Depression and diabetes

Daniel Sher explores how diabetes and depression are linked, and gives some pointers for managing diabetes and depression together.


If you have diabetes, your chance of developing depression is two to three times higher than that of other people. As if we didn’t have enough to worry about already.

Why is this a problem?

Depression can make it harder for you to manage your glucose levels, often leading to diabetes burnout. Before you know it, you’re stuck in a vicious cycle of sadness, mood swings and poor blood glucose control.

What is depression?

Depression usually involves feelings of sadness, but depression and sadness are not the same thing. Rather, depression is a psychological disorder that affects a person not just emotionally, but also in terms of their thoughts and bodily functions.

Some of the symptoms of clinical depression include:

  • Ongoing sadness that doesn’t seem to ease up.
  • An inability to enjoy activities that previously brought you happiness.
  • Sleep disturbances.
  • Mood swings at home or at work are interfering with your relationships.
  • Concentration difficulties.
  • Suicidal thoughts and behaviours.
  • Inappropriate guilt and poor self-esteem.
  • Social withdrawal.
  • Changes in weight and appetite.
  • Low energy.
  • Less motivation to test your blood glucose, exercise and take insulin (diabetes burnout).

How common is depression in people with diabetes?

Time and time again, research studies have shown that having diabetes puts one at risk of developing depression. For example, a 2012 study showed that people with Type 1 diabetes are three times more likely to have depression; while people with Type 2 diabetes are twice as likely to be depressed.

Another 2019 study confirmed these numbers, leading the authors to say that reducing diabetes by 25% could stop 2,34 million cases of depression from happening. But, believe it or not, research shows that the relationship goes both ways. Having depression can also make a person more likely to develop (Type 2) diabetes.

Clearly, then, a close link between the two conditions exists. But why does this link exist? Why do depression and diabetes occur together so often?

Explaining the link between diabetes and depression

Injections. Finger pricks. Doctor’s visits. Lows. Highs. Dietary restrictions. Worry and fear. Yes, as people living with diabetes, we deal with a whole lot of stress. Is it really that surprising that we’re more likely to end up with depression?

Of course, living with diabetes comes with a psychological burden which in and of itself can trigger depression. But, the stress of diabetes alone doesn’t completely account for this link. This is where things get interesting.

Diabetes, depression and the brain

Recent research suggests that high blood glucose levels have a direct impact on the parts of the brain that affect mood and thinking. The researchers used a (fMRI) brain scanner to compare the brains of people living with diabetes versus people without the illness. The people living with diabetes were given some glucose to raise their sugars.

The scanners showed that when blood glucose levels went up, a certain brain chemical (glutamate) was released in parts of the brain that control thinking and emotions. Glutamate is closely linked to depression. The researchers also showed that people with worse glucose control over time had patterns of electrical activity in the brain that are linked to depression.

So, in other words, this study tells us that the link between diabetes and depression is not just a matter of increased life-stress: the two disorders are linked on a biological level. People living with diabetes experience changes in the brain that make depression more likely; and this is especially the case when blood glucose levels are high.

A vicious cycle

Many clients who approach me for help are stuck in a vicious cycle. They struggle to control their diabetes as well as they would like; and they soon start to develop signs of depression. The depression makes it harder for them to stay motivated and hopeful. They start to slack-off in terms of self-monitoring, diet and exercise. Their glucose control suffers as a result. This leads them to become even more depressed.

Why is this important?

For starters, if you are one of millions of people living with diabetes who is struggling with depression, know this: it’s not all in your head. The stress and strains of living with diabetes are very real. But, the illness also predisposes you to depression because of altered brain chemistry.

Now that we know this, it’s absolutely vital for doctors, patients and family members of people living with diabetes to know how to recognise the signs of diabetes and get help where needed. Treating both diabetes and depression together is vital.

How to get help

The good news is that this cycle can be broken. In most people, depression responds well to treatment. Let’s look at the two most common treatment options:

  1. Psychotherapy

Also known as talk therapy, counselling or just therapy. Speaking with a licensed mental health professional can help you to change the thoughts and behaviours that make depression more likely.

Cognitive behavioural therapy (CBT) is one of the most popular forms of therapy for treating depression. If possible, try to find a therapist who is experienced in working with people living with diabetes. It can really help to speak with someone who understands the struggles and nuances of living with a chronic illness.

  1. Medication

One of the most common forms of antidepressant medications is called a selective serotonin reuptake inhibitor (SSRI). Examples include Celexa, Lexapro, Zoloft and Zytomil. A 2006 research paper suggests that medication and therapy are equally effective in managing depression; and that the best outcomes usually occur when the two are combined.

  1. Lifestyle interventions

Therapists often include ‘behavioural modification’ to their treatment. This means empowering the client to make healthier choices when it comes to their diet, diabetes management and exercise patterns. Making positive choices in this regard can help you manage your depression and diabetes at the same time.

How to get help

If you are concerned that you may be developing depression on top of your diabetes, speak to your endocrinologist or general practitioner. Alternatively, you may want to make direct contact with a clinical psychologist or psychiatrist in your area. If possible, try to consult with a mental health professional who has experience in working with diabetes.

If you or a family member are suicidal, contact the South African Depression and Anxiety Group on their 24-hour suicide hotline: 0800 567 567.

Final thought

So, we now know that people living with diabetes are more likely to experience depression. Not just because their lives are a whole lot more stressful, but because diabetes, depression and the brain are all linked on a biological level. For those of us with diabetes, this means that we need to remain vigilant for signs of depression.

By getting the mental health treatment that you deserve, it’s possible to improve your overall quality of life and your blood-sugar control at the same time.


References

Bădescu, S. V., Tătaru, C., Kobylinska, L., Georgescu, E. L., Zahiu, D. M., Zăgrean, A. M., & Zăgrean, L. (2016). The association between Diabetes mellitus and Depression. Journal of medicine and life, 9(2), 120-125.

Chireh, B., Li, M., & D’Arcy, C. (2019). Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. Preventive medicine reports, 100822.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., … & Atkins, D. C. (2006). Randomized trial of behavioural activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of consulting and clinical psychology, 74(4), 658-670.

Endocrine Society. (2014, June 23). High blood sugar causes brain changes that raise depression risk. ScienceDaily. Retrieved June 19, 2019 from www.sciencedaily.com/releases/2014/06/140623092011.htm

Roy, T., & Lloyd, C. E. (2012). Epidemiology of depression and diabetes: a systematic review. Journal of affective disorders, 142, S8-S21.

MEET OUR EXPERT


Daniel Sher is a registered clinical psychologist who has lived with Type 1 diabetes for over 28 years. He practices from Life Vincent Pallotti Hospital in Cape Town where he works with Type 1 and Type 2 diabetes patients to help them thrive. Visit www.danielshertherapy.com


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What are the best sweeteners for people living with diabetes?

There is a lot of controversy regarding  sweeteners (sugar substitutes) and which is better for people living with diabetes. Retha Harmse simplifies the facts.


Sugar consumption

The dangers of excessive consumption of sugar is well-documented. Including how it negatively affects the health status of individuals but even more so for people living with diabetes.

The typical South African consumes 24 teaspoons of sugar daily. More than double of the World Health Organization guidelines for daily intake. Added to that, 7% of the South African population has diabetes (3,85 million people, aged between 21 – 79 years old).

In 1985, 30 million people had diabetes. Its prevalence has increased six-fold and today  425 million people worldwide are currently. If nothing is done now to prevent this, this number will continue to increase to 629 million people by 2045.

Sugars that increase blood glucose levels

Some foods will be labelled “no added sugar” but will still be high in natural sugar (e.g. fruit sugars). These natural sugars also raise blood glucose levels and should be monitored for people with insulin resistance and diabetes.

Sugar Forms & uses Other things you should know
  • Brown sugar
  • Maltodextrins
  • Icing sugar
  • Agave syrup
  • Invert sugar
  • Brown rice syrup
  • White sugar
  • Corn syrup
  • Dextrose
  • High fructose corn syrup
  • Fructose
  • Maple syrup
  • Glucose
  • Fruit juice concentrates
  • Lactose
  • Honey
  •  Maltose
  • Molasses
  • Sucrose
  • Barley malt
  • Used to sweeten foods and beverages.
  • May be found in certain medications.
  • There is no advantage to those with diabetes in using one type of sugar over another (in other words, one teaspoon of sugar has the equal effect of one teaspoon of honey).
  • Sugars may be eaten in moderation. Up to 5% of the daily caloric requirement can come from added sugar.
  • High-sugar diets are not recommended, since such foods could replace more nutritious foods and lead to deficiencies.

Sugars that don’t affect blood glucose levels

Non-nutritive sweeteners, such as aspartame, sucralose, saccharine, stevia, xylitol, and neotame, are so popular due to it being approximately 300 to 13 000 times sweeter than sugar. Though, they don’t have any nutritional value (meaning no or low kilojoules).

Although artificial sweeteners may help to reduce total energy intake, the effectiveness in weight loss or diabetes management has not yet been established. We think fewer calories consumed equals less weight gained or more weight lost, right?

However, according to a recent review, regular consumption of non-nutritive sweeteners is related to an increase in BMI. This might be explained by sweeteners being associated with an amplifying of general cravings and appetite.

Despite this, and this is imperative: sweeteners are not all the same. They have different biochemical structures, with different routes of metabolisation and absorption. Certain sweeteners metabolise differently and are therefore better than others in maintaining blood glucose and weight management. Let’s look at a few different sweeteners and how they weigh up.

Sucralose

Sucralose (sold as Splenda) is 600 times sweeter than normal sugar. It’s mostly secreted which means it does not get absorbed in the body.

Although this might sound great, don’t be so quick to jump on the bandwagon. Sucralose has been associated with inflammation, and there is still ongoing research on whether it increases blood glucose level. The data is leaning towards a ‘no’ for people living with diabetes, as long-term use can cause insulin resistance.

It’s also worth mentioning that added table sugar, if consumed in excess, also causes inflammation and has also been associated with insulin resistance.

Conclusion: Consuming sucralose (or normal sugar) in excess over a long period of time has been linked to inflammation. Sucralose should rather be avoided if you’re diagnosed with any inflammatory diseases such, as rheumatoid arthritis or Crohn’s disease, as it can worsen the inflammatory state.

Aspartame

Aspartame is mostly used in sugar-free or low-sugar drinks and Iced Tea lite.

After the big media frenzy of aspartame causing cancer, recent human studies proved aspartame had no carcinogenic effect. However, it’s worthwhile to note that it’s still not beneficial for your health. More specifically gut health, as aspartame increases certain bacteria in your gut that are directly associated with weight gain.

Furthermore, the long-term (more than 10 years) use of aspartame has been negatively associated with cardiac health. Lastly, aspartame also leads to an increase in carbohydrate cravings, which can lead to increased appetite.

Conclusion: Although aspartame was set-free from being cancer causing, it still increases carbohydrate cravings and the effect it has on gut- and cardiac health shouldn’t be neglected.

Remember that moderation is key. Try to replace diet drinks with infused water or homemade iced teas (rooibos is such a good option). But if you still plan to consume aspartame, be sure to include extra fibrous vegetables, or even a probiotic, to keep the microbiota in balance.

Stevia, erythritol and xylitol

These three sweeteners have been categorised as natural sweeteners. The benefits of these sweeteners are that they don’t need insulin to be metabolised. Therefore, improves glucose tolerance and reduces insulin levels.

Stevia does have an undesirable bitter aftertaste, and erythritol and xylitol are quite expensive (roughly R150-160p/kg). But it seems worth it, because when consuming these natural sweeteners, the rewards system is activated leaving you feeling satisfied. And, in contrast to the previous mentioned sweeteners, they do not increase cravings.

Conclusion: Stevia, erythritol, and xylitol are superior. They can improve glucose levels and aid in weight management, in comparison to the other artificial sweeteners.

Still, moderation remains a key factor in any healthy diet. Therefore, using it sparingly will benefit your health as well as your wallet.

MEET OUR EXPERT


Retha Harmse (née Booyens) is a registered dietitian and the ADSA public relations portfolio holder. She has a passion for informing and equipping in the field of nutrition. She is currently in private practice in Saxonwold, Houghton and believes that everyone deserves happiness and health and to achieve this she gives practical and individual-specific advice, guidelines and diets.


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Make time to move

Physiotherapist, Saadia Kirsten Jantjes, gives us practical moves to up your everyday exercise and move.


A few weeks ago, while scrolling through social media, I came across the following quote: “If you do not make time for your wellness, you will be forced to make time for your illness.”

It dawned upon me that so many of us wait to be told by a doctor or medical professional, “You have diabetes/high cholesterol/high blood pressure, so you need to move and start exercising and taking better care of your health.”

After attending a diabetes workshop last month, I realised how much time and effort really goes into managing diabetes. Constantly checking blood glucose levels; being conscious of the amount of food consumed; how eating different food groups will affect your blood glucose at different times of the day; and adjusting doses accordingly. It definitely is time consuming.

Add that to all your day-to-day activities, means that you have very little ‘me-time’. Yet, your doctor and dietitian constantly tell you to add exercise to your routine. So, when and where are you meant to do this?

Make movement a part of your lifestyle

Our bodies are meant to move and not be sedentary. If we look back to our old friends, the cavemen, they were hunting, dancing around fires and exploring their surroundings. Ah what a life!

Unfortunately, in this day and age, we must schedule time for movement otherwise our day just runs away with us. But it shouldn’t have to be like that. Making movement an integral part of your daily living will result in more active calories been burnt throughout the day and, essentially, more time for yourself.

Start with baby steps…literally. Take the stairs.

Skip the lift and elevators and take the stairs whenever and wherever you can. Studies show that climbing just eight flights of stairs lowers early mortality risk by 33%; seven minutes of stair climbing a day can half the risk of heart attack over 10 years; and just two minutes of extra stair climbing a day is enough to stop middle age weight gain.

There are numerous other benefits like improving muscular tone, strength and balance as well as increasing your cardiovascular fitness. Riding the elevator up three flights burns 3kcal while walking up three flights of stairs burns over 20kcal.

Get in touch with Mother Nature…in your backyard

Gardening can be a relaxing and rewarding and it is particularly exerting. Using a leaf blower for 30 minutes burns 115kcal but raking leaves for 30 minutes burns 175kcal.

Add some simple exercises to your gardening regime to increase your calorie count. For example, performing a deep squat every time you bend down to water the flowers. Standing on your toes to pair the leaves. Doing some overhead presses with the watering can. Or, if you’re up for it, add a jog around the garden or some high knees on the spot. So, not only are you working out while gardening, but you’ll reap the benefits of some fresh air too!

Move at work

You probably spend most of your waking hours at work. So, what if you could workout while you work, without having to carve out a big chunk of your time?Try these quick moves in the workplace:

  • If you sit at a desk, make it a habit to stand up every time you make or answer a phone call. March on the spot or pace in a circle to keep moving.
  • Need an energising break? Stand up and do some basic strength and balance exercises. For example, squats, desk push-ups, wall sits, calf raises, tree pose and chair pose.
  • Walk to a nearby restaurant for lunch instead of driving or ordering in.
  • Alternate sitting and standing throughout the day, with lots of walking and stretching breaks.
  • Explore your options for using a standing desk, treadmill desk or sit-stand desk riser.

These are all practical tools to get you moving throughout the day. It can also be a great way to figure out what you may actually enjoy in terms of exercise. So, that when you’re able to set time aside for exercise, you’re able to do so with something that you enjoy.

MEET OUR EXPERT


Saadia Kirsten Jantjes is a physiotherapist with a passion for health and wellness. With a second degree in Sport Science, exercise is one of her favourite rehabilitation tools, to not only rehab injuries but prevent injuries too. Saadia has her own private practice in Morningside, Gauteng, SKJ Physiotherapy while working at a Sub-Acute Clinic and furthering her studies in Pilates.

 


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The see-saw of life

Noy Pullen tells us about the see-saw of life when living with diabetes.

When I got the email with the theme, The highs and lows of living with diabetes, for the winter issue of Diabetes Focus, two parts of me start wrestling, like Jacob and the angel – the informed scientific one and the creative artist. One instance of the see-saw of life.

One thing you can learn from the creative process is to use what comes to meet you. The material is not always obvious. You need be awake to possibilities, to recognise the miracle in the day. Or, to use the modern term – be mindful.

The day I got the emailed theme, two things happened which energised me. A radio interview with South African, Paddy Upton, a renowned cricket coach, about his new book: The Barefoot Coach. Something drove me to go and buy his book immediately.

Then came a post on Facebook from a friend whose younger daughter, aptly named Faith, has certain mental and physical difficulties. It read: When she can’t do something, Faith doesn’t say “I got it wrong”, she says, “I’m learning!”

This and Paddy Upton’s use of a quote of T. H. White’s The Once and Future King, where the wizard, Merlin, gives advice, “You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then – to learn…That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting.”, 1showed me my direction for the article. We can learn.

How do we communicate? From autocrat to collaborator

Living or working with diabetes affects everyone nowadays, even if it is only being aware of the dangers of a careless lifestyle.

The current way of giving so-called health education (via recommendations, instructions and advice) when dealing with patients, whether with diabetes awareness, prevention and management, has been found to be ineffective according to many of our participants on the Agents for Change modules.

Comments that are shared are: “The patients are non-compliant.” The term that is used on patient records is defaulter. All health providers are trained in what is called health education. This is a similar model of that of the coach who has the strategies, the answers and the plan that the players need to obey.

Paddy Upton introduces a refreshing possibility of collaboration through questions, self-reflection and opportunities for growth in both the player and the coach. Learning effective ways based on conversations.

Our philosophy was to create an environment that empowered the players to think and decide for themselves. For the players to be able to make good decisions, they needed to become and be treated as the leading experts on their own lives, physical, mental and spiritual. No one knows you better than you do, and sometimes you just need a bit of help in allowing that understanding to emerge from within you.” 1(p103)

When my son, who is living with Type 1 diabetes, had to undergo surgery, his surgeon said to him, “You know your body better than anyone so please advise the surgical team on how your insulin should be administered.” The staff nurse had the same request. An empowering discussion followed and all ended well.

See-saw of patient-focused rather than disease-focused

The individual who has diabetes is not a diabetic, but rather a person with aspirations and unique talents who also happens to be living with diabetes.

It is by unlocking the potential within that the healing becomes reality. So, that people can radiate their individuality, and not just aim for acceptable blood glucose levels. Vibrant health is not absence of disease; it is empowering self-knowledge and the possibility of development.

Upton explains that when one is criticised, the negative emotion causes the body to produce cortisol, triggering a shutdown in thinking. This can cause one to go into conflict or defence mode, and generate unnecessary stress.

The way to manage so-called failure is to view it in terms of a solution in the future – a learning moment. The person can be asked, “When you are faced with a similar situation in the future, what will you do differently?” Possibilities can be explored in relation to the suggestions, offered by both the person and the coach.

See-saw of head-thinking and heart-thinking

There are two kinds of knowing: head-thinking –  the left brain, logical, academic, instructive, outer and scientific aspect. The kind that has the motto: ‘If it can’t be measured, it can’t be managed!’1

Then there is heart-thinking: the inner space, creative, sensing, inspired and intuitive knowing. The kind when you just know something. You have a hunch, or it just feels right.

Why did I go out to by The Barefoot Coach? What does diabetes have to do with cricket? It is not logical. Within the heart-thinking one finds an ‘ear’ amid the word heart. It has to do with subtle listening with every fibre of your being, to find the direction that the moment wants to go. The health provider or loved one of the patient who can practise this kind of sensing/minding will help develop the sense organs for finding the healthy option in any situation – a truly collaborative effort.

Minding or sensing – being in the zone or in flow

Paddy Upton refers to what he calls the small wins. The ones and twos that are often the runs that can make a difference between winning and losing.

Changing micro-habits that you practise daily. Perhaps ,just one eating habit, a small change in physical activity or a decision to meditate, can deliver significant results.

Tick your own tendencies

Look at the lists of the words below. Invite yourself to tick your own tendencies to add to your self-awareness.

These are natural tendencies which we can acknowledge and treasure as bits of self-knowledge. It is not a self-corrective tool, but rather one to make one more aware of your own one-sidedness. Knowing this may help you with managing micro-habits. This may highlight what you are very good at and you could use this when planning a change.

Upton also shares an amusing thought that some of us are born optimists while others veer more to the pessimistic side. According to George Bernard Shaw, both contribute to society, “The optimist invented the airplane and the pessimist invented the parachute.”

Enjoy finding your position on this verbal see-saw. The right side tends toward flair, flamboyance, exaggeration while the left is strict, law-related, rigid, cold or paralysing. In between these extremes are the lessons we are given by life to become more centred.

Optimist                          Realistic                      Pessimistic

Confident                        Present                       Doubting

Artistic                             Intuition                    Scientific

Feeling                              Holistic                      Thinking

License                             Foster                          Instruction

Success                             Practise                       Failure

Win                                   Grow                            Lose

Flattery                             Collaborate                 Criticise

Fun                                   Play                             Rules

Addiction                        Compassion                Violence

Abandon                     Rhythm                       Rigidity

Enjoy finding your special uniqueness and working with that to change what you choose to change. Change is like singing (or cricket). Anyone can do it with a bit of practice and enjoy the see-saw of life.

For information about the Agents For Change project, contact Noy Pullen.


Reference

  • Paddy Upton: The Barefoot Coach LIFE-CHANGING Insights from Coaching the World’s Best Cricketers. Published by Paddy Upton Coaching

Please contact Noy Pullen if you would like more information: linoia@web.co.za or 072 258 7132.


AGENTS FOR CHANGE IS A DIABETES SOUTH AFRICA PROJECT

MANAGED BY NOY PULLEN

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Energy drinks: are they safe?

Energy drinks can be the go-to solution when one is feeling tired. However, are they safe for people living with diabetes? Jessica Pieterse reviewed the latest research and some commonly found energy drinks on the SA market to attain insight.


Caffeine

When most of us think of energy drinks, we assume the caffeine will be sky-high compared to other drinks. Most energy drinks provide an average of 114mg caffeine per standard 455ml can, or 176mg caffeine per the larger 550ml can. This is surprisingly similar to a cup of filter coffee that contains on average 170mg caffeine per 250ml mug.

Though, not all drinks and food fare as closely. A standard 455ml can of energy drink has one and half times the caffeine than a cappuccino (75mg in 250ml) as well as 1,4 times than normal tea (80mg in 250ml), 2,8 to 3,8 times than sweetened fizzy drinks (30 – 40mg in 330ml), and almost 10 times than a chocolate bar (12mg in 40g).

It’s recommended to consume less than 300mg per day of caffeine, or 2,5mg caffeine per kg body weight per day. Meaning a 50kg person should keep caffeine below 125mg/day which is less than one large can of energy drink.

Consuming excessive amounts of caffeine can lead to trouble sleeping, anxiety, irritability, nervousness, rapid heart rate, headaches and dependency on caffeine.

Research behind caffeine consumption in people living with diabetes was surprisingly lacking. The Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) 2017 guidelines give no mention of caffeine.

Sugar

Energy drinks are consumed often for the caffeine boost, but people living with diabetes should be aware of the sugar contents of these drinks.

Energy drinks that contain sugar and not sweeteners, can offer 11 – 62g of sugar per can which equates to 3 to 16 teaspoons of sugar per can (440 – 550ml). Consuming 16 teaspoons of sugar in one seating would greatly raise blood glucose levels, and regular intake increase HbA1C levels.

We found six energy drinks that offer no sugar as they use sweeteners, such as sucralose, aspartame and acesulfame K. Drinks that use sweeteners will affect blood glucose levels much less. However, avoid large intakes of sweeteners as they may have negative effects on gut functioning.

Vitamins

Energy drink manufactures may use the fact that B vitamins are added as a selling point. B vitamins act as co-factors to support energy processes in the body. A dietary intake that is low in B vitamins can contribute to fatigue. Therefore, B vitamins contribute to boosting energy.

B vitamins are safe for people living with diabetes. People taking long-term Glucophage medication should supplement with vitamin B12. However, most drinks won’t provide sufficient levels of B12 needed. It should be noted that B vitamins are water-soluble and excessive amounts will be urinated out and not stored.

Energy-boosting ingredients

Energy drinks often contain ginseng and guarana. Guarana is a Brazilian plant that has seeds with four times the amount of caffeine found in coffee beans (on a percentage basis), along with other xanthines which also stimulate the central nervous system.

Ginseng comes from a root of a Panax plant. Although manufacturers claim ginseng increases energy and boosts the immune system, evidence is lacking. Ginseng has been shown to interact with immunosuppressive and blood pressure medications and as no warnings appear on the product, this could lead to serious effects. People living with diabetes should therefore, be very careful in taking herbal products as they are often on several medications.

Closing thought

To end things off, I don’t recommend people living with diabetes to consume energy drinks. Mainly due to the high-sugar intake of most drinks. The risk that the added herbal ingredients may also negatively affect medication taken is of great concern.

Caffeine is possibly less of the concern with energy drinks as people living with diabetes can still have high caffeine diets without including energy drinks. However, I would still recommend a safe daily caffeine intake of less than 300mg/day.

These findings are supported by the American Diabetes Association which advocates to avoid energy drinks and rather consume water, unsweetened herbal teas/coffee and milk.

Disclaimer: There is no conflict of interest with the author and any energy drink companies. The dietitian does not work for any companies and there was no payment received from any companies.

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Jessica Pieterse is the director Dish Up Dietitians, Pieterse and Associates and also works at several private hospitals as a part-time locum dietitian, working in the ICU, medical and surgical wards. She has a special interest in nutrigemonics (DNA testing), critical care, weight loss, diabetes, hypercholesteromia, hypertension and gut disorders.


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Tips for injecting insulin

Jessica Oosthuizen shares some useful pointers when injecting insulin.


Insulin therapy remains a fundamental and essential part of diabetes management. Many patients with Type 2 diabetes and all patients with Type 1 diabetes require insulin to keep blood glucose within target ranges.

However, this practice is still not performed optimally in many healthcare facilities, and insulin therapy is only effective if delivered into the correct tissue in the correct way.

The goal of exogenous insulin (insulin that is not made by the body but injected) is to reliably deliver the medication into the subcutaneous tissue, without causing any pain or discomfort and without any leakage of insulin.

The aim is to prevent injecting into the muscle. Injecting into the wrong space can affect the absorption and action of insulin. This can lead to unpredictable blood glucose control. To achieve this objective, it is important to select a needle that is the correct length.

What needles should be used for injecting insulin?

Studies have shown that shorter needles of 4mm are as safe and well-tolerated in comparison to longer ones.

Needles come with a different diameter and length. Those with a higher gauge number have a smaller needle diameter. Needles are available in 4-, 5-, 6- or 8-mm. Needles with a length of 12,7mm have an increased risk of intramuscular injection (which you want to avoid).

It is often assumed that a heavier person, with a higher BMI, may require a longer needle. However, we now know that 4-, 5- or 6-mm needles are suitable for all people with diabetes. Regardless of their BMI.

Insulin therapy should ideally be started using shorter length needles and these injections should be given at 90 degrees to the surface of the skin.

Children and teenagers

Children and adolescents should only be using needles with a length of 4-, 5- or 6mm. There is no clinical reason for using needles longer than 6mm. When injecting insulin into limbs, a skin-fold may be necessary, especially when using a 5- or 6mm needle.

Adults

In adults, including those with a high BMI in the overweight or obese category,  a needle that is 4mm, 5mm or 6mm in length should be used. There is no clinical reason to be using a needle >8mm. Patients who are using these needles should ideally change to a shorter needle. If this is not possible then lifting a skin-fold and/or injecting at a 45 degree angle should be adopted to avoid an intramuscular injection.

Injecting insulin into the muscle will cause: your body to absorb it too quickly; a more painful injection; and a shorter duration of insulin action time.

How many times can you use the same needle?

In a perfect world insulin needles would be used once and then safely discarded. Yet, realistically it’s common practice for needles to be reused. Especially, in a country, like South Africa, where resources are limited in both state and private sectors.

Although the risk of complications is relatively low in relation to the reuse of needles, some evidence does show that the reuse of needles can cause an increased risk of lipohypertrophy. This refers to swelling of the fatty tissue under the skin which causes fat lumps. It’s a relatively common side effect of insulin injections and can occur if multiple injections are given around the same area repeatedly.

Lipohypertrophy causes inconsistent and unpredictable insulin absorption, which can result in unexplained hypoglycaemia and glucose variability. It is for this reason that proper rotation of injection sites and regular changing of needles is essential.

Priming your pen

It’s important to remember that your insulin pen device should always be primed before the first dose and after every needle change.

Priming helps to remove any air bubbles that can collect during everyday use of your pen and ensures that you receive the full dose when administering insulin.

To prime your pen, dial up 2 units, hold your pen with the needle facing upwards and press down on the plunger. If you see drops of insulin come out at the top of the needle, then you know that your pen has been primed.

However, if you don’t see a flow of insulin then you must repeat the steps and continue until drops of insulin are visible at the top of the pen.

These same steps can be followed if you notice an air bubble in your pen. If an air bubble is present and you don’t remove it then you will not receive the correct dose of insulin.

You will notice this when you inject yourself. The air bubble causes a negative pressure when pointing the needle downwards into your skin and you will see a flow of insulin that is not injected and rather ‘spills’ out when removing the needle.

Final comment

Choosing the correct needles and ensuring removal of air when priming your insulin pen are two things that are easy enough to do. They can have positive effects on blood glucose control for people living with diabetes requiring multiple daily injections.


References

  1. FIT forum for injection technique in South Africa. Recommendations for best practice in injection technique. 1st 2014.
  2. Kreugel, G., Keers, J., Kerstens, M. and Wolffenbuttel, B. (2011). Randomized Trial on the Influence of the Length of Two Insulin Pen Needles on Glycaemic Control and Patient Preference in Obese Patients with Diabetes. Diabetes Technology & Therapeutics, 13(7), pp.737-741.
  3. Shah, R., Shah, V., Patel, M. and Maahs, D. (2016). Insulin delivery methods: Past, present and future. International Journal of Pharmaceutical Investigation, 6(1), p.1.
  4. Frid, A., Kreugel, G., Grassi, G., Halimi, S., Hicks, D., Hirsch, L., Smith, M., Wellhoener, R., Bode, B., Hirsch, I., Kalra, S., Ji, L. and Strauss, K. (2016). New Insulin Delivery Recommendations. Mayo Clinic Proceedings, 91(9), pp.1231-1255.
  5. Bahendeka, S., Kaushik, R., Swai, A., Otieno, F., Bajaj, S., Kalra, S., Bavuma, C. and Karigire, C. (2019). EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management. Diabetes Therapy, 10(2), pp.341-366.

MEET OUR EXPERT


Jessica Oosthuizen is a registered dietitian and works in private practice at the Wits Donald Gordan Medical Centre. Being a Type 1 diabetic herself, since the age of 13, Jessica has a special interest in the nutritional management of children and adults with diabetes. She also has a key interest in weight management and eating disorders.


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Irene Aarons – accepting diabetes with words

Poet and writer, Irene Aarons (nom de plume – Irene Emanuel), tells us how writing poetry about her medical conditions, including Type 2 diabetes, has helped her comes to term with them.


Irene Aarons (75) lives in Port Elizabeth, Eastern Cape. She has three children, four step children, three grand-children and nine step grand-children.

Irene not only has Type 2 diabetes. She has chronic allergic asthma; a hernia; high blood pressure; rhinitis; osteoarthritis, and she is on medication for all these conditions.

Though, she explains that the upside of all the above is that she has material to work with; many of her poems are about medical matters.

“I live the best life that I can, by finding the funny side of any limitations that there are. The poetry process gives me the chance to make light of a serious condition. By writing it down, I understand that this illness (diabetes) is not the end of my life but the beginning of new experiences. Poetry gives me an understanding that there is life after all my ailments; and whatever else finds me.”

“I always know that there are people far worse off than me. At least I am able to laugh at myself and write poetry that might make someone else laugh. One of my greatest joys is presenting a poetry talk to adults and children; to having them come up to me afterwards and telling me that my words have helped them in some way,” Irene explains.

Family history of diabetes

Irene was diagnosed with Type 2 diabetes in December 2008, at the age of 64. “I was vaguely expecting it as my mother, two uncles and an aunt all had diabetes. My oldest brother had Type 1 as well as his son. Since my diagnosis, another nephew has been diagnosed with Type 1. So, it definitely runs on the maternal side of my family.

After seventeen years of marriage to her second husband, Irene became a widow, in 2000, when he died of diabetic complications (Type 2). “My second husband was on dialysis for about three years, had lost the sight in one eye and was quite ill for a long time,” she explains. “He was diagnosed when he was in his twenties. But refused to take pills and carried on as if there was no problem at all. He lived life to the full and took no notice of his condition.”

“By the time I married him, he was still a heavy smoker and a fearless “anything-goes” person. When he finally gave in (I pressured him), it was too late. From his mid-fifties, he suffered from peripheral neuropathy, lost the sight in one eye, had a heart attack and then a multiple bypass, which made him give up smoking. His kidneys were damaged and he had to go for dialysis three times a week.”

“He died in his sixties. An early death which could have been delayed had he taken better care of himself. I supported him by going to support group meetings and ensuring that he followed a healthy way of eating. I helped him wherever I could by supporting him in his business and looking after all the children.”

Diabetes management

Currently, Irene is on 1000mg Glucophage twice a day. “Having diabetes is not a problem but rather a challenge. But a challenge that I accept to overcome every day,” she explains.

“The downside of diabetes is that I have to be cautious about what I am able to eat safely. I do cheat. But as I get older, I find that I eat less and very plain food. However, I admit that my downfall is a Steers hamburger, which I do treat myself to about once a month.”

Irene certainly does see the humour in everything. The proof is in the train of thought regarding diabetic food items. “I am curious as to why the cost of diabetic food is always so expensive, considering that half the ingredients are left out.”

She adds that she prefers Hermesetas sweeteners. But since they are imported from Switzerland, they seem to be harder to get. For this reason, she uses Equal sweetener instead.

Exercise doesn’t form part of Irene’s daily regime. Though, she adds “I do park far from mall entrances so that I can walk a fair amount. I do enjoy walking and sightseeing, especially if I am somewhere that I have not been before.”

Keeping busy is the way to go

The 76-year-old is officially retired. Though, she  keeps herself very busy. She is the bookkeeper for a family business, which involves at least two days a week. She also offers her time in two different charity shops, twice a week. Lastly, she always avails herself for talks, let it be on poetry or health.

“I have always been willing to talk to people on subjects, ranging from poetry to books, health, or whatever is needed. I have given talks at schools, clubs and societies. My favourite being schools because I have written poetry on rape, babies, abuse and topics that children can relate to. I am adamant that reading is the pathway to becoming informed and a useful member of society.

Publications

Irene has published four poetry anthologies. The poet has also had poetry and short stories published in both local and overseas books, as well as newspaper articles published in South Africa. She has won poetry awards and an award for general success in the publishing world.

See two of her poems below.

CHRONICALLY CHALLENGED

By Irene Emanuel

I’m working and walking

though chronically challenged;

I’m thinking and talking

though chronically challenged;

I’m laughing and crying

though chronically challenged;

I’m sitting and lying

though chronically challenged;

My insides are messed

and chronically challenged;

My outsides are dressed

though chronically challenged.

The list of what’s challenged

is endlessly long

is medical science

going to write me a song?

In medical books, I’m living proof,

though chronically challenged

I’m still waterproof.

I’ve asthma, diabetes and rhinitis too,

hernia, depression and no-one to sue;

Though chronically challenged,

and living on pills;

I know that my life

is still full of thrills.

So hit me again, what else is in store?

though chronically challenged,

at least I don’t snore.

 

PILLORIED

By Irene Emanuel

I am a rainbow ghost, see-through in the light;

A conglomeration of multi-coloured pills

that prevent me from becoming a real ghost.

The pills play music tattoos on my skeleton

as they race down my gullet, looking for signage

direction to the weak spot.

I wonder what the outcome would be if the signs got scrambled?

Would my diabetes become asthmatic?

Would my high blood pressure run into the blood thinner and become watery?

Would that increase the water on my lungs and cause flooding?

What would happen if there was a traffic jam?

Would the various pills just give up, dissolve into a heap and suffer a melt-down?

Would my body rebel, fight back, expel the pills, lie down and fade out?

A bitter pill to swallow is the fact that I am chained forever, to staying alive with pills.

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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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Zoné Oberholzer – the beauty living with Type 1 diabetes

Modelling, insulin pumps, make-up and studying. This is all in the life of Zoné Oberholzer, a Type 1 diabetes patient and a Miss Supranational SA 2019 finalist.


Zoné Oberholzer (21) lives in Pretoria, Gauteng. She is an Education (BEd) student at Aros University.

The young Pretoria beauty recently celebrated her 21stbirthday which came at an apt time as she just finished her first year June exams. We caught up with the  model to find out how she has handled living with Type 1 diabetes for 17 years.

When were you diagnosed?

In September 2002. I was four years old. My nursery school teacher mentioned to my mom that I was no longer playing outside and that I was constantly thirsty. She suggested that we see a doctor, where upon I was diagnosed.

I spent a week in hospital where my blood glucose was stabilised, and my parents were educated about Type 1 diabetes. The doctor said the most likely cause was the chickenpox virus which I had contracted nine months earlier.

I started using a pump (Medtronic Minimed Paradigm) at age six. My mother decided it would be easier for me to be on pump therapy before I started school. This helped my parents to regulate my blood glucose levels.

They educated the teachers in using it. We, however, quickly learnt that it would be best for me to handle my own pump. This forced me from a very young age to know my pump and also calculate carbohydrates. Although, it was very difficult to start off with, it helped me to manage my condition from an early age and to take responsibility.

The insulin pump only operates on short-acting insulin (NovaRapid). I think it makes life easier to not have to use a long-acting insulin as well.

When did you start modelling?

As soon as I was diagnosed, my mother decided to boost my self-confidence by enrolling me to do a modelling course. Since then it has been an absolute passion. Not only has it motivated me to look after myself, but it has inspired me to use it as a platform to promote diabetes awareness.

Did modelling boost your confidence as your mom hoped?

Modelling definitely boosted my confidence. But, it was a learning process throughout all the years to eventually bear the fruit. It definitely takes the correct attitude to use the experiences I learned from modelling for a positive growth experience. It stays crucial to seek your identity in Christ and not in modelling.

Why did you enter Miss Supranational SA 2019?

I entered as I saw it as an opportunity and platform to make a difference. Especially, among the diabetic community.

Miss Supranational South Africa 2019 focuses primarily on social upliftment. It creates a platform for finalists and winners to achieve their goals within the pageant, entertainment and business industries.

I am so grateful to be a finalist and thankful for the opportunity. The winner will be announced on 27 July at the Arto Theatre.

Have you been in any other contests?

Yes. Besides some smaller contests, I am currently a title holder (Apprentesses Charity 1st Princess) for Apprentesses SA. I was also a finalist for Top Model South Africa.

Do you proudly wear your insulin pump during modelling competitions?

In the past I would hide my pump as I was ashamed. I saw diabetes as my identity. This led me to hide myself from the world, but I realised that diabetes is only a part of me. A part of me that I should embrace and be proud of. This only happened after school. 

It is my goal to wear my insulin pump with pride at Miss Supranational SA. It’s not always easy as pageant dresses don’t always cater for an insulin pump. But, I will definitely wear it if the costumes allows.

Has it been easy to manage your diabetes?

No. It hasn’t been easy. Nonetheless, I’m grateful for the lessons learnt through my diabetes journey. Every day has its highs and lows. One just has to learn how to deal with it and not run away from it.

I would definitely not exchange living with diabetes for an easier life, because the lessons I’ve learned and keep on learning are far too valuable. The hardships of this condition empower me to empower those around me with positivity.

What are the highs of having diabetes?

There’s a valuable lesson that diabetes teaches every day. From a lighter viewpoint, you will live a healthier life than the average person out there. This is because you must be sensitive to what you eat, what you do, how you do things, and where you do things.

What are the lows of having diabetes?

Personally, the low is that no matter how healthy and cautious you live, there is always the risk of unexpected blood glucose drops and highs.

Do you follow any any special diet?

I’m not on a special diet, but I do follow a balanced healthy diet. I eat according to my blood glucose levels. I give my body what it needs. Not what it wants.

Do you make use of sweeteners?

My mother raised me to be a healthy child living with diabetes. She taught me from an early stage that sweeteners aren’t necessary to live a happy full life.

What helps you the most to manage your diabetes?

My support system, my family, boyfriend and, most importantly, God! If it wasn’t for Him, I wouldn’t have made it this far. He turned my misery into a ministry.

Tell us how puberty affected your blood glucose

Puberty took my blood glucose levels on a roller coaster. My menstruation also affected my blood glucose levels. I usually struggle with a higher blood glucose level during menstruation.

We wish Zoné all the best for the finals of Miss Supranational SA 2019.

 

Photos by Kayleigh Kruger

Zoné Oberholzer - the beauty of living with Type 1 diabetes

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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The keto diet – what you need to know

Recently, the ketogenic diet (keto for short) has been in the spotlight as the new diet to try. With that dietitian, Retha Harmse, educates us on the ‘latest craze’ diet.


The keto diet is everywhere; it’s difficult to avoid seeing it on influencers’ Instagram stories; keto options in supermarkets and on restaurant menus; and even friends or relatives speaking about their wonderful results. But, let’s take a closer look at the ketogenic diet.

What it the keto diet?

The ketogenic diet is a high fat, low carbohydrate and low to moderate protein diet that changes the body’s metabolism into ketosis. Any diet where fat is metabolised instead of carbohydrate is essentially a ketogenic diet.

Understanding ketosis

During a ‘normal’ or well-balanced diet, the body’s main source of energy is carbohydrates. More specifically, glucose which is the end-product of carbohydrate metabolism/digestion.

But the body is also able to burn fat for energy, and this is utilised in the form of ketones. Ketones are molecules produced by our liver when fat is metabolised; this metabolic switch is called ketosis.

However, the body doesn’t go into ketosis if there is enough carbohydrates available. Consequently, carbohydrates need to be drastically reduced or eliminated to move towards ketones as the primary energy source.

What does it involve?

Generally, on the ketogenic diet, the macronutrient ratio varies within the following ranges:

  • 65 – 80% of calories from fat.
    • Fat-intake is often over 150 grams (double the usual intake of fat).
  • 20 – 25% of calories from protein.
  • 5 – 10% of calories from net carbohydrate.
    • Roughly 20 – 50 grams a day (compared to the recommended daily amount of 200 – 300 grams per day).

What does this mean in non-dietitian language?

The keto diet prescribes high amounts of fat (both animal and plant sources), low-carbohydrate vegetables, nuts, seeds, and modest protein in the form of meat, fish and eggs. It excludes grains, dairy, legumes, soy, most fruits and starchy vegetables.

Meticulous planning

Ketogenic diets require meticulous planning to ensure the liver continues producing a constant supply of ketones to supply the body with energy.

To maintain ketosis, an individual’s diet needs to be precisely planned and tracked daily, as limiting carbohydrates and increasing fat is not the only focus of the ketogenic diet.

It’s also imperative not to consume protein in excess, as proteins can also be broken down to glucose (through a process called gluconeogenesis). This will in turn inhibit the ability for the body to move into ketosis. Also, if carbohydrates are not restricted enough, it might result in ketonuria (ketones in the urine and not used as energy). This is detectable by urinary dipstick analysis.

The history of keto diets

Although ketogenic diets might seem like the new ‘craze’; they are nothing new. Ketogenic diets have been around from the early 1900s, when they were discovered to have an efficacy in the treatment and management of epilepsy in children.

It is still used for this purpose; although more recently these diets have gained popularity for the management of obesity and Type 2 diabetes.

However, it’s important to note that the macronutrient ratios and recommendations for the ketogenic diet in the management of paediatric epilepsy are substantially different than those advocated for the management of obesity and Type 2 diabetes.

What are the benefits?

In terms of weight loss, evidence suggests quicker initial weight loss. This might be due to the initial use of glycogen stores (glucose stored in the muscle and liver), or reduced energy intake due to increased satiety from eating a large amount of fat and protein.

But long-term differences in weight lost showed no significant difference in comparison to other diets.

As mentioned previously, ketogenic diets have been used for decades to treat epilepsy. But, more recently, research has suggested that they might have a role in treating Type 2 diabetes and inflammatory conditions, such as chronic pain. That been said, there isn’t sufficient evidence just yet to support ketogenic diets for these conditions in terms of its long-term safety and efficacy.

Lastly, research has found that people consuming fewer calories from carbohydrate tend to eat fewer foods high in added sugars, such as soft drinks, doughnuts, etc. Yet, other research has found that the more carbohydrate consumption is restricted, the greater risk there is for poor nutrient intake. 

Potential side effects

  • High fat diets, especially when it’s high in saturated fat, increases total cholesterol. More specifically LDL cholesterol which is the “bad” cholesterol.
    • Both total and LDL cholesterol are both biomarkers for poor cardiovascular health.
  • Reduced energy and decrease in performance in activities that use short bursts of power, because ketogenic diets depletes the energy stores in your muscles (glycogen as mentioned previously).
  • Fatigue, general weakness, headaches and sluggishness, or brain fog.
  • Due to the very low fibre intake of ketogenic diets, you may experience constipation, increased risk of digestive problems and microbiota imbalances.
  • Limited fruit, vegetables and grains consumption – thereby limiting nutrient intake that might lead to deficiencies.
    • Nutrients (lack of) of particular concern on the ketogenic diet are calcium, vitamin D, selenium, magnesium, zinc and phosphorus.
  • Increased oxidation and inflammation in the body.
    • Recent evidence has shown that high fat diets, especially saturated fat, may promote inflammation and lead to the progression of inflammatory diseases, such as Alzheimer’s disease.
  • Possible loss of lean muscle mass.
  • Dry mouth, frequent urination, halitosis (bad breath = acidic, fruity odour).

Take-home message

Currently, there is a lack of strong evidence for ketogenic diets, based on their health claims about longevity, gut microbiome and heart health. Diets that are higher in carbohydrates and lower in protein, in fact, have the strongest links to longer lives and happy guts.

There are various probable side effects when following a ketogenic diet, which is why there is a need for ongoing monitoring and consistent assessment by a qualified dietitian.

Overall, unless medically indicated, I do not recommend following a ketogenic diet. Considering fat and carbohydrates, it’s all about balance.

  • The types of fat you include and the quantities you consume does matter.
  • Carbohydrates does form part of a healthy balanced diet.

My tactic is always to look at sustainable changes you can make that doesn’t include elimination of entire food groups.

MEET OUR EXPERT


Retha Harmse (née Booyens) is a registered dietitian and the ADSA public relations portfolio holder. She has a passion for informing and equipping the field of nutrition. She is currently in private practice in Saxonwold, Houghton, and believes that everyone deserves happiness and health. To achieve this, she gives practical and individual-specific advice, guidelines and diets.


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Ramadan and diabetes: a collaborative approach to fasting

Dr Salim Parker gives a collaborative approach to Ramadan fasting.


One of the five pillars of Islam

Fasting from dawn (the meal in the morning is called Suhoor) to dusk (Iftaar) during the Muslim month of Ramadan is one of the five pillars of Islam. The Quran specifically instructs all mature and healthy Muslims that: “Oh you who believe! Fasting is prescribed to you as it was prescribed to those before you so that you may attain self-restraint.

Most Muslims start fasting from a very young age. Even though, it’s only obligatory when puberty is attained and it is a religious, social and community in most societies. The Islam religion follows the lunar calendar and Ramadan occurs 10 days earlier each successive year. This year (2019) it will be nearly the whole of May.

The sick are allowed to postpone the fast and may even be exempted from it, as stated in the Quran: “Whoever witnesses the month (of Ramadan) then he/she should fast. But, if any of you is ill or travelling – then he or she is exempted from fasting.”

Despite this concession many sick Muslims will fast despite learned religious scholars and medical professionals advising them not to. This applies equally to people living with diabetes and this article outlines some guidelines as to how to approach diabetics intending to fast.

Benefits of fasting

It’s known that there are several potential benefits of fasting during Ramadan. Feelings of compassion for the less fortunate and underprivileged are evoked in Muslims who fast. Though the hunger and thirst senses are heightened, the natural sense to eat or drink is controlled. This leads to a sense of having willpower and to be in control of the senses.

The long-term ideal is for Muslims to ultimately be able to resist daily unnecessary and potentially harmful forms of food as urged by the Quran to: “Eat of what is lawful and wholesome on the earth,’ and ‘And He (God) enforced the balance. That you exceed not the bounds; but observe the balance strictly and fall not short thereof.”

Fasting also offers a time to ‘cleanse’ the body and the soul. The person fasting is encouraged to develop a greater sense of humility, spirituality, and community involvement.

There are also indications of physiological benefits of fasting. Some studies indicate that intermittent fasting limits energy intake. This promotes weight loss in obese individuals, which could be cardio-protective. Insulin sensitivity is also increased.

A holistic approach needed

Currently, of the 366 million humans on earth living with diabetes, more than 50 million are Muslim. In 2015, diabetes was the leading cause of death amongst South African females, and the sixth most frequent one amongst males. Diabetes was the second leading cause of death overall in South Africa after tuberculosis that year.

Many South African Muslims living with diabetes will fast irrespective of their health status. It’s important that there should be synergy between the healthcare professionals, the Islamic scholars and the Muslims living with diabetes who want to fast. Several factors need to be considered:

  • Age of the person
  • Medications used
  • Insulin dependency or not
  • Co-morbidities
  • Recent complications
  • Whether living alone or not
  • Easy access to a glucometer
  • Social support

Lifestyle management

All Muslims living with diabetes should ideally have a pre-Ramadan consultation beforehand with their healthcare practitioner. Fasting and the management of lifestyle conditions go hand in hand and a holistic approach should be adopted.

Dietary intervention is essential and the inclusion of more fibre, complex carbohydrates, vegetables, legumes should be encouraged, as should sparing salt use.

There is increasing evidence that dates, a staple food type during Ramadan, may have beneficial effects on glucose and cholesterol levels during Ramadan and may lead to a decrease in cardiovascular risk factors. Dates, consumes in moderation, are rich in fibre and is high in fructose, which has a lower glycaemic index than sugar.

It’s known that not having breakfast, in the normal population, increases the possibility of being overweight by a factor of five, and increases the chance of developing diabetes. The consumption of the pre-dawn meal is hence paramount. Stopping smoking and optimising of medication and co-morbid conditions should be discussed as well.

Maintaining some form of exercise, such as the optional nightly Ramadan prayers (if possible and depending on level of fitness), is part of lifestyle maintenance.

Complications associated with fasting

Hypoglycaemia

Hypoglycaemia is the concern of most doctors and patients when fasting is contemplated by the Muslim living with diabetes. Several patients, especially the elderly, are not always aware when their glucose levels drop. In one study, 24 out of 29 subjects were not aware that their glucose levels were low.

Different patients will have different signs and symptoms at different levels, with a glucose level below 4 mm/L being dangerous in most instances. Signs are often subtle, such as slight inattentiveness, and may not be easily be picked up by household members. The easy availability of glucometers is paramount in all circumstances and it should be emphasised that checking the levels (finger prick test) does NOT invalidate the fast. If levels are low, the fast should be broken immediately with the religious edict that life and health are MORE important than obligations emphasised.

Hyperglycaemia

Ramadan, contrary to its intention, is associated with caloric excess. An abundance of savouries, pastries and desserts is the norm and people living with diabetes consume as much as others. Hyperglycaemia can thus occur and at times is difficult to distinguish from hypoglycaemia, based on signs and symptoms alone.

The availability of glucometers is thus again important. Patients often fear hypoglycaemia and reduce, or even stop, their medication on their own. Coupled with the dietary excess, the chances of hyperglycaemia are increased and in some countries, such as Pakistan, more cases of hyperglycaemia than hypoglycaemia are seen during Ramadan.

Dehydration

Dehydration, especially if the diabetes is poorly controlled, is a possible complication of fasting during Ramadan. Polyuria (production of abnormally large volumes of dilute urine) and a reluctance to consume too much fluids at night (to avoid urinating) increases the possibility and the development of pre-renal failure, and thrombosis may have to be considered.

Risk categories1 

Category 1: Very High Risk

This include patients with one or more of the following:

  • Severe hypoglycaemia within the three months prior to Ramadan.
  • Diabetic ketoacidosis (DKA) within the three months prior to Ramadan.
  • Hyperosmolar hyperglycaemic coma within the three months prior to Ramadan.
  • History of recurrent hypoglycaemia.
  • History of hypoglycaemia unawareness.
  • Poorly controlled Type1 diabetes mellitus (T1DM).
  • Acute illness.
  • Pregnancy in pre-existing diabetes, or gestational diabetes (GDM) treated with insulin or sulphonylureas.
  • Chronic dialysis or advanced kidney disease.
  • Advanced macrovascular complications.
  • Old age with ill health.

Patients in this category MUST NOT FAST. If they insist on fasting, close monitoring and counselling is essential, with specific instructions given on when they MUST break their fast if necessary. They must be informed that they are putting their health and life at risk.

Category 2: High Risk

In this category are patients with one or more of:

  • T2DM with sustained poor glycaemic control.
  • Well-controlled T1DM.
  • Well-controlled T2DM on MDI or mixed insulin.
  • Pregnant T2DM or GDM controlled by diet only or metformin.
  • Chronic kidney disease stage 3.
  • Stable macrovascular complications.
  • Patients with comorbid conditions that present additional factors.
  • People with diabetes performing intense physical labour.
  • Treatment with drugs that my affect cognitive function.

Patients in this category SHOULD NOT FAST. If they insist on fasting they should also be closely monitored.

Category 3: Moderate/low risk

The following fall in this category:

  • Lifestyle therapy
  • Metformin
  • Acarbose
  • Thiazolidinediones
  • Second-generation Sus
  • incretin-based therapy
  • SGLT2 inhibitors
  • Basal insulin

These patients should be able to fast with sound advice being given first.

Medication adjustment

Each person living with diabetes will have unique circumstances and should be counselled individually. Explaining the risks and symptoms of hypoglycaemia and what appropriate actions to take must be emphasised.

Patients on medication need to be advised to change their dosages to accommodate the daytime fast. Some general guidelines are given below. But, again it must be emphasised that each Muslim who intends fasting must have advice tailored to their unique situation.

Metformin

Metformin has a low-risk of causing hypoglycaemia and generally no dose adjustment is needed. Some authorities advise taking two thirds of the total daily dose with the evening meal, with one third taken with the morning meal. The once-a-day formulation should be taken at the usual dose in the evening.

Sulphonylureas (SU)

The first-generation SUs had a high propensity of causing hypoglycaemia and should be avoided. The second-generation SUs are much safer. The general rule for stable patients living with diabetes is to take half the morning dose and the normal evening dose.

The other option is to switch evening and morning doses and reduce the morning dose. The once-a-day formulation should be taken in the evening, instead of the morning with a halving of the dose for the first few days. The dose can then be adjusted as needed.

Insulin

The dose of basal insulin or once a day premix should initially be decreased by 20% and given in the evening. When basal insulin is given twice a day, the morning dose should be given in the evenings with half the evening dose given in the morning. The same applies to premixes given twice a day. Insulin that is used three times a day should have the midday dose omitted and the morning dose halved. The dosages can then be adjusted as needed.

Other diabetic medications

These generally do not need dose adjustments. Once daily doses should preferably be taken in the evening.

Conclusion

Ramadan is an ideal time for people living with diabetes to implement lifestyle changes that would be in accordance with their religion and improve their health as well as their diabetes control.

Each patient must be consulted well before the commencement of Ramadan and their risks stratified according to their unique circumstances.

Access to glucometers is an important aspect of fasting, as well as knowing who should and should not fast, how and when to test for glucose abnormalities and when to break the fast. A collaborative approach between patients living with diabetes, religious scholars and medical professionals is the ideal approach to ensure the safety of those who want to fast, and to assure those who should not fast that their religion most certainly permits that.

 


Reference:

  1. JEMDSA 2017 Volume 22 Number 1 (Supplement 1) Page 119-136

MEET OUR EXPERT


Dr Salim Parker is a general practitioner in Elsies River. He is an Honorary Research Associate: Department of Medicine, University of Cape Town and Immediate Past President: South African Society of Travel Medicine (SASTM).