sometimes prefer to pay for certain pumps.

Medtronic 780 G is the newest of the Medtronic pumps and is a hybrid close loop system.

Tandem T slim 2 is the newest of the Tandem pumps and is also a hybrid close loop system pump.

Roche Accucheck Combo is a traditional pump.

Understanding hybrid close loop pump systems

In this type of system, the insulin pump “talks” to a continuous glucose sensor. The pump has a built-in algorithm; this allows the insulin to increase or decrease according to the blood glucose to attain the target. The only interaction the patient has with the pump is the input of carbohydrates consumed. Currently this is the ‘top’ pump to have if possible.

Disadvantages

Pumps are technology and they can break or malfunction
Cannulas can kink and this will stop insulin delivery.
Infusion sites can get infection or inflammation. This will cause rapid development of extreme hyperglycaemia, especially in Type 1 diabetes patients.

Pumps are not yet perfect but they are very close to it. Safeguards, such as alarms that warn of delivery problems or low amount of insulin in the pump reservoir are now standard features of insulin pump.

Many people living with diabetes are not aware of the importance of audiology and how diabetes may affect their hearing and balance system. Sakhile Nkosi and Kayla Van Rie tell us more in a Q&A.

Our bodies are made up of 30 trillion cells. Each cell has its own specific function and operates all day like a factory, absorbing and producing products that our body needs to survive daily.

For our cell factories to be operational, they need to have electricity (power). This power is provided to our cells by a substance known as glucose. It essentially keeps all the lights on and all the operations in the cell running smoothly.

When you have diabetes, the hormone, insulin, that allows the cell to absorb glucose is not sufficient. This causes your body’s cells to be less efficient and sometimes causes the cells to die, causing the factory to shut down completely.

Because the entire body is made up of cells, diabetes can affect the whole body and every organ, including the hearing and balance organs.

As a person living with diabetes, you may find yourself needing to consult with a team of medical professionals to make sure you are managing your diabetes well and that it isn’t causing other side effects. However, many diabetes patients are not aware of the importance of audiology and how diabetes may affect their hearing and balance system.

Q&A

What is an audiologist?

The Health Professions Council of South Africa (HPCSA) defines an audiologist as “a healthcare and educational professional who deals with the prevention, identification, treatment and management of organic disorders of the auditory and balance system, auditory processing disorders and developmental or acquired speech disorders caused by hearing loss.”

Why should I visit an audiologist as a person living with diabetes?

Since 1857, it has been known that persons living with diabetes are at risk of developing hearing and balance problems compared to healthy individuals.

When the cell bodies of the ear experience an irregular ‘power shortages,’ the cells may begin to be less effective. You may not notice that you’re not hearing or balancing well immediately, because the cells are weakened slowly over time, especially if your diabetes is left unmanaged.

Signs of hearing and balance deterioration

The signs of hearing and balance deterioration will not usually be obvious, for example, you may experience one of the following:

You may start to realise that you are not hearing well when you are struggling to discriminate what someone is saying whilst in a noisy setting.
You may experience a high-pitch ringing sound in your ears (known as tinnitus) every now and again, or all the time.
You may notice that your balance is not what it used to be when you are walking on a gravel road at night.
You may notice that you seem a bit clumsier while walking, stumbling more regularly.

These small signs may be cues that you need to visit your audiologist. It’s best to consult with an audiologist as soon as possible so action can be taken to prevent the effects of hearing and balance difficulties from having dire consequences on your life. As with most things, early intervention is key.

How can I prevent having a hearing and balance impairment?

There are no special preventative precautions dedicated to diabetes. This precaution, however, may be applied by every human being:

Limit exposure to harmful noise. If exposure cannot be avoided especially in a case of occupational noise exposure, the use of hearing protection devices is mandatory.

With regards to diabetes, it’s advisable to take note of the following:

Take your medication as prescribed to prevent advanced diabetic complications.
Find out about the side effects of any medicine you take and ask for a medication review.
Importance of diabetes control (ABCs). This refers to A1c, blood pressure, cholesterol and smoking. All of which needs to be closely monitored and managed to prevent diabetes progression and diabetes-related complications (including hearing loss).

How will an audiologist quantify hearing and balance problems in a context of diabetes?

Audiological procedures are non-invasive, meaning they are pain free. First your audiologist will take a thorough case history which will broadly comprise of your medical, hearing and communication history. The following questions may be asked:

Are you struggling to understand speech, particularly in noisy environments?
Are you experiencing any ringing in your ears?
History of high levels of noise exposure.
History of ototoxic drug use (ototoxic drug use implies any medication that has potential to damage your auditory organ).
Sensitivity to loud sounds.
Ear pain or drainage.
Dizziness or imbalance complaints.
History of falls.
Concern for falling.

Diagnostic hearing assessment

The second step to your evaluation would be a diagnostic hearing assessment. The audiologist will perform a series of test procedures such as:

Pure tone audiometry which is used to determine the type and severity of a hearing loss.

Speech audiometry which will identify if the effects of diabetes have affected your ability to discriminate speech at normal levels and in noisy environments.

Tympanometry which will identify if there are any abnormalities or infections within the middle ear.

Otoacoustic emissions is used to assess the hair cells (hearing cells) in the cochlear, which are commonly damaged in people living with diabetes.

Auditory brainstem which will identify if the effects of diabetes as caused to your auditory nerve or portions in the brainstem that process sound.

Balance evaluation enables the audiologist to look at the interaction of your vestibular (portion of the ear that controls balance), visual and somatosensory (sensors in your body that tell your brain where your body is in space) systems to identify if you have any abnormalities that may be causing balance difficulties or if you are at risk of falling.

Your audiologist may decide on any additional tests or alter the test battery according to his or her objectives.

After the hearing or balance evaluation, your audiologist will discuss the findings and develop an intervention plan tailored for your needs.

How often should I visit an audiologist?

Your audiologist will develop a personalised plan of care after the initial appointment. This plan is normally based on what the audiologist might have come across during your baseline hearing and balance assessment.

In an event where hearing loss or balance difficulty was identified, your audiologist might ask you to visit on a regular basis to start intervening.

In a scenario where your hearing or balance was found to be normal, studies recommend an annual or two-year interval visits to your audiologist to monitor your hearing and balance functioning.

Is there home-based hearing screening?

The following screening questions regarding perceived hearing difficulty may provide insight on hearing status and help inform the need for further evaluation. These questions are based on those used in the Guide for Pharmacy, Podiatry, Optometry, and Dentistry [PPOD] for Diabetes Management):

Do you or your family perceive any change in your hearing?
Do you have hearing difficulty in quiet or noise?
Do you feel unsteady when standing or walking?
Do you worry about falling?
Have fallen in past year?
Have you had your hearing tested in the past two years?
Do you know how diabetes can affect your hearing?
Do you know what to do if you perceive a change in hearing?
Do you know how to reduce your risk for hearing loss?

If you answer “Yes” to questions 1 through 4 or “No” to questions 3 through 6, it’s recommended you visit an audiologist for a diagnostic audiological and balance evaluation.

HearZA

Other home-based hearing screening methods includes the use of smart phone-based hearing screening applications such as HearZA hearing screening app:

Android: play.google.com
iOS: apps.apple.com

It’s however important to understand that this screening app may miss subtle forms of hearing loss, such as slight, mild losses or auditory processing difficulties. Hence, the screening app does not substitute a visit to an audiologist for a full diagnostic hearing assessment

To find an audiologist, click here.

References:

Adebola, S. O., Olamoyegun, M., Sogebi, O., Iwuala, S., Babarinde, J., & Oyelakin, A. (2016). Otologic and audiologic characteristics of type 2 diabetics in a tertiary health institution in Nigeria. Brazilian Journal Otorhinolaryngology, 82(5), 567-573. doi:dx.doi.org/10.1016/j.bjorl.2015.10.016.

Akinpelu, O., Mujica-Mota, M., & Daniel, S. (2014). Is type 2 diabetes mellitus associated with alterations in hearing? A systematic review and meta-analysis. Laryngoscope, 124, 767–776. Retrieved from https://doi.org/10.1002/lary.24354.

Arlinger, S. (2003). Negative consequences of uncorrected hearing loss – A review. International Journal of Audiology, 42(2), S17–2 S20.

Hlayisi, V., Petersen, L., & Ramma, L. (2018). High prevelance of disabling hearing loss in young to middle-aged adults with diabetes. International Journal of Diabetes in Developing Countries, 39(1), 148-153. doi:10.1007/s13410-018-0655-

MEET THE EXPERT

Sakhile Nkosi is an audiologist in clinical practice at a district hospital, South Africa. He obtained his undergraduate degree in Communication Pathology (Audiology) at University of Pretoria. He is chairing the South African state cohort at The Audiology Project (TAP), a project that aims to advocate for the inclusion of audiological services in the care of patients with diabetes. Sakhile is currently completing his master’s degree in Audiology at the University of KwaZulu-Natal. theaudiologyproject.com

MEET THE EXPERT

Kayla Van Rie is a research, clinical and training audiologist at Amtronix Diagnostics. She is passionate about her patient’s quality of life and a has a special interest in vestibular audiology. Kayla is currently completing her Master’s Degree in Audiology at the University of the Witwatersrand.

What is homeopathy?

Homeopathy is a holistic form of medicine. The word homoeopathy is derived from the Greek word homoios, meaning like, and pathos meaning suffering. In treating an illness, it takes into account the unique mental, emotional and physical characteristics of the patient.

Homeopathy is based on the principle of “likes cure likes.” That is, an illness should be treated by a substance capable of producing similar symptoms to those being suffered by the patient.

When the homeopathic remedy, made from the plant, mineral or animal kingdoms, that most closely matches the patient’s symptoms is prescribed, it will activate the body’s defence system and the body will start to heal itself.

Homeopathically prepared remedies are safe, non-toxic and can be administered during pregnancy and to new-born babies. The safety and efficacy has been proven by the worldwide support and interest of patients and health professionals and by research and clinical trials in related areas. Homeopathy is a system of medicine with which any medical condition has the potential to be treated.

Homeopathy is classified as complimentary medicine, meaning it can be used in conjunction with pharmaceuticals and homeopathy compliments it

A poor diet and lifestyle, stress, bad habits, environmental stressors e.g. pesticides, pollution, etc. will slow the healing process as the body may not be able to function optimally. These factors are taken into consideration and are addressed during a consultation with a homeopath. This implies that the patient needs to take responsibility and be actively involved in the healing process by adopting a healthy, balanced lifestyle.

Diabetes treatment

The goals of diabetes treatment are to control blood glucose levels, eliminate symptoms and to prevent, or at least, slow the development of diabetic complications.

Once a homeopath has got a full case history and a physical examination has been done, blood tests may be required. Depending on these findings, a homeopath may advise that a particular diet, or way of eating is followed. This may include eliminating refined carbohydrates (white bread, pasta, potatoes), sugar, fried foods and alcohol from the diet as well as increasing consumption of vegetables and some fruits, and increasing fibre-rich foods, such as wholegrains and pulses. A homeopath may also advise lifestyle modifications, such as increasing activity levels and stress reduction, etc.

Homeopathic diabetes medications

In combination with dietary and lifestyle interventions, some medications may be prescribed. Medicines may include either a single homeopathic remedy e.g. Syzygium jambolanum, Helonias dioica, Iodum; herbal medicines, such as Berberine, Bitter melon; or nutraceuticals (these are combinations of herbals, vitamins, minerals, amino acids and/or glandular extracts), all in aid of lowering and/or controlling blood glucose levels and diabetic complications.

Each approach has its own scope and limitations and therefore a homeopath has to make a decision as to which approach is best for the particular patient. This largely depends on the patient’s general health, complications and organs/systems affected, age, and duration of illness.

Working together

A homeopath will generally refer diabetes patients to a GP or endocrinologist if we can’t get the blood glucose levels under control. Often patients consult with both a GP/endocrinologist and a homeopath and we can both manage the cases.

Type 1 diabetes is impossible to treat without insulin, but homeopaths can advise in terms of diet and assist in improving general health, but not solely treating diabetes. Type 2 diabetes patients can use homeopathy, but again if blood glucose levels are out of control, they may use a combination of homeopathy and pharmaceutical meds.

Dr Jessica Leske is a registered homeopathy and iridologist.

MEET THE EXPERT

Dr Jessica Leske is a registered homeopath and iridologist. She is a member of the Homeopathic Association of South Africa (HSA) (2010), Registered Allied Health Professions Council of South Africa (AHPCSA) and Board of Healthcare Funders of South Africa (BHF) (2016).

Header image by FreePik

Diabetes nurse educator, Kate Bristow, weighs out the pros and cons of insulin pump therapy for Type 2 diabetes.

Sometimes people with Type 2 diabetes need to take insulin and there are two ways of doing this: injecting it or using insulin pump therapy. A pump can be used if you are doing multiple injections a day.

What is an insulin pump?

It’s a computerised device which releases insulin in a similar way to how your pancreas would do it. So, between meals or at night a small dose of insulin is constantly delivered to keep your blood glucose level as close to target as possible. This is called a basal insulin.

For mealtimes, the pump can be programmed to give a bolus dose. This dose is adjustable much like a dose of mealtime insulin would be, so a bigger dose of insulin could be given for a larger meal.

Some pumps available in South Africa come with continuous glucose monitoring (CGM). In other words, you wear a sensor which reads your blood glucose levels so you can always see on the pump where your levels are sitting.

Some pumps are even clever enough to make small insulin adjustments according to these readings and they can also help you calculate your mealtime dose if you’re able to count your carbs.

Advantages of insulin pump therapy for Type 2 diabetes patients

If you have CGM, fewer needle sticks for testing or injections.

A pump needs a set change every three days. Sensor change times vary according to the make of sensor/pump.

Effectively managed, a pump can help you improve your blood glucose levels, including HbA1c levels. and your diabetes.
A pump can help to prevent or reduce lows (hypoglycaemia).
If you like to exercise, it can help you manage your levels more accurately during exercise.
It’s so simple to give a bolus dose.
Basal doses can be adjusted according to the trends in your blood glucose levels. So, you can have different doses for all 24 hours of the day if needed. These are set with your diabetes care team.

Challenges that come with wearing insulin pump therapy

If you don’t have a pump with CGM then it’s vital to check your glucose levels at least four times a day, sometimes more often.
You need to always carry an insulin pen for both basal and bolus insulin in event of the rare case of a pump failure.
You need to enter information regularly into the pump and change the infusion set every three days.
It requires commitment and effort to learn how to use a pump, including checking your blood glucose regularly.
Pumps are expensive and the supplies comes at additional costs. Many medical aids will only partially reimburse costs if at all.

A pump is not the right choice if you:

Are not comfortable wearing a pump or having people know you have diabetes.
Don’t want to be attached to a device on a permanent basis.
Are not comfortable with technology or operating the pump.
Don’t want to test your glucose regularly – at least four times a day. Obviously, testing your glucose is important in managing your diabetes with or without a pump.

Insulin pump therapy is a good choice for anyone who wants to manage their diabetes well but it’s not for everybody. Your choice of device must be carefully made and is personal to you and your own needs.

Funding is an important issue to consider and you need to be willing to put in the pre-pump therapy work to learn how to best manage your diabetes with pump therapy. This includes insulin dosing, carb counting, and dietary and exercise management. Your healthcare team will support and guide you if you make a choice to pursue pump therapy.

MEET THE EXPERT

Sister Kate Bristow is a qualified nursing sister and certified diabetes educator. She currently runs a Centre for Diabetes from rooms in Pietermaritzburg, providing the network support required for the patients who are members on the diabetes management programme. She also helps patients who are not affiliated to a diabetes management programme on a private individual consultation basis, providing on-going assistance and education to assist them with their self-management of their diabetes.

Explaining reflexology

Therapeutic reflexology is defined as an art (because the quality of the treatment depends on how skilfully the therapist applies their knowledge) and a science (because it’s based on continued training and study within various fields, such as traditional Chinese medicine, physiology and neurology).

The underlying theory behind therapeutic reflexology is that there are “reflex” areas and points on the feet, hands and ears that correspond to specific organs, glands, and body parts. The aim of reflexology is to help the body find balance and equilibrium and stimulate its innate healing potential.

Reflexologists use hand, finger, and thumb pressure techniques to systematically stimulate these reflex areas. Levels of pressure must always be within the comfort level for each patient undergoing treatment.

These pressure techniques stimulate the central nervous system (CNS) and cause the body to provide endorphins from the brain which naturally bring down stress levels and reduce the sensation of pain.

How reflexology may assist people living with diabetes?

Reflexology may help people living with diabetes in controlling insulin, blood glucose and energy levels by stimulating the bio-electrical charges from the nervous system to the important organs that are involved therein. These include the stomach, pancreas, and liver, as well as the hormonal glands. The benefits of reflexology are innumerable and periodic detoxing is vital if our bodies are to function properly.

People living with diabetes should inform their treating doctor before commencing regular reflexology treatment as the treatment may affect dosage of current medication. The medication may need to be altered accordingly. The same applies with patients with pacemakers or on blood pressure medication.

Peripheral neuropathy

Below are signs and symptoms of peripheral tissue ailments, such as peripheral neuropathy, which is a common side effect of diabetes.

Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms.
Sharp, jabbing, throbbing, freezing or burning pain, and/or electrical sensations.
Extreme sensitivity to touch.
Lack of coordination and falling.
Muscle weakness or paralysis if motor nerves are affected.
Heat intolerance and altered sweating if autonomic nerves are affected.

Peripheral neuropathy can affect one nerve (mononeuropathy), two or more nerves in different areas (multiple mononeuropathy) or many nerves (polyneuropathy).

What can reflexology be used for?

Therapeutic reflexology may offer good overall support for a person suffering pain associated with peripheral neuropathy as well as chronic foot conditions that is a side effect from diabetes. These can be:

Arthritis (in the toes, ankles, knees and other joints).
Severe cramping, restless leg syndrome.
Hard skin build-up, such as corns and calluses.
Severely cracked, dry, or flaking skin on the soles of the feet, heels, and toes.
Fungal nails.
Eczema, skin rashes, or other inflammatory skin conditions (especially on the shins).
Varicose veins.

Benefits of reflexology

This form of complementary therapy is found to be positively beneficial in caring for other tissues located peripherally in the feet, not only the nerve endings. Namely the skin, nails, muscles, tendons, ligaments and bones.

This is thanks primarily to the enhanced blood flow from regular therapeutic massage of the feet. Reflexology techniques help to ensure relatively richer supplies of oxygen, electrolytes, and nutrients to reach cells found in the extremities of the body more efficiently.

In particular, these nutrients include magnesium, vitamin D and some of the B vitamins, moisturising lipid fats, and other building blocks, needed specially for the nerves and general tissue health.

The goal of treatment is also to aid related organ and hormonal systems, in regulating essential minerals, such as calcium, usage and distribution in the body, as well as balancing the body’s use of electrolytes.

Another benefit when receiving regular treatments is that one can be made more aware of any new loss of feeling or extra sensitivity that may not have been noticed before. It’s always good to have an ‘extra pair of eyes and hands’ monitoring the feet.

Therapeutic reflexology is holistically aimed at treating the autonomic nervous system whose job it is to oversee these kinds of physiological functions. Regular sessions can also support in helping to clear the feet more readily of waste products, heavy metals, lactic acid build-up and calcium deposits derived from high acidity and problems with glucose metabolism that usually occur in people living with Type 2 diabetes.

What to expect during a reflexology session?

During the session, usually lasting 30-60 minutes in duration, the patient may experience sensitivity in certain reflex areas, which may vary from treatment to treatment. The therapeutic reflexologist usually completes the treatment by using gentle massage techniques which will leave the patient relaxed and soothed, thus enhancing the body’s capacity to utilise its natural healing potential. The therapist will devise a treatment plan and recommendations based on each individual patient.

Safety and side effects

Generally, reflexology appears to be safe and does not cause serious side effects. Because most people feel relaxed after a treatment you might feel a bit light-headed. Some people say their feet feel more tender afterwards. Others can have an emotional response or need to pass urine more often.

Tell your reflexologist about any after-effects that you have. Reflexology cannot be used as a primary procedure intended for the diagnosis or treatment of any medical condition or disease.

Ask your doctor

Reflexology isn’t contra-indicated for any condition, although caution is to be taken if you have any of the below conditions. So, check with your doctor before.

A low platelet count, which means you may bruise or bleed more easily.
Tumours and metastases.
Deep vein thrombosis
Broken/fractured bones (in the feet or ankles)
Circulatory problems of the feet
Inflammation or blood clots in the leg veins
Gout
Foot ulcers
Fungal conditions of the feet, such as Athlete’s foot.
Thyroid problems
Epilepsy
Type 2 diabetes

To find a registered therapeutic reflexologist, visit sareflexology.org.za

MEET THE EXPERT

Registered therapeutic reflexologist, Nicolette Da Costa-Schmidt (Nici Schmidt), has a passion for her field of Therapeutic Reflexology and Meridian Therapy. She has been in practice for 15 years and is based in the East Rand, Gauteng. Visit healthspots.co.za.

As we celebrate the centenary of insulin therapy, Dr Angela Murphy reflects on what a change it has made in the management of diabetes. It’s a life-saving medication.

Present day

How does insulin work?

Insulins available in SA

BASAL INSULIN

TWICE DAILY PRE-MIX INSULIN

Insulin diary log

BASAL BOLUS INSULIN

CALCULATION OF A BOLUS INSULIN DOSE

Constant communication with doctor

HbA1c readings

Getting the best response from insulin therapy

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Dr Louise Johnson gives us a breakdown of the insulin pump therapy available in South Africa.

Continuous subcutaneous insulin infusion

How is insulin delivered?

Advantages

Type 1 ideal candidate

Indications for insulin pump therapy

Types of pumps in South Africa

Understanding hybrid close loop pump systems

Disadvantages

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Many people living with diabetes are not aware of the importance of audiology and how diabetes may affect their hearing and balance system. Sakhile Nkosi and Kayla Van Rie tell us more in a Q&A.

Q&A

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Why should I visit an audiologist as a person living with diabetes?

Signs of hearing and balance deterioration

How can I prevent having a hearing and balance impairment?

How will an audiologist quantify hearing and balance problems in a context of diabetes?

Diagnostic hearing assessment

How often should I visit an audiologist?

Is there home-based hearing screening?

HearZA

References:

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What is homeopathy?

Diabetes treatment

Homeopathic diabetes medications

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What is an insulin pump?

Advantages of insulin pump therapy for Type 2 diabetes patients

Challenges that come with wearing insulin pump therapy

A pump is not the right choice if you:

MEET THE EXPERT

Nici Schmidt educates us on how therapeutic reflexology treatment may help peripheral neuropathy and general tissue health for people living with diabetes.

Explaining reflexology

How reflexology may assist people living with diabetes?

Peripheral neuropathy

What can reflexology be used for?

Benefits of reflexology

What to expect during a reflexology session?

Safety and side effects

Ask your doctor

To find a registered therapeutic reflexologist, visit sareflexology.org.za

MEET THE EXPERT