Albany boiled egg sriracha mayonnaise sarmie

INGREDIENTS

  • 2 slices Albany Low GI Wholewheat Bread
  • ¼ Small Avo (30g)
  • 2 Large boiled eggs (100g)
  • 10ml sriracha
  • 15ml mayonnaise
  • 45ml Low Fat Plain Yoghurt
  • Juice of ½ a Fresh Lemon
  • 15g Parsley
  • Black pepper
  • Handful of fresh rocket leaves (25g)

METHOD

  1. Spread mashed avo on both slices of bread
  2. Chop one boiled egg (keeping the other aside for the sarmie), stir together with the sriracha, yogurt, lemon juice, parsley and mayonnaise, season with black pepper
  3. Slice the remaining egg in quarters, place the quarters of boiled egg on the mashed avo
  4. Then fill with the sriracha egg mayo mix and scatter with fresh rocket leaves
  5. Top with the remaining slice of bread spread with mashed avo.

Nutritional Information for the recipe (per serving):

Energy (kJ) Protein (g) Carbohydrates (g) Added Sugars (g) Dietary Fibre (g)
2440 26.6 47.7 0.9 9.5
Total Fat (g) Saturated Fat (g) Monounsaturated Fat (g) Polyunsaturated Fat (g) Sodium (mg)
30 7.5 11.5 8.4 814

When losing is winning – Tash Minto

Natasha Minto, who does not have diabetes, openly speaks about her struggle with her weight, weighing 155kg at the age of 23, and how she came to lose 70kg and how her weight loss has positively affected her relationship.


Natasha Minto (30), better known as Tash, originally comes from Boksburg, South Africa but moved to Hampshire, England in 2012. She lives with her partner of six and half years, Tony Waterhouse (35).

I didn’t feel like I had to lose weight for Tony but it was because he loved me at my worst that I felt he deserved me at my best.”

When did you start battling with your weight?

I started getting a bit chubbier than my friends in my last year of primary school. I was always a bit bigger than most of the people I knew. Though, it really escalated when I finished school. When I was younger, my grandad would spend the afternoons with us and treated us to sweets. I think I associated this with feeling safe.

As a child, I was was the fussiest eater. I never ate cooked vegetables, onion, and no food could touch on my plate and don’t even think of giving me a salad.

Unfortunately, I made my parents life very difficult and since we had a lot of other stuff going on at home, my mom let it slide most of the time. I was so fussy that I would eat crisps and slap chips but not roast potatoes or jacket potatoes. This also applied to fruit. I never used to eat mango or kiwi fruit.

Only at the age of 23, did I stop picking onions out of my food. I also now eat tomatoes because I enjoy them rather than I must.

Did your weight bother you? If so, how did you deal with it?

My weight bothered me more and more as I got older. Older kids would pick on me and then when I went to high school, other people would too.

I always had a good group of friends, though, who made me feel welcome and comfortable. So, for the most part it was never a constant thing. Only on occasion. Shopping for clothes, especially for parties, was tough.

Sometimes if my friends and I went out for the night, my friends would get attention from boys and get asked out. But, I very rarely did and this is when it hurt the most. I knew and still maintain that people (guys) wouldn’t give me the time of day because I wasn’t slim and pretty. It was a harsh lesson to learn but made me tougher.

I learnt very early on that if I wasn’t going to be the prettiest, I had to be the funniest or the nicest, or something else for people to like me. So, I worked very hard on that.

I did try dieting and have possibly done every single diet you can think of. Banting, high-carb, low-carb, cabbage soup, popcorn diet, Gummy Berry juice, juicing, shakes only, fruit only, meat only, appetite suppressants, hypnosis. Everything!

This unfortunately has resulted in disordered eating on my part and my relationship with food is still quite damaged. I work on it every day.

What was your heaviest?

I weighed in at 155kg when I was about 23 years old. I tried to avoid the scales when I could.

When did your weight loss journey start and why?

In 2012 my father passed away suddenly three days before Christmas. Then the following year, I developed alopecia (hair loss) and was diagnosed with an autoimmune disease, Hashimoto’s and hypothyroidism (thyroid gland doesn’t produce enough thyroid hormone). The Hashimoto’s was the cause of the alopecia and hypothyroidism.

This was a real wake up call for me and after losing my dad, it really hit home how important it was to stay healthy and for weight loss.

I started really trying in November 2014. Tony and I used to eat out a lot and we were very much in the honeymoon phases of our relationship so we didn’t really try to be healthy. This is when the light came on. Something was working and for the very first time in a long time, I stuck with it. When the weight came off, it was easier to be active and I had more energy so I enjoyed it for the first time ever.

Plus, Tony is a vegetarian so I started exploring vegetables for the first time and my pallet started to change. I enjoy broccoli now!

When did you meet Tony?

We met in 2013. I had just come back from my dad’s funeral in South Africa and was vulnerable. My friend said I should try online dating. By this point, I was probably about 135kg so felt a lot better about myself and gave it a go.

After six months of going on a few unsuccessful dates, I decided to cancel my account. The day I went on to do so, I saw a message from Tony. We got talking and chatted for about four weeks before we met in person and have been together ever since.

Was your weight an insecurity in your relationship with Tony?

My weight was and probably always will be an insecurity of mine. Though, Tony has a way of making me feel like nothing in the world matters other than us. He has never treated me any differently and never even commented on my weight until one day I did.

We did lots of activities and he never once said, “We can’t do this because of your weight or we can’t do that.” And so, we did so much more than I have ever done and this was a huge eye opener.

Tony’s family also treated me like gold. They made me feel very welcome and it was comfortable to talk openly about my feelings with them.

I didn’t feel like I had to lose weight for Tony but it was because he loved me at my worst that I felt he deserved me at my best.

How much do you weigh now?

Since my heaviest of 155kg, I have lost 70kg and now weigh somewhere between 85/90kg depending on the day.

What does your exercise regime consist of?

I developed a real love for exercise and it’s constantly changing. As it stands now, I run three times per week (about 5km), go to Bootcamp three times per week and sometimes add in a boxing class or fit club of some sort.

I tend to have one or two days off a week but even then, I make sure to walk every single day and try to at least hit 10k steps.

Outside of this, Tony and I try to be as active as possible. We go hiking, do outdoors sports, water sports, etc. and I really enjoy it.

What does your diet entail?

Again it depends on the day and I don’t proclaim to be a saint. But, for the most part I stick to a low carbohydrate diet. Very little bread, rice, pasta and potatoes. Low sugar where I can and moderate fat/protein.

For the most part, my weight came off when I reduced my calorie intake. It’s that simple and honestly, I feel the only sustainable way to lose weight is eat less and move more.

I have completely curbed my crisp addiction and went from having a packet a day to almost one per year. Though, I still enjoy chocolate but try to keep it low sugar where I can, and I will almost always have a piece of cake on someone’s birthday.

I really try to live an 80/20 balanced lifestyle so that it doesn’t feel like such hard work.

Have you reach your goal weight?

I haven’t really got a goal. This is very much my life now so if weight loss is a by-product then great but I will keep going regardless. I have always had 80kg in my head as a goal number but as long as I am active and healthy I am happy. I’m trying not to get hung up on a number.

How has your confidence changed?

I’ve always been a fairly confident person, as I explained before. I’ve never battled for friends or jobs, etc. but being able to shop for clothes in normal shops (my mom used to have to make clothes for me at my biggest) and being able to take part in so many adventure activities has completely changed my outlook on life. I have so much to live for.

With extreme weight loss comes the battle of the excess skin. Do you have plans to get it removed?

I have no immediate plans but it’s on the wish list. It’s very heavy and weighs me down and pulls a lot when I exercise. So, I must wear compression gear to stop it from hurting.

Does the excess skin interfere with intimacy with Tony?

The excess skin is a constant battle. I will be honest as it has moments of affecting our intimate moments. But, I am quickly reminded to be proud of my hard work and to enjoy my new body, thanks to the weight loss, as I never would have before.

Tony loved me when I was much bigger and has never been bothered by it. So, why should I be? He truly does love me for what is inside and for that I can’t dare to bring myself down when all he does is lift me up.

If I had the money I would have it removed tomorrow but until then I make peace and enjoy this new lease on life. I won’t let my old body hold me back any longer. How can I let excess skin hold me back when I’ve come so far?

How do you feel being 70kg lighter?

I feel like for the first time in my life, the inside matches the outside. For so long I felt trapped inside a body that didn’t belong to me. Like I was a prisoner. But now, I have a freedom and a future I could only once imagine.

I wouldn’t say I feel sexy but there are moments when I am so proud that I could burst. It’s not always like that and I often must remind myself of how far I’ve come.

I think as women, we naturally will always find something wrong but for the most part I feel like I am the prettiest, healthiest and definitely happiest I’ve ever been.

We chat to Tony

When you first met Tash, what attracted you to her?

We initially met online so it was mostly her personality. She only had a couple of pictures to view. While I was attracted to her physically, I needed a lot more than that to be truly interested in her and didn’t trust online pictures completely.

When we got chatting, we found that we both had a love of music, travel and shared a real interest in different cultures. It was really easy conversation between us that flowed well with just the right amount of laughter. It was only when we first met face to face that I knew I was physically attracted to her.

Did her weight ever bother you and did you want her to lose weight?

I certainly didn’t need her to lose weight. But, I was aware that she wasn’t happy with her size. Wanting her to feel good about herself led me to want her to lose weight.

I was never bothered about her size but did notice her getting a bit out of breath when we would go on walks and stuff, although this never stopped her.

How has Tash changed since she her weight loss?

Tash has found a real love of exercise, which wasn’t apparent at all in the first couple of years together.

She has also started eating a much wider variety of foods but I’m not sure that’s due to the weight loss. Could just be changing taste buds through time.

She has also started to experiment with fashion and is getting more confident wearing brighter colours.

How do you motivate her?

I don’t need to motivate her much as she has great personal motivation. On the odd occasion when she has a down day or a moment where her confidence isn’t great, we might have a little conversation about being proud of what she has achieved and how far she has come with her weight loss.   

I believe there is diabetes in your family. Please explain.

My Nan had Type 2 diabetes in her eighties, and my uncle and father have been diagnosed in the last couple of years with Type 2. So, I’m very aware that I may be genetically prone to the disease, albeit later in life.

We have a rule in our house that anything with over a 10% sugar content we avoid but that doesn’t always stick. A bar of chocolate or a couple of beers isn’t uncommon once a week. 

With Tash’s weigh loss, did you ever get insecure?

No, I don’t mind other men looking or chatting with Tash because I’m confident in our relationship and trust her completely. It makes me happy that she feels more confident in herself. I would never want her to be miserable just because I was insecure. 

Have you ever battled with your weight or health?

I’ve been lucky that I have never had weight or health issues. Although, I did consider myself too skinny in my early 20s. As I get into my late 30s though I’m more aware of healthy eating and keeping fit.

MEET OUR EDITOR


Laurelle Williams is the Editor at Word for Word Media. She graduated from AFDA with a Bachelor of Arts Honours degree in Live Performance. She has a love for storytelling and sharing emotions through the power of words. Her aim is to educate, encourage and most of all show there is always hope. Feel free to email Laurelle on editor@diabetesfocus.co.za


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A toast to bread and all its benefits

Dietitian, Nicola Walters, tells us all the good things about bread and why we should eat it.


Bread is a staple food that has been around for more than 10 000 years. It’s delicious, convenient, and satisfying, sure, but what if I told you it was healthy too?

With advancements in recipe development, the composition of bread has been perfected over many years. What has evolved has created a selection of bread choices that, when eaten as part of a healthy, balanced diet, can add valuable nutrition elements.

A loaf affair

When choosing the perfect bread to suit your needs, look for the nutrition information label and be sure to size up the competition. Not all breads are created equal.

If it’s weight management and weight loss you desire, focus on the overall kilojoule value of the bread.

To lose weight, daily energy intake (measured in kilojoules) from food and fluids should be less than total energy expenditure (energy spent on daily activities, exercise and normal body functions).

A lower total kilojoule content per slice means a lower contribution to total daily energy which means more wiggle room for calorie deficits.

But that’s not all that matters; the quality of the kilojoules is equally important. Quality kilojoules come from foods that offer additional nutrition related benefits over and above the energy they provide.

Fibre is one such nutrition factor that offers huge health benefits, such as controlled blood glucose levels for sustained energy. Fibre also improves gut health; keeping the tummy bloat-free and regular.

Any bread that has more than 6g of fibre per 100 g serving is considered high in fibre and will increase daily fibre intakes and boost health. Well, isn’t that the best thing since sliced bread?

Low GI options

Sustained energy you say, but do we still have your attention? For this, it might be worthwhile to focus on low GI bread options. No, this isn’t a new Wi-Fi speed to rival 5G; the glycaemic index (GI) is referred to as the GI.

The GI of a food indicates how quickly that particular food (normally a food that contains carbohydrates) will raise the amount of glucose in the bloodstream.

A croissant for example, will be considered a high GI food because it increases blood glucose levels as fast as lightening, after being eaten.

A slice of low GI, high-fibre bread on the other hand, is considered a low GI food because it steadily releases glucose into the bloodstream, over a period. This means no more concentration rollercoasters and more stable energy cycles throughout the day.

If it’s health you’re after, you can have your high-fibre, wholegrain bread and eat it too. But when you do, remember the whole truth: no one food or diet can be “best” for health. The true effect of bread, like any other food eaten, must be considered in the context of the diet as a whole.

MEET OUR EXPERT


Nicola Walters is a registered dietitian and has workedas an associate Dietitian at Nutritional Solutions in Johannesburg since 2013. Nicola is an accredited DNAlysis practitioner and enjoys optimising her patient’s health outcomes through the individualised interpretation of genetic results.


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Using diabetes guidelines: the right medicine for the right person

Dr Angela Murphy helps us understand the recent changes in the guidelines for treating diabetes.


The purpose of treating diabetes is to improve the symptoms which result from high glucose levels and to prevent other complications in the future. Diabetes is a risk for heart disease, stroke, kidney failure, amputations and loss of vision. In fact, heart disease is the most common complication of diabetes, encompassing angina, heart attack and heart failure.

With good control, these conditions can be avoided. Achieving good control is the challenge for both patient and healthcare provider (HCP). We must never under estimate the benefit of a healthy lifestyle and this is always the building block in any treatment algorithm.

Controlled portions, choice of unrefined carbohydrates and good fats, as well as regular exercise are essential to have a holistic approach to managing diabetes.

When insulin was first discovered in 1922, it seemed the only feasible treatment for diabetes. It remains the cornerstone of treatment for Type 1 diabetes to this day. Although, there have been advances in types of insulin and ways to deliver it.

The initiation of treatment for Type 2 diabetes is generally straightforward in that most patients will be counselled regarding a healthy lifestyle and given metformin. Metformin reduces levels of blood glucose by decreasing the amount of glucose produced by the liver. It also improves the action of insulin, secreted by the pancreas, at the level of the muscle cell.

Many people, particularly those eating and exercising correctly, may control their blood glucose levels on metformin indefinitely. However, if the glucose levels and HbA1c start to rise, further treatment will need to be added.

At this point, the choice of medication becomes quite extensive. The critical question the HCP must now ask is: what is the right medication for the patient in front of me?

What is the right medication for the patient?

There are eight groups of diabetic medications with various types within each group. This means that the possible combinations of drug types and dosages can count into the hundreds. HCPs have for many years looked to clinical practice guidelines to assist in their choice.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) are sentinel voices in the world of diabetes. Many experts over many years have come together to work out diabetes management guidelines.

Most countries, including South Africa, will consult the content of these guidelines when drawing up local recommendations. In recent years, the experts from ADA and EASD have come together on several occasions to issue a Combined Consensus Statement on the management of Type 2 diabetes. The latest one, published at the end of 2018, suggested some basic changes to our approach of diabetes management.

2018 guidelines

The reason for the new guidelines is that it recognises the excess risk of cardiovascular disease in diabetic patients and takes into consideration the evolution of diabetes drugs, particularly with the advent of the sodium-glucose transport protein 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists.

SGLT2 inhibitors

SGLT2 inhibitors (Forxiga; Jardiance), also known as the gliflozins, act by blocking the re-uptake of glucose that has been filtered through the kidney. This results in excess glucose being excreted in the urine. The advantage of this glucose loss from the body is that this translates into a calorie loss as well which helps with some weight loss in the patient.

As the name of the medication suggests, not only excess glucose but sodium is excreted. The lowering of sodium helps reduce blood pressure and has beneficial effects on the heart.

Jardiance is registered in America for the indication of cardiovascular death reduction in the patient with Type 2 diabetes and previous cardiovascular disease (angina, heart attack, need for stents).

Forxiga has recently been shown to improve heart function in patients with heart failure; in both diabetic and non-diabetic subjects.

GLP-1 receptor agonists

GLP-1 (Byetta; Victoza) is a hormone secreted by the cells in the wall of the small intestine in response to food. The GLP-1 then stimulates the pancreas to secrete insulin and, thus, lowers post-meal glucose levels. The GPL-1 receptor agonist drugs also delay the emptying of the stomach and increase the sense of fullness which results in weight loss.

In addition, Victoza has proven to reduce the risk of a heart attack, stroke or death from these causes in Type 2 diabetic patients who have already had an event. The Federal Drug Agency (FDA) in America have added this benefit to the indications for the use of Victoza.

Cardiac protection changes how Type 2 diabetes patients are managed

The incredible cardiac protection these new medications offer in addition to diabetes control is so important that it has initiated a change in how we mange Type 2 diabetes.

It is crucial that HCPs identify the patients who would benefit from these medications as soon as possible. For this reason, the 2018 guidelines now advise that after initiation of metformin, patients should be divided into two groups.

The first group is those patients with atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD); i.e. patients who have already suffered from a heart attack or angina, had coronary stents, a stroke or have chronic decrease in kidney function.

The second big group is the patients who have not had heart or kidney disease to date. The latter group then gets subdivided into three main groups aiming for treatment that addresses a patient’s most pressing concern.

The groups identify those patients struggling with hypoglycaemia (low blood glucose), obesity, and those patients who need to keep costs of treatment down.

It makes sense that those patients with established ASCVD and CKD be given one of the classes of medication which have been proven to protect the heart from further events or a deterioration in heart function. As one would expect with a ‘designer drug’, the cost is significant and reimbursement from medical aids is not guaranteed.

SGLT2 inhibitors and GLP-1 receptor agonists do not cause hypoglycaemia. So, they would be possible choices in patients who need to avoid hypoglycaemia.

Dipeptidyl peptidase-4 inhibitors

Another group of medications, called dipeptidyl peptidase-4 inhibitors, also increase the natural GLP-1 levels and do not cause hypoglycaemia. The class of drugs most effective with weight loss is the GLP-1 receptor agonists, especially Victoza. However, much higher doses need to be used for weight loss management than just for diabetes management. A higher dose pushes up the cost.

South African setting

In South Africa, where most of the diabetes patients receive healthcare from the state and, in the current climate of escalating costs in the private healthcare system, cost effective medicine is essential.

The oldest group of oral medications used in Type 2 diabetes are the sulphonylureas (SUs) which increase insulin secretion from the pancreas.

The South African diabetes guidelines, drawn up by Society of Endocrinology and Metabolism of South Africa (SEMDSA), advocate the use of the newer generation SUs, such as gliclazide MR (Diamicron MR, Diaglucide MR and other generic formulations), as acceptable second-line treatment for Type 2 diabetes.

More than two million South Africans are living with diabetes. To improve their present and future health aiming for good glucose control is important. However, with increasing types of medication available to manage Type 2 diabetes, choosing the right drug for the right patient is becoming ever more important.

The newer agents have made it possible to improve long-term complications from the outset, by mechanisms other than just glucose lowering. It may not be necessary, or possible, for everyone to access these medications at present but the guidelines from both local and international societies will continue to guide the diabetes community to make the correct choice.

MEET OUR 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.


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DSA News Summer 2019

DSA Port Elizabeth news

Diabetes Awareness in Happy Valley, Port Elizabeth on 30 September 2019


Martin and Elizabeth Prinsloo were invited to attend  a gathering of more than 100 senior citizens who were treated by the South African National Zakah Fund to an outing in our beautiful Happy Valley to enjoy the fresh air and the beauty of nature and, at the same, be encouraged and informed about living a healthy and happy lifestyle. Many of those who attended either had diabetes or had a friend or family member with diabetes. Some refreshing Spring showers greeted us early the morning, but the sun soon appeared to brighten the day. Soraya Boomgaard, a fitness coach, who is associated with our Springdale Diabetes Wellness Group demonstrated easy exercises everyone can do and then invited the more active people present to join her on the lawns for some fun exercises.

People listening to the talk about Diabetes.
Some of the people there.
Soraya Boomgaard leading the fun exercises.
The DSA and the SANZF banners.

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Life after a heart attack – Vaughan Wood

Vaughan Wood, who has Type 2 diabetes, tells us how he survived a heart attack and about his recovery process.


Vaughan Wood (55) lives in Port Elizabeth with his wife, Gail, and their son, Cameron.

Watching my mom suffer with Type 1

My mother passed on at the age of 67, in 2003. She was diagnosed at the age of 16 with Type 1 diabetes and used Humalog insulin.

She first lost a toe with gangrene, then a foot, the first leg, and then the second leg was also amputated.

As a young child growing up, I often came to her rescue with glucose tea when she had a hypo. Sometimes it was quite difficult as she would clench her teeth refusing help, saying that she was fine.

With her last amputation, she was too weak for general anaesthetic. She had some sort of epidural type of anaesthetic, and she said she could hear the instrument of the surgeon as it cut the bone of the leg.

My diagnosis

I was diagnosed with Type 2 diabetes, at the age of 52, after struggling for energy at the rear of a mountain bike race.

The doctor sent away the blood sample for an average test. Later, he prescribed metformin and Diaglucide, including a complimentary diet sheet to follow.

My wife and I run a small care home and approximately one quarter of our residents are on diabetic medication.

I considered my diet to be relatively conservative. However, I had been known to polish off more than one cake at one sitting. Comfort food was my thing.

I managed to control the obvious process, and sweet products, with my glucose levels being mostly in the correct ranges with the new medication.

I decided to enter the Karoo to Coast Mountain Bike Race, which I last rode in 2004.

Heart attack

One night, on the 17th April 2019, my breathing was a little strange. With the weather becoming colder in the evenings, I presumed it was the result of a virus.

As a precaution, I missed an evening ride, not realising that I would be rushing to hospital with a heart attack later that night.

Dizziness, shortness of breath, and a panic attack off the scale. I made the emergency room in survival mode, not even checking in, just making my way to the nearest bed.

I was handled very well. Although in my mind, I wondered why they were taking so long, and why the nurse was so insistent on drilling me on whether I had taken any Viagra.

Later I found out that Viagra does not mix well with the medication they were to give me, before placing me in cardiac care. LuckiIy, I responded well and the next morning I received two stents, one of which, even the cardiologist seemed excited about.

Recovery

Heart medication was added to my list of medications, and all was going well until the panic attacks started. The first one, in my mind, was another heart attack. I would easily have passed a lie detector as this was so real.

The heart was like a tree, I was told, and the roots would have to feed it, till the affected part recovered. No strenuous activity for seven weeks until my treadmill test. At first, just walking from shop to shop was tiring enough.

After a couple of weeks, I started short walks, progressing a few hundred meters every time. Eight weeks after saw my first short cycle. I was given the go ahead to exercise after the cardio test which was hugely uplifting.

Best advice

I was advised to smell the roses by someone who had a similar experience.

There are two other bits of advice that stick out for me. The first from our regular dietitian at the diabetic support group I attend, was to make one change at a time.

The second was from a Canadian doctor. He told me that our taste buds can change with time.

Not only am I making positive changes, but I am starting to enjoy making better choices with food.

I am not sure what has made diabetes the epidemic it is today. However, I know that we have more information at our disposal than my mom had in her day to deal with it, and live a good life.

I decided to walk a trail instead of riding this year. While walking I saw a Knysna Loerie in beautiful natural surroundings. That is me smelling the roses.

When I am ready, I will collect my number for the next ride, in my own time.

Vaughan's wife, Gail.
Vaughan and his son Cameron.

MEET OUR EDITOR


Laurelle Williams is the Editor at Word for Word Media. She graduated from AFDA with a Bachelor of Arts Honours degree in Live Performance. She has a love for storytelling and sharing emotions through the power of words. Her aim is to educate, encourage and most of all show there is always hope. Feel free to email Laurelle on editor@diabetesfocus.co.za


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Healthy Type 2 diabetes summer eating

While welcoming in the warmer weather and Diabetes Awareness Month, it’s a perfect opportunity to re-look at your eating. Are you warming up to good health?


Food and eating means so many different things to each of us. We are influenced by culture, access to foods, emotion, knowledge and personal preferences. There certainly isn’t one ‘diabetic diet’ that will suit everyone.

A person living with Type 2 diabetes does not need to eat any differently (in terms of types of foods) from the rest of the family. Everyone should be eating as you eat.

Enjoy a variety of foods

Variety is the spice of life and enjoying a variety of foods ensures you are getting all the nutrients your body needs. You can enjoy foods that are easily accessible and affordable.

Be creative and experiment with different colours and different preparation methods (boiling, steaming, baking, grilling, and braaing).

Guidelines for healthy eating in diabetes suggest that there is no special need for products marketed as Suitable for diabetics. Some of these, although low in sugar, may still be high/higher in carbohydrates, energy, and/or fat than their non-diabetic alternatives.

Make starchy foods part of most meals

Aim, as the ideal, to select wholegrain carbohydrates (e.g. barley, rolled oats, quinoa, seed/rye breads, high-fibre bran flakes, corn, unrefined maize, wild/brown rice, wholegrain cereals, brown rice). The quality (high fibre, nutrient dense) and quantity of the carbohydrate you eat is very important as carbohydrates are the foods that are likely to affect your blood glucose levels the most. So, remember the two Qs – quality and quantity.

Focus on carbohydrates that are high in fibre. Aim for a fibre intake of between 30-50g per day. Some high fibre foods are: bran flakes/high-fibre cereals, sweet potato (with skin), fruit (eaten with skin where possible), vegetables, beans and nuts.

If you are needing to increase your fibre intake, do so gradually so to avoid unnecessary side effects.

Food Quantity Fibre content (g)
Hi-fibre bran ½ cup 11
Orange 1 9
Apple with skin 1 5
Sweet potato (with skin) ½ cup 4
Brussels sprouts ½ cup 4

Try to eat carbohydrates at the same time and in the same quantities each day to help control your blood glucose levels and weight.

Interest in the microorganisms found in our guts (gut microbiome) is growing. The gut microbiome may have a role in obesity, how sensitive you are to insulin, and how glucose is used in your body. However, a lot of human research still needs to be done to understand the impact of different dietary approaches in changing gut microbiome and its effect on the management of diabetes. This is definitely a space to watch.

Please note, it’s best to work with a registered dietitian to establish the ideal amount of carbohydrate in your diet as individual responses to carbohydrate containing foods can vary greatly.

Eat plenty of vegetables and fruit every day

Vegetables and fruit are great in that they are fibre-rich (provided you eat the skin where possible) and rich in vitamins and minerals.

South African guidelines suggest a minimum of five portions per day. These can be fresh, frozen or tinned (in own juice). You need to be more careful with quantities of dried fruit. Try and stay away from fruit juices as these are concentrated sources of carbohydrates.

Think of a traffic light when planning your fruit and vegetable intake throughout the day – aim to include red, yellow/orange and green colours each day.

Vegetables are very versatile. They can be included in soups, stews, curries, salads, dips, crudités; as isigwamba* (spinach and mealie meal), mixed into protein dishes or eaten by themselves (e.g. imfino (wild spinach) with onion).

Fruit can be added to smoothies, eaten with wholegrain cereals or porridge, combined with savoury snacks (e.g. apples and cottage cheese/peanut butter), eaten with plain yoghurt or eaten on its own.

*Ensure mealie meal is cooked, then cooled and reheated as this is likely to have a better effect on blood glucose levels than cooked mealie meal.

Eat beans, split peas, lentils and soya regularly

These are very good sources of fibre and protein and are also extremely versatile. Different beans (e.g. kidney beans, butter beans, cannellini beans, black beans, sugar beans), chickpeas, lentils, split peas and soya beans can all be used in soups, stews, curries and salads or dips (e.g. chickpeas in hummus).

Beans can also be eaten in the form of baked beans or made into isigwagane* (sugar beans and rice) or mashed with a small amount of margarine or lite mayonnaise as an alternative for bread spreads.

* You will need to watch your portion size of isigwane as both the rice and sugar beans contain carbohydrate. Try and use brown rice if possible.

Fish, chicken, lean meat and eggs can be eaten daily

Good protein choices include lean meat cuts, organ meats, lean biltong, skinless chicken, eggs, fresh or tinned fish (mackerel, sardines and pilchards are rich sources of omega 3 fatty acids). Limit your intake of processed meats (e.g. luncheon meats, bacon, and polonies).

Use fat sparingly: choose vegetable oils rather than hard fats

The type of fats that you enjoy is important. Focus on fats that come from foods, such as plant oils (sunflower, canola, olive), avocado pear, olives, nuts, seeds and soft margarine.

If you are eating lots of saturated fat (animal fats and tropical oils), replace these with fats indicated above rather than refined carbohydrates (e.g. flour, sugar) to decrease your risk of heart disease.

Try to stay away from trans fats. Government legislation restricts the trans-fat content of any oils or fats on the market, or used in food production (shops, catering business, restaurants, bakeries, etc.).

Have milk, maas or yoghurt every day

Milk, maas and yoghurt are good sources of protein and provide vitamin D, calcium, magnesium and potassium. Include plain, low-fat yoghurt and low-fat milk. Milk can be fresh, long life or powdered. Remember a coffee/tea creamer is not the same as powdered milk.

Use salt and foods high in salt sparingly

Limit your intake of sodium to no more than 2300mg/day (approximately 1 teaspoon of salt) as high intakes may lead to high blood pressure. Remember this 1 teaspoon of salt includes the salt added to manufactured food products.

Foods higher in sodium include: biltong, dried sausages, salty snacks (chips, pretzels, etc.), fast foods like pizza, processed meats (luncheon meat), packaged sauces, condiments (tomato sauce, pickles), stock cubes and salty seasonings, packet gravies, many breakfast cereals and breads.

Government has passed legislation to limit the salt content in packaged foods. But still be aware of extra salt added to food. Try and use fresh and dried herbs, spices, garlic and lemon juice as alternatives to dousing your food in salt.

Use sugar and food and drinks high in sugar sparingly

Guidelines with regards to added sugar intake in diabetes differ around the world. There seems to be agreement that sucrose can be used in line with the World Health Organisation Guidelines (10% of total energy intake (±50g) or 5% (±25g) for additional health benefits)*. Remember these guidelines also include any sugar that is added to food and beverages during the manufacturing process.

If you do wish to enjoy sugar, minimise your intake of foods, like sweets, chocolates, cakes and biscuits and pastries that are rich in sugar and fat. Rather focus on more nutrient dense foods that may have sugar e.g. baked beans, peanut butter, or a small sprinkling on your porridge. Peanut butter that contains no added sugar and tinned baked beans that are low glycaemic-index are also available.

There is, however, unanimous agreement that you should not consume sugar-sweetened beverages if you have diabetes.

Non-nutritive sweeteners (NNS) are safe to use provided they are used within the daily acceptable levels established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA). While NNS do not seem to have a significant effect on blood glucose control, they can reduce your overall energy and carbohydrate intake.

*Please note 5% is a WHO conditional recommendation (see WHO website for more information on conditional recommendations).

Be active

Physical activity helps to improve effectiveness of the diet and your medication. An exercise specialist should be part of your care team. He/she can advise on suitable physical activity.

Drink lots of clean, safe water

Water should be the drink of choice for you and your family.

Do you need to take supplements if you have Type 2 diabetes?

A balanced diet should always be your priority. Routine supplementation of micronutrients, antioxidants (e.g. vitamin D, E and C, chromium), cinnamon or curcumin is not recommended unless you have a known nutrient deficiency or have additional requirements.

If you are following a diet low in energy, are pregnant or breastfeeding, are a strict vegetarian, or your intake of nutrients may be compromised or reduced, you may require supplementation.

Supplementation with omega 3 fatty acids has not been shown to improve blood glucose control in those with Type 2 diabetes.

Guidelines suggest that there are several different eating patterns that can be adopted to maintain good health and blood glucose control. There is also a lot of current research interest in intermittent fasting and low-carbohydrate diets so these are areas to watch too!

A registered dietitian can assist you in finding a dietary pattern that best suits your needs and goals to ensure you are eating a diet that is of good quality and energy controlled. Visit www.adsa.org.za to find a registered dietitian in your area.

Warm up to good health this summer!


References

American Diabetes Association. 5. Lifestyle Management: Standards of Medical Care in Diabetes – 2019. Diabetes Care 2019: 42(Suppl 1):S46-S60.

Diabetes UK. Evidence based nutrition guidelines for the prevention and management of Diabetes: March 2018.  (www.diabetes.org.uk)

Sievenpiper JL, Chan CB, Dworatzek PD, Freeze C, Williams SL. 2018 Clinical Practice Guidelines Nutrition Therapy. Canadian Journal of Diabetes 2018: 42:S64-S79.

The Society for Endocrinology, Metabolism and Diabetes of South Africa. Type 2 Diabetes Guidelines Expert Committee.  “Medical Nutrition Therapy” in 2017 SEMDSA Guideline for the Management of Type 2 Diabetes Guideline Committee. JEMDSA 2017: 21(1)(Supplement 1):S1-S196.

Vorster HH, Badham JB, Venter CS. An Introduction to the Revised Food-Based Dietary Guidelines for South Africa. S Afr J Clin Nutr 2013: 26(3):S1-S164.

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Wendy Girven is a registered dietitian. She has worked in private practice, academia (community nutrition) and in the food industry and has an interest in the nutritional management of non-communicable diseases.


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Challenges facing SA in the fight against diabetic retinopathy

Did you know the earliest changes in the body caused by diabetes can be seen in the eye? Dr Stephen Cook advocates early screening of diabetic retinopathy.


Diabetes epidemic

According to reports on World Diabetes Day 2018, about 3,5 million South Africans suffer from diabetes, and a further 5 million are estimated to have pre-diabetes.

The diabetic epidemic presents a massive burden to healthcare services. Type 2 diabetes mellitus is said to be the fastest growing chronic disease in the world. South Africa, in particular, is badly affected.

South Africa faces a plethora of healthcare needs, and specialist services are few and far between. More so in the field of preventable blindness. According to Orbis Africa, there are only six ophthalmologists for every million South Africans.

One of the biggest challenges currently facing South Africa is the diabetic epidemic. Examination of the eye can provide important information regarding the state of health of the nerves and small vessels of the body. These changes can be observed in the retina of the eye. The changes are referred to as diabetic retinopathy.

Diabetic retinopathy

Diabetic retinopathy (DR) refers to damage and loss of function of the retina (back of the eye) due to uncontrolled diabetes, and without a healthy, functioning retina, the eye cannot see.

Having uncontrolled elevated blood glucose levels causes the blood vessels in the retina to ‘leak’ or close off, leading to damage, which, in some cases, can be permanent.

When diabetic retinopathy is detected the person is said to be retinopathy positive. This status provides extremely important information regarding the risk of future events, particularly heart attack.

Determining the person’s retinopathy status is the most important part of screening, as this provides the person and their healthcare team with their “score” in the struggle against the disease.

Screen for Life

The Ophthalmological Society of South Africa (OSSA) has developed a diabetic retinal screening programme, called Screen for Life (S4L). The programme aims to raise awareness and expand screening capacity.

The S4L programme trains optometrists and interested GPs in retinal screening. In addition, artificial intelligence (AI) software is also proving beneficial in some centres.

Screen for Life has several components, including the patient-held record, quality assurance and suggested management plans. A basic screening for diabetic retinopathy entails having a retinal photograph taken with a fundus camera. It is quick and painless. This photograph is then graded by an accredited grader who makes a recommendation on further management.

Every person living with diabetes needs to know their retinopathy status. This informs them, their family and carers, as to their risk of serious systemic illness, such as heart attack and stroke. The earliest changes in the body caused by diabetes can be seen in the eye.

The OSSA diabetic retinopathy screening programme has been developed to get the most out of every screening opportunity. The programme follows the outline of the Scottish (NHS) diabetic retinopathy screening system.

This system has a track record of being evidence-based and cost-effective. In addition, our programme incorporates innovative risk calculation and co-screening for glaucoma.

Apples and red flag communication

Screen for Life uses the #redflag communication strategy. The patient held record is used to document the communication. Apples and red flags are used as images to convey the communication.

There are three distinct prompt points that help motivate for lifestyle changes. Lifestyle changes, particularly diet, exercise and stopping smoking can prevent suffering and save lives. The first prompt is communicating the diabetic status.

Retinopathy negative persons are congratulated and an apple sticker given or drawn onto the record. They are encouraged to stay negative to keep the apple.

Retinopathy positive persons receive a red flag indicating increased risk of systemic complications, particularly heart attack. They are encouraged to make changes to reverse the disease process. A follow-up appointment is set up to establish the trend of change.

Progression shows that whatever steps have been taken, have not been enough to stabilise the disease. This prompts a second red flag communication.

Where sight-threatening diabetic retinopathy or other disease (glaucoma, age-related macular degeneration, etc.) is detected, a third red flag is given and the person is referred to an ophthalmologist.

The patient-held record serves as a score card which helps practitioners know which stage of disease their patients are at. The programme uses a quality assurance and education system for graders.

Use of AI

The system is also artificial intelligence (AI) ready. AI is an enabling technology. In the short-term, this will enable safer high-quality, high volume grading.

In the long-term, AI is expected to provide powerful predictive information regarding other conditions, such as cardiovascular and dementia risk.

Challenges facing SA

I am extremely concerned that in general, medical doctors are not using diabetic retinopathy screening to modify the medical management of our patients.

We are failing to provide DR screening as part of our primary healthcare. This means that valuable medical information regarding the current micro-vascular state and future risk is not being taken into consideration.

People living with diabetes are unaware of their retinopathy status. Our experience is, sadly, that by the time the person consults a doctor for decreased vision, the eye disease is already advanced.

Awareness of the need for screening is the main problem. Communication about the significance of any retinopathy is the second, and a lack of access to fundus cameras is the third problem.

The threat of blindness, heart attack, stroke and other end-organ failures help motivate for better lifestyle choices to control and manage the disease.

Research has shown that diabetic retinopathy is a powerful indicator of the future risk of these things happening. The complexity of the disease and the socio-economic situation of the person living with diabetes make it very difficult to make changes. Communication needs to be supportive and ongoing if it is to contribute positively to making changes last.

End-organ failure causing blindness

Ophthalmology is a specialist field. As such, it is easy to feel overwhelmed by the scale of the disease and isolate our inputs to managing the current tsunami of end-organ failure causing blindness.

In doing this, we may be ignoring the opportunity to contribute to the primary care of people living with diabetes. Diabetic retinopathy may be the first sign of diabetic disease. This may predate the onset of end-organ failure by many years.

Lifestyle changes early in the disease process have powerful and long-lasting beneficial effects. Our communicating the significance of the discovery of any retinopathy early in the disease may just provide the necessary prompt for someone to change on time to prevent suffering and loss of life.

Better control of risk factors is the best means of preventing end-organ failure. Diabetic Retinopathy is an important biomarker for the systemic disease burden.

For more information, visit www.screenforlife.co.za

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Dr Stephen Cook is an ophthalmologist at The Eye Centre in East London.He developed the Screen for life diabetic retinopathy screening programme on behalf of the ophthalmology society (OSSA) www.ossa.co.za


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Preventative foot care for people living with diabetes

Riaan Knight, a medical orthotist and prosthetist, explains why preventative foot care is so important for people living with diabetes.


Father’s loss of limb directs choice of career

As a medical orthotist and prosthetist, I frequently deal with the debilitating effects of foot ulcers and amputation caused by vascular disease. Sadly, in my practise, vascular disease is almost always directly linked to diabetes.

Speaking from personal experience, I can’t emphasise enough the importance of diabetic foot care. As a young man, I had to watch my dad, who was diabetic, deal with the devastating effects of a recurring foot ulcer.

At first, he lost his mobility, he had to walk with crutches. Later, he lost his ability to drive a vehicle and then eventually, as to stop infection from spreading, he had to undergo an amputation of his left lower limb.

Although the medical aspect was dealt with successfully, he now faced a new dilemma, he used up all available sick leave and had to deal with the loss of his income.

On the upside, his successful rehabilitation with a prosthetic limb left a huge impression on me. I immediately knew I wanted to study medical orthotics and prosthetics.

It was during my studies that I realised to my dismay that if only the medical team followed proper orthotic management protocols, he may have never had re-ulceration or limb amputation. Research proved the effectiveness of foot orthotic treatment to assist in recurring foot ulcers.

I have often asked myself could we have cured his foot ulcer? Could we have prevented the amputation of his limb? What I do know is that foot orthotic studies confirm positive results.

Study with astounding results

A well-known study, done on the effectiveness of orthotic treatment in patients with recurrent diabetic foot ulcers, by Fernandez ML, Et al, published in the American Journal of Podiatric Medicine showed astounding results:

  • “Before foot orthotic treatment, the re-ulceration rate in diabetic patients was 79% and the amputation rate was 54%. Two years after the start of orthotic therapy, the re-ulceration rate was 15% and the amputation rate was 6%.
  • Orthotic therapy reduced peak plantar pressures in patients with re-ulcerations and in those without.
  • Sick leave was reduced from 100% to 26%.”

The results are staggering. Yet, sadly the incidence of pressure ulcers in the diabetic community remains high and may very well increase.

Diabetes on the rise

The World Health Organisation (WHO) has predicted that there will be 380 million diagnosed diabetic patients worldwide by 2025. They further determined that Africa will face the second highest increase in prevalence of the disease.

A research study by the Non-Communicable Diseases Research Unit, based at Tygerberg Hospital, confirmed this “increase” prediction for South Africa. Their research found an above normal increase in persons diagnosed with diabetes in SA.

In fact, they state that the prevalence of diabetes increased amongst the female population from 8 to 14% and amongst male population from 5 to 10% for the period between 1980 and 2014.

Risk for foot ulcers

WHO further state that the lifetime risk for foot ulcers in people with diabetes is estimated to be as high as between 15 and 25%. Research further showed that 85% of all amputations done in diabetics are preceded by ulceration.

The at-risk diabetic would need to take cognisance of the fact that due to insufficient vascularity and neural dysfunction associated with diabetic neuropathy, he/she will always be at risk of developing a plantar foot ulcer. Preventative action should be high priority.

Preventative plantar pressure screening is essential

Unfortunately, an aspect that can greatly assist with the early detection of possible ulcer prone areas of the diabetic neuropathic foot has been ignored to a fair extend. Preventative plantar pressure screening is essential. Stop the ulcer before such can develop.

I am obviously aware of all other avenues of diabetic screening and complication prevention protocols. But, I do feel that it’s of paramount importance that diabetic foot care screening via specialised medical plantar pressure devices are developed and implemented in addition to those throughout South Africa.

Although such medical devices are available in the private sector, only a small handful is available to state patients. The conundrum is to convince government to invest in such fairly-expensive systems.

However, the money saved in long-term (unnecessarily used to fund wound treatment and limb prosthetics) would be astronomical and will far outweigh the initial set up cost.

Studies prove effectiveness of these systems

The effectiveness of these systems has been proved in many a medical research study. A study, by Joslin Beth Israel, Et al, at the Deaconess Foot Centre, Harvard Medical School, concluded that both the rearfoot and forefoot pressures are increased in the diabetic neuropathic foot, indicating an imbalance in pressure distribution with increasing degrees of neuropathy. The later stages of peripheral neuropathy play an important role in the aetiology of diabetic foot ulceration.

Another study, by the Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, showed that claw/hammer toe deformity is associated with elevated plantar pressures at the metatarsal heads in neuropathic diabetic patients. This condition increases the risk for plantar ulceration.

The fact remains that even healthy tissue placed under abnormal pressure over a prolonged period will break down and ulcerate. Unfortunately, in the case of diabetic patients even more so.

How does a plantar pressure device work?

Planter pressure devices can predict areas of abnormal pressures by measuring pressure over time and relating such to normative values from healthy individuals.

Another plus point is the ability of specialised integrated software as to recommend areas and percentage of correction to be applied via a suitable foot orthotic.

I strongly advise all high-risk diabetics to seek referral from their diabetologist (or medical doctor) to undergo such preventative foot care (preventative plantar measurement) screening on an ongoing basis. Prevention is better than the cure.

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Riaan Knight is a medical orthotist and prosthetist based in Port Elizabeth. He has been in private practise since 1994. He served as Chairperson to the South African Orthotic and Prosthetic Association for 10 years and is regarded as the forefather of plantar pressure measurement devices in SA. Riaan was the first person (2003) to import and train local orthotists on the use and advantages of plantar pressure measurement devices in SA.


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