Author: Diabetes Focus eMag

One-on-one with Dr Cliff Allwood

Posted on by
Share

Dr Cliff Allwood, specialist psychiatrist – Akeso Clinic Pietermaritzburg, explains how diabetes and depression are linked.

What comes first – depression or diabetes?

As far as we know, there is not a causative link between the two conditions and they may occur at different times. However both conditions may be linked to a significant physical, medical or emotional stressor. The onset may have occurred at a similar time.

Is there a link between the two? And how does this work?

There does not seem to be a direct link, however, we do know that clinically the two conditions do affect each other. Each makes the other worse. Both conditions need to be adequately treated.

How do you break this vicious cycle?

Both conditions have to be taken seriously. Diabetes and any other medical conditions must be treated. Ongoing monitoring and control is essential. Depression must be treated with whatever biological, psychological, social or spiritual interventions are appropriate and effective. Lifestyle changes may have to be made in both conditions, and exercise is essential for both conditions.

How does depression in a diabetic patient differ to any other form of depression?

In the diabetic patient, mood can be affected by blood sugar changes. The patient has to be aware of the effects of both ‘highs’ and ‘lows’. Sometimes the medications used for diabetic control may have an effect on mood. Diet and lifestyle changes may also affect mood. The patient is encouraged to be observant about the effects of changes. A partner or close friend can be helpful in observing changes. On the other hand, depression may affect the manner in which the patient is managing his/her diabetes. Depression may have a negative effect on motivation and compliance with treatment.

In advanced stages of diabetes sufferers may lose sight, limbs, or have other medical conditions. These profound disabilities will commonly result in depression. The depression requires full treatment. Untreated depression may have severely negative effects on later compliance and efforts towards treatment and rehabilitation.

Is there an increase in this?

There is a worldwide increase in the incidence of depression.

What are the signs of depression in the diabetic patient? Do these differ from other forms of depression?

Depression in a diabetic patient is no different from depression in people who don’t have diabetes, except as mentioned in question four. However, any signs of ‘confusion’ in the patient must be taken very seriously since this indicates that either the blood-sugar is out of control, or there is some reaction to the medication. This requires a full medical examination and appropriate treatment.

How is depression beaten?

Treatment for depression varies dependent on the specific history and symptoms of each sufferer. Research does however indicate that treatment with medication and psychotherapy is generally most effective. Substantial lifestyle changes may be required and the recruitment of social support is also necessary, as self-isolation makes depression worse. If the depression is severe the sufferer can be treated with the assistance of an inpatient treatment programme, such as the programmes offered by Akeso.

When should partners or family members worry?

When the depression is preventing the sufferer from functioning as they wish to.

Are there tips and tools to reducing your levels of depression if you have diabetes?

Self-care is an important practice as is increasing self-awareness. The establishment of good habits like journaling (a food and mood diary); moderate and consistent cardiovascular exercise (brisk walking etc.); dealing proactively with negative thoughts; sustaining healthy friendships; ensuring compliance with medication; supplementation with Omega 3s; getting 20 minutes of sunshine every day; developing resilience; practicing self-acceptance and being kind to oneself – are just a few ways to limit the destructive impact of depression.

Read more on depression

Let’s talk depression

Posted on by
Share

World Health Day is celebrated on the 7th of April to mark the anniversary of the founding of the World Health Organisation. This year’s theme is “Let’s Talk: Depression.”

One in three South Africans will or do suffer from a mental illness in their lifetime – and depression is the most common mental illness. About one in six South Africans suffer from depression – although only about a quarter of people living with a mental illness ever seek or receive treatment.

Depression is the leading cause of suicide and, in South Africa, there are 23 completed suicides every day – and a further 460 attempted suicides every 24 hours. “Men are more likely to commit suicide than women as they don’t seek help until it’s too late,” said the South African Depression and Anxiety Group’s (SADAG) Director, Cassey Chambers.

It may not always be easy to tell the difference between a run-of-the-mill bad mood and depression. If you have five or more of these symptoms for most of the day, nearly every day, for at least two weeks, and the symptoms are severe enough to interfere with your daily activities, you may have depression:

  • Depressed mood, sadness or an ‘empty’ feeling or appearing sad or tearful to others.
  • Loss of interest or pleasure in activities you once enjoyed.
  • Significant weight loss when not dieting, or significant weight gain.
  • Inability to sleep or excessive sleeping, always feeling exhausted.
  • Restlessness or irritation (irritable mood may be a symptom in children or adolescents   too), or feelings of ‘dragging’.
  • Fatigue or loss of energy.
  • Feelings of worthlessness, or excessive or inappropriate guilt.
  • Difficulty thinking or concentrating, or indecisiveness.
  • Recurrent thoughts of death or suicide.

Depression affects people of all ages, from all walks of life and negatively impacts a sufferer’s ability to carry out everyday tasks. Depression has consequences for families, friends, workplaces, communities, and healthcare systems. Untreated depression can lead to self-injury and suicide. SADAG, like the WHO, believes that educating people about depression can reduce the stigma that surrounds mental illnesses and encourage more people to seek help.

We all have days when we want to hide under the covers and wish the world would leave us alone; days when we feel precariously on the verge of tears or an angry outburst. Minor things can trigger a bad day: having a squabble with a friend or colleague, getting stuck in traffic, or just waking up on the wrong side of the bed. Off-days happen to everyone, but when a bad day turns into a bad month, it’s time to take a closer look at your mood. It’s time to talk depression.

This year, for World Health Day, SADAG aided the whole of South Africa to talk about depression, using the following tools:

  • New online videos from actress and celebrity Lillian Dube sharing her experience with depression; Dr Frans Korb discussing depression in men; Dr Chabalala sharing information on depression in the elderly; psychologist Zamo Mbele giving tips on coping with depression as well as support group leaders Sheila and Thuli talking about how you can benefit by joining a local support group. Visit www.sadag.org to watch these videos, which were launched on Friday 07 April.
  • SADAG hosted a FREE Online #FacebookFriday Q&A Chat on “Let’s Talk: Depression” with psychologist, Liane Lurie at 1-2pm and again at 7-8pm with psychologist, Linda Blokland. Participates asked questions regarding depression diagnosis, symptoms, treatment plans as well as how to get help and support. Visit our Facebook Page “The South African Depression and Anxiety Group”.

This year’s World Health Day theme gives us a unique opportunity as the global community to talk about a health topic that concerns us all. Depression can be treated and suicide can be prevented. The more we understand about depression and suicide, the better we can help our communities.

In a country where access and services for people suffering with mental health issues is scarce, SADAG provides an invaluable service through their counselling call centre offering free telephonic counselling, referrals, information and support, as well as through various projects including school talks, rural outreach programmes, corporate talks and training.

To speak to a SADAG counsellor, call 0800 21 22 23 or SMS 31393 if you or a loved one are going through depression and need help.

SADAG is a mental health advocacy group, running a call centre with 15 helplines offering free telephonic counselling seven days a week, 365 days a year, and runs the only Suicide Crisis Helpline (0800 567 567) in the country. SADAG gives referrals nationwide, as well as information and support for all mental health issues encouraging people to speak out and get help.

Important SADAG Numbers:

SADAG Helpline – 0800 21 22 23

Suicide Crisis Helpline – 0800 70 80 90

24 Hours Substance Abuse Helpline – 0800 567 567

SMS – 31393

facebook Website – www.sadag.org

Article written by SADAG

Retinal detachments and diabetes

Posted on by
Share

When discussing complications and risks that diabetes patients face when it comes to the health of their eyes, the most common warnings are usually retinopathy, cataracts, refractive errors and dry eyes. However, people with diabetes also have a risk of developing another serious condition, known as retinal detachment.

The retina is the light-sensitive layer in the back of the eye that is responsible for the conversion of light into signals that are sent to the brain via the optic nerve. A retinal detachment occurs when the retina separates from its supporting layers. This can lead to complete loss of vision if it is not treated immediately.

A common form of retinal detachment in diabetic patients is called diabetic tractional retinal detachment1. This advanced form of retinal disease usually occurs in cases of proliferative diabetic retinopathy, as a result of extensive abnormal vessel growth, which in turn leads to the forming of fibrous scar tissue within the vitreous (jelly-like substance within the eye)1. The retina has a risk of detaching when this scar tissue contracts and pulls, and could also lead to the formation of retinal tears or holes1.

Symptoms of retinal detachment

This is not a painful condition, but it is an ocular emergency and requires urgent assistance in order to prevent total visual loss. When you see any of the following symptoms, it is crucial to get to your ophthalmologist as soon as possible:

  • Flashing lights2
  • Sudden occurrence of floaters (dark floating spots that look like threads or flecks)2
  • Black curtain-like appearance over visual field1

Risk factors

Although diabetic patients have a risk of retinal detachment, there are also several other risk factors that could lead to retinal detachment even in people who don’t have diabetes. This includes the following:

  • Severe myopia (near sightedness)2
  • Injury to the eye2
  • Cataract surgery2
  • Family history of retinal detachments2
  • In the case of diabetic patients, uncontrolled blood sugar levels is a big risk factor1

Treatment

There are several different treatment options that can be used to repair a retinal detachment, depending on the severity of the tear. With a full retinal detachment, surgery is most definitely required. Surgery will ensure that the retina gets placed back in its proper position, in order to recover full function of the retina3. The surgery method to be used will depend on the nature and characteristics of the tear3. Different types of retinal detachment surgeries include:

Scleral buckling surgery

With this surgery, a flexible band (made from silicone or rubber2) gets placed around the eye, counteracting the force that is pulling the retina out of place3. This method of surgery flattens the retina by pushing or ‘buckling’ the sclera towards the middle of the eye2. This allows the tear to settle against the wall of the eye2. This procedure will most likely be done in conjunction with cryopexy (extreme cold) or diathermy (heat) or laser photocoagulation to seal the retina to the bottom layers2. This is a same day procedure that gets done in theatre under local or general anaesthesia, and proves to be successful in retaining vision, especially when the macula was not affected by the detachment2.

Vitrectomy

A vitrectomy entails the removal of the vitreous where the abnormal blood vessels are growing1. The scars left by the abnormal blood vessels will then be microscopically dissected and laser therapy will be performed to prevent further vessels from forming1. A gas or silicone oil is then placed in the eye to keep the retina in place. A vitrectomy involves serious risks, such as cataracts; bleeding into the vitreous; increased pressure inside the eye; and infection2. It does, however, restore some of the vision and prevent the detachment from getting worse2.

Pneumatic retinopexy

This procedure combines the insertion of a gas bubble into the eye with laser therapy or cryopexy to flatten out the retina2. The patient must then keep their head at a certain angle for one to three weeks after the procedure, to keep the gas bubble in place2. This procedure is generally considered when a single break or tear caused the detachment or when the detachment is located in the upper part of the retina2. This is an effective surgical method to repair a retinal detachment but has an extensive recovery period.

Your ophthalmologist will discuss the treatment options with you and choose the suitable treatment for your specific case.

Last thought

It is important to maintain a HBA1C (long-term measure of blood glucose control) level of 7,0 or less. Although diabetic retinopathy can’t be prevented, maintaining proper blood glucose levels together with yearly visits to your ophthalmologist will go a long way to maintain the severity and progression of the condition. Constant self-monitoring and quick response to any of the abovementioned symptoms plays a key role when it comes to retinal detachments, so keep your ophthalmologist on speed dial if you know you might be at risk.

References:

  1. http://retinavitreous.com/diseases/dm_trd.php
  2. http://www.webmd.com
  3. https://www.aao.org

MEET OUR EXPERT - Dr Marcel Niemandt

Marcel is an eye surgeon specialising in cataract and laser refractive surgery. He has qualifications through the Universities of Pretoria and KZN and is a member of the CMSA and OSSA. Refer to www.drmcniemandt.co.za for further info or call the rooms at 012 809 6027.

Staying healthy together

Posted on by
Share

When starting your fitness journey, it can be challenging at first. Sheana Abrahams suggests getting a training buddy – partner, family member or friend – to help make it less of a burden. Training with someone will make exercise fun and gives you the support you need, and allows both of you to hold each other accountable for every training session. Sheana shares the benefits of exercise and provides tips on how to support each other and how to stay on this fitness journey together.

What are the benefits of exercise?

Where to start? Before you start any exercise, make sure you have spoken to your doctor and that he/she has cleared you for exercise and set out clear guidelines. If there are any other complications, or certain limitations have been set by your doctor, you should consider obtaining a personalised exercise program prescribed by a health professional, e.g. a biokineticist, to make sure that you’re doing the right exercise for your type of diabetes and at the right intensity level.

Let’s look at what some of the benefits are:

  • Better control of your diabetes and blood glucose levels: when you exercise, your muscles use glucose for energy. That being said, it is important to constantly check your blood sugar levels when you exercise. Physical activity may affect your blood sugar levels both during and after exercise, so make sure you check it regularly.
  • It can help avoid long-term complications: by exercising, you are in turn controlling your blood glucose levels, which is important to help prevent long-term complications such as kidney disease, nerve pain and heart problems.

Other benefits of exercise are:

  • Helps lower blood pressure
  • Better control of weight
  • Stronger bones
  • Stronger and leaner muscles
  • Exercise gives you more energy
  • Helps improve your mood
  • Makes you sleep better
  • Helps with stress management
  • Helps prevent diabetes in family members by lowering their risk factors.

What exercise can you do?

There are three types of exercises that you should do: aerobic; strength/resistance training; and stretching. Your aim should be to have a good balance of all three1.

Examples of aerobic exercises are:

  • Walking
  • Jogging/running
  • Tennis
  • Swimming
  • Dancing
  • Cycling, etc.

The American College of Sports Medicine (ACSM) guidelines say that you should aim to get at least 30 minutes of aerobic exercise most days of the week. Remember, this does not have to be done in one go, you can split the 30 minutes up throughout the day, for example you can do 10 minutes in the morning, 10 minutes in the afternoon, and 10 minutes in the evening. As you get fitter, you can gradually build up to doing exercise for a continuous 30 minutes.

Be creative with your exercise; go for a walk in the park, or after dinner get the whole family to walk together, put the music on and dance, walk with a friend, take the dog for a walk, or go for a nice jog near the beach. The more fun exercise is, the more you’ll stick to it. Find activities that you really love and enjoy, and ask your friend, partner or family to do the exercises with you. This will help keep you motivated.

Strength training

Once you have started doing your aerobic training and you’re managing to fit in 30 minutes most days of the week, chat to your doctor about adding strength training to your exercise regime.

Simple strength training on at least two days of the week is important in Type 2 diabetes as it helps to control the blood sugar levels and improves the action of the body’s own insulin2. Strength training builds lean muscle, and it also helps to maintain strong healthy bones.

Strength training doesn’t mean that you need to lift weights, you can use your own body weight to build up strength. Using your own body weight, you can do exercises such as squats, push-ups, lunges, crunches or sit-ups.

When you’re starting a strength training program, make sure that it is prescribed specifically for you. Always seek advice from your doctor, biokineticist or personal trainer who has experience in working with people who have diabetes. It’s important for you to start with the right exercises and the right intensity as well as being taught how to do the exercise correctly. Doing strength training for 20-30 minutes two or three times a week is sufficient1.

Flexibility training

Flexibility training can help prevent pain, stiffness, and injury of muscles and joints1. Stretching before and after training reduces muscle tenderness and relaxes your muscles2. Yoga is a great activity to do to help increase your flexibility.

Exercise safety

  • Remember to start slowly, especially if you have not exercised before.
  • Check your blood sugar before and after exercise until you’re aware of how your body responds to exercise4.
  • Do a nice warm up before training and a cool down after training.
  • Remember to stay hydrated and drink plenty of water before, during and after exercise4.
  • Be prepared for any episodes of low blood sugar. Always have something sweet with you that can increase your blood sugar level4.
  • Always carry a cell phone with you when exercising in case of an emergency4.
  • Do not exercise in extremely hot or cold temperatures.
  • Wear proper shoes and socks to protect your feet when doing any physical activity4.

Remember to be conscious of your body, if you become short of breath, dizzy or light-headed, stop exercising. Seek advice from your doctor if you continue to have any of the above symptoms or feelings or experience any other unusual problems4.

What can you do as a partner, family member or friend?

  • Talk to your partner, family member or friend who has diabetes about seeing the doctor before starting an exercise program. This will allow him/her to know their exercise limits and from there you can both set realistic goals and choose the right exercises for the type of diabetes.
  • Suggest going for walks a few days in the evening after work.
  • Instead of going out and getting takeaways, take a nice walk together or do a fun activity and then make a healthy meal.
  • Sit down and work on your training plan together, set your goals, and decide on the exercises that both of you can do. Make it a team effort.
  • Encourage your friend, partner or family member who has diabetes to do his/her blood checks before, during and after exercise, and to keep an exercise journal and write down all training sessions and blood glucose readings.
  • Encourage each other to make exercise a daily habit, and choose fun activities to do together that you both enjoy.
  • Get educated about diabetes, know the signs and symptoms of low blood sugar and learn what to do in these situations.
  • Constantly acknowledge your partner, friend or family who has diabetes, and let them know how proud you are of them for keeping up with their exercise regime, and remind them how this is an important part of managing their diabetes3.

Any chronic illness can have a profound impact on the family member, partner or friend. Looking at ways to stay active and healthy can be a fun and rewarding journey that you can all take together.

References:

  1. https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-exercise
  2. http://prescription4exercise.com/patientpublic/health-enhancing-recommendations/condition-specific-recommendations/type-2-diabetes/type-2-diabetes-prescription/
  3. https://www.ghc.org/healthAndWellness/?item=/common/healthAndWellness/conditions/diabetes/familyAndSupport.html
  4. https://health.clevelandclinic.org/2014/06/5-best-exercises-for-people-with-diabetes/

MEET OUR EXPERT - Sheana Abrahams

Sheana Abrahams studied a BSc. Sport and Exercise Science and then completed a BSc. (Honours) Biokinetics. Based in Cape Town, she the Head of Health and Wellness at GetSmarter, and frequently presents the fitness segment on the Expresso Show on SABC 3.

Maintaining a healthy sex life

Posted on by
Share

Newly diagnosed diabetes patients may have many questions at first, but, “How will this chronic illness affect my sex life?” is probably not one of them. However, diabetes and the medications used to treat it can cause sexual challenges for men and women, but with some education and a little extra planning, there’s no reason for diabetes to be a downer in the bedroom.

It’s important to be aware of these possible sexual changes, and to discuss any sexual malfunctions with your doctor no matter how embarrassing you may find the topic.

Women’s sexual health

Most commonly, women who have diabetes will experience a lower sex drive compared to women without the condition.

This can be for several reasons:

  • Blood glucose level changes can cause irritability or a lack of energy.
  • Depression and anxiety associated with diabetes can lower a desire for sex.
  • Anti-depressive medications can lower sex drive.
  • Autonomic neuropathy can lead to vaginal dryness and painful sex.

In some cases, nerve damage in diabetic women can make it more difficult for a woman to experience an orgasm. Sex can also be uncomfortable and unpleasant when a woman has a yeast infection or experiences vaginal itching.

These sexual difficulties are not a normal part of aging and can be addressed if you broach the topic with your doctor. They may suggest the following options to maintain a healthy sexual appetite:

  • Monitor your blood glucose levels closely before having sex to increase energy and reduce irritability.
  • Seek medication for depression or anxiety.
  • If anti-depressive medicines are causing your low sex drive, speak to your doctor about trying a different medicine, or discontinuing the medication and seek counselling instead.
  • Use water-based lubricant to combat vaginal dryness and practice Kegel exercises to relax vaginal muscles.
  • Avoid drugs that may cause painful yeast infections.

Men’s sexual health

Diabetes can also cause sexual complications in men; most notably, erectile dysfunction and retrograde ejaculation. Those with erectile dysfunction cannot get or maintain an erection. In men with retrograde ejaculation, semen empties into the bladder, rather than out of the tip of the penis. In both cases, diabetes-related autonomic neuropathy is likely the cause. This type of nerve damage often occurs when a person maintains poor control over their glucose levels.

In the case of erectile dysfunction, when the autonomic nerves are damaged, they can no longer communicate arousal from the brain to the penis. Similarly, damaged autonomic nerves may stop a sphincter in the bladder from opening, stopping semen to exit the penis. Erectile dysfunction can be embarrassing and makes the act of sex physically impossible. Men with retrograde ejaculation will likely experience infertility.

Additionally, some uncircumcised men who take certain drugs may also notice a high frequency of genital bacterial infections. While neither condition is, painful or causes bodily harm, both can cause problems in the bedroom.

Fortunately, both erectile dysfunction and retrograde ejaculation have solutions. To treat erectile dysfunction, men may consider trying:

  • Oral prescriptions, such as Viagra.
  • Injections of prostaglandins into the penis.
  • Vacuum pumps to draw blood to the penis.
  • Surgical implants.
  • Counselling to reduce anxiety about sexual performance.

To treat retrograde ejaculation, men may consider trying:

  • Meeting with a urologist for a more specific diagnosis of the condition.
  • Medication that strengthens the bladder sphincter muscles.
  • Fertility treatments, such as extracting semen from the urine to use in artificial insemination.
References:
American Diabetes Association. (2013, June 7). Autonomic Neuropathy. Retrieved from http://www.diabetes.org/living-with diabetes/complications/neuropathy/autonomic-neuropathy.html.

American Diabetes Association. (2013, August 1). Sexual Health. Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-and-care/women/sexual-health.html

Auteri, S. (2014, March). How Chronic Illness Can Affect Sexual Function. Retrieved from https://www.aasect.org/how-chronic-illness-can-affect-sexual-function

The National Institute of Diabetes and Digestive and Kidney Diseases. (2008, December). Diabetes & Sexual & Urologic Problems. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/sexual-urologic-problems

Nyirjesy, P. (2013, May). Genital mycotic infections in patients with diabetes. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23748505

MEET OUR EXPERT – Taylor Griffith

Taylor Griffith2Taylor Griffith is an award-winning journalist with a background in newspaper, magazine and digital writing. She earned her degree from the University of Maryland’s Philip Merrill College of Journalism. She regularly contributes to drugwatch.com, along with other publications.

What it takes to have that ‘perfect’ smile
for you

Posted on by
Share

There is something rather special about a big bright smile. There is a certain warmth that we feel when greeted by someone who is smiling broadly. What is it about a full smile that makes it so attractive? Is there such a thing as a perfect smile? Marc Sher touches on some of the fundamentals of aesthetics in dentistry.

When the human eye sees things in proportion, we immediately find this attractive. This concept is known as the golden proportion or golden ratio, and is mentioned countless times in literature pertaining to cosmetic surgery and dental aesthetics. The golden proportion is an ancient concept, dating back to the times of the ancient Greeks. It has helped us understand why the relationship of adjacent shapes/objects makes it appeal to the human eye. The golden ratio is 1:0.618 or Pi, and is consistent in nature. The ratio between the front eight teeth, when looking directly at the central incisors, is one of these natural concepts that follows the golden proportion.

When the eight front teeth (smile line) of the top jaw follow the golden proportion, they will immediately look attractive; this is what we aim to achieve in dental aesthetics. It will always be a dentist and dental specialist’s greatest challenge when trying to recreate a smile.

The concept of the golden ratio is also seen in the relationship between the lips and teeth, the smile and teeth, and even the eyes and teeth. For any dentist to achieve that perfect smile for their patient, they must understand the golden ratio.

Just to clarify, the perfect smile does not exist in isolation and cannot be copied from person to person. To have a perfect smile is to have the right smile for you. Yes, we follow the principles that can help create that perfect ratio which may lead to a more attractive smile, but to try and achieve ‘perfection’ is only in the eye of the beholder.

Many dentists who specialise in aesthetic dentistry will understand the concept of a smile design. This is a process that we use to analyse a specific patient’s smile that helps guide the dental team in achieving their desired result; it involves using digital photography and videography to evaluate a patient’s smile line, lip line and central line, amongst other important features. We can use this information to digitally design a smile. It allows us (the dentist/specialist) to communicate the needs to the dental laboratory, in order, to create the ceramic/porcelain crowns or veneers which are to be bonded onto the front six to eight teeth (sometimes more) in the smile line. We then communicate this back to the patient. The use of a specialised dental laboratory is essential in this process as the dental technician is the one creating the ceramic/porcelain teeth.

The process of crowning/veneering teeth can be incredibly invasive as the tooth is usually irreversibly cut down to allow the ceramic prosthesis to fit. I, personally, do not advocate the cutting of healthy teeth to change their appearance. Once a tooth is cut/drilled on, there is no turning back. In cases where all other non-invasive options have been investigated and a tooth is already compromised, filled, broken, or missing, only then should the use of ceramics/porcelains be used.

I usually urge a patient to follow a less invasive route if they’re looking at changing their smile line. Orthodontics is my preferred method of moving teeth into their ideal proportion/relationship as orthodontists are incredibly skilled in creating the correct relationship between teeth. I always encourage my patients seeking an ‘aesthetic makeover’ to investigate the orthodontic process. This specific process does involve a sacrifice of sorts; wearing braces or retainers to move the teeth can be uncomfortable, cumbersome and obviously less attractive. However, it is important to understand that it is only a short-term sacrifice in the grand scheme of things, and the benefit is that you do not land up cutting healthy tooth structure.

“We shall never know all the good that a simple smile can do” – Mother Teresa

Tooth whitening

Tooth whitening plays a massive roll in the realm of aesthetic dentistry. I am often bombarded with requests to make my patients teeth whiter. What is important to understand, is the concept of tooth colour and staining. A natural tooth can have a variety of different levels of whites, yellows, blues and, even, greys. Therefore, we classify tooth colour in shades. This can be seen quite easily if you look at your canines; the neck of a canine has more of a yellow shade then the adjacent incisor.

Tooth whitening or bleaching changes the intrinsic (natural) shade of a tooth by penetrating the enamel layer and ‘bleaching’ the layer below, the dentine. The process involves the use of a peroxide-based bleaching agent, and a heated exchange reaction takes place. Tooth sensitivity is a very common side effect. However, it is not long-lasting.

Staining of teeth involves the extrinsic surface of the tooth. This is the after-effect caused by many of the wonderful things we love to eat and drink, such as coffee, tea, red wine, fruits, some vegetables and more. Smoking is also a major factor in extrinsic tooth staining. Fortunately, extrinsic stains can be quite easily removed by an oral hygienist or a dentist with specialised cleaning instruments. I always recommend a professional cleaning before any bleaching procedure is commenced.

All the concepts I have mentioned play a pivotal role in aesthetic dentistry. In today’s times, we can easily become obsessed with our appearance and be incredibly self-conscious of our smile. We may feel pressured to achieve perfection in our smile, and that obsession can alter the very essence of why we smile in first place. The act of smiling is far more important than the way it looks!

It is vital to protect what nature has given you by following a strict protocol of maintenance and prevention. You must also never compromise your dental health and function to achieve an aesthetic outcome. It is however comforting to know that with the help of modern technology in dentistry and with the skilled hands of a dentist, specialist and dental technician, we’re able to create beautiful bespoke smiles if needed.  

MEET OUR EXPERT - Dr Marc Sher

Dr Marc Sher (B.Ch.D) practices at The Dental Practice in Sea Point, Cape Town, and can be reached via email: marc@drmarcsher.co.za

The low down on South Africa’s sugar tax

Posted on by
Share

The Minister of Finance announced in the February 2016 National Budget a decision to introduce a tax on sugar-sweetened beverages (SSBs), with effect from 1 April 2017, to help reduce excessive sugar intake by South Africans. A revision of the proposed tax was discussed in the February 2017 Budget Speech, where it was announced that the tax will be implemented later in 2017 once further consultations have taken place. The Association for Dietetics in South Africa (ADSA) welcomes this step as one part of the solution to address the obesity problem and improve the health of South Africans.

How much sugar do South Africans really consume?

When you think of sugar-sweetened beverages, the first thing that comes to mind is the regular fizzy drink, but the term encompasses far more than that. SSBs are beverages containing added sweeteners that provide energy (calories or kilojoules) such as sucrose, high-fructose corn syrup or fruit-juice concentrates. This includes carbonated drinks (fizzy soft drinks and energy drinks), non-carbonated drinks (sports drinks, iced teas, vitamin water drinks and juice concentrates), sweetened milk drinks and sweetened fruit juices. And, many of us do not realise just how much sugar is found in these drinks. For example, a 330ml bottle of iced tea has a little over six teaspoons of sugar.

ADSA is concerned that the intake of added sugars (sugars added to foods and drinks during processing by the food manufacturing companies, cook or consumer) is increasing in South Africa, both in adults and children. Some estimate that children typically consume approximately 40-60g/day of added sugar, possibly rising to as much as 100g/day in adolescents. High intakes of added sugar, particularly as SSBs, has been shown to lead to weight gain and cause dental caries. The added sugar in these drinks makes them high in energy (kilojoules). Because these drinks don’t make us feel full in the same way that eating food does, most of us don’t reduce our food intake to compensate, making it easy to consume too many kilojoules. Over time, these extra kilojoules can cause one to become overweight, putting us at risk for diabetes, heart disease and certain cancers. Obesity is already a massive problem in South Africa, with two in three women and one in three men being overweight or obese, as well as almost one in four children.

What is ADSA’s recommendation for sugar intake?

ADSA supports the recommendations by the World Health Organisation (WHO) and the South African Food-Based Dietary Guidelines that we need to reduce the intake of beverages and foods that contain added sugars, such as sugar-sweetened beverages, sweetened yoghurts, frozen desserts, some breakfast cereals, ready-to-use sauces, cereal bars, health, savoury and sweet biscuits, baked products, canned or packaged fruit products, sweets and chocolates. The WHO advises reducing the intake of free sugars found in foods and beverages (including added sugars, but excluding sugars naturally present in fresh fruits, vegetables and milk) to less than 10% of total energy (kilojoule) intake for the day (i.e. 50g of sugar, which is approximately 12 teaspoons per day), with a conditional recommendation to further reduce intake to 5% of total energy (approximately six teaspoons per day) for additional health benefits. The South African Food-Based Dietary Guidelines also advise to ‘use sugar and foods and drinks high in sugar sparingly’. To put this into perspective, a 500ml bottle of a carbonated drink will provide your maximum sugar allowance for an entire day!

The sugar tax – is it a good idea?

The proposed tax on SSBs will mean an additional tax will be added on to the purchase price of sugary drinks, which is intended to decrease the purchase and consumption of SSBs. Encouragingly, in Mexico, a sugar tax has reduced sugary drink sales by 12% in the first year. The sugar tax is likely to affect shelf prices, but will also motivate manufacturers to reduce the amount of sugar added to their products. Initially, the proposal was for a tax rate of 20% on the added sugar content of a beverage. But in the February 2017 Budget Speech, it was announced that the proposed tax rate has been reduced to about 11%. ADSA is concerned that the lower tax rate might not be sufficiently high enough to have a significant impact on purchasing behaviour, and has submitted comments to National Treasury to motivate to strengthening the tax. ADSA welcomes the proposed tax on SSBs, but acknowledges that the sugar tax is only part of the solution to address the growing obesity problem. Just as taxing tobacco does not reduce or stop smoking by all people, taxing SSBs will not reduce or stop all purchasing and consumption of SSBs and reduce obesity on its own. Obesity is a complex condition, and sugar is not the only cause. There is a need for multiple interventions across a variety of different sectors to address unhealthy diets and lifestyles and have an impact on the obesity epidemic. ADSA recommends that revenue generated from the tax should go towards health promoting interventions, such as subsidies to reduce the costs of fruits and vegetables, education around healthy choices, and creating an enabling environment to make those healthier choices easier.

In addition to reducing the consumption of SSBs to prevent obesity and promote long-term health, ADSA continues to recommend a healthy diet which includes whole grains, fruit, vegetables, nuts, legumes, healthy oils, proteins such as lean meats and seafood, and a reduced intake of processed meats and salt, accompanied by regular physical activity.

To find a registered dietitian in your area, visit http://www.adsa.org.za/

ADSA’s detailed Position Statement on the Proposed Taxation of Sugar-Sweetened Beverages, with references, can be accessed here: http://www.adsa.org.za/Portals/14/Documents/2017/March/ADSA%20Position%20Statement%20on%20Sugar%20Tax_Updated%20post%20budget%20speech_2%20Mar%202017.pdf

This article was written by The Association for Dietetics in South Africa (ADSA).

Family ties

Posted on by
Share

Research has shown that families play a key role in how well people with diabetes adjust to the disease, integrate it into their lives, and manage it well. This suggests that good diabetes control depends on a healthy psychological environment. Rosemary Flynn advises on how to achieve this.  

You have diabetes, but in a way your family has diabetes too because you are one part of a whole family, whatever the family looks like: a partnership, married parents with children, grandparents or extended family. Each member of the family has an influence on all the others. On the one hand, how you deal with your diabetes will have an impact on your partner and family, and on the other hand how your partner and family supports you will impact you and how you handle your diabetes.

 

Creating a healthy psychological environment

If you manage your diabetes well and show that you can cope with the daily demands of diabetes, and get it right, your partner will relax and leave you to it and only be involved when you need it.

If you don’t take responsibility for your diabetes and either ignore it or defy it, your partner will become very anxious and will possibly try to persuade you to do the ‘right thing’ whether it is to do with what you eat or how you exercise or taking medications. They may do it in an annoying way and perhaps will need to learn how to do it more gently, but when you think about it, they have to deal with the stresses that diabetes brings too, particularly if you have Type 1 diabetes.

When your partner has these worries, he or she is not paranoid or unreasonable; they are natural responses because they love you. You may want to be totally independent and cope with your diabetes on your own, but if you are not being responsible about managing your diabetes, your partner will want to help. The more responsible you are, the less they will feel they need to nag you. Some of your partner’s worries would be the following:

  • Partners worry a lot about your lows when you have Type 1 diabetes. They’re afraid that you’ll have a low in the night and not wake up, or you’ll become unconscious, or have a seizure, and that they will not wake up to help you. So they often have disturbed nights, because they want to check on you at some time during the night.
  • They worry that you’ll ignore the symptoms of a low or not have the glucose you need to address the symptoms.
  • Since diabetes is not curable, they fear for your future. They really worry about complications developing, especially when your control is poor.
  • They often feel very sad that you have diabetes. They feel it as a loss as much as you do. They may fear that you will die and they will lose you. They also need to be reassured that you can overcome your diabetes.
  • When they’re being bossy, it may be because they’re afraid that you’ll get it wrong and they’ll lose you.
  • They may feel that the good relationship you had before the diabetes has been lost, and they miss what you had before.

Striking a balance is not easy. How much does your partner play a part, and how much do they leave you to get on with it? This needs to be negotiated between the two of you, until you find a way to work together without conflict. And then there are life stressors that complicate your relationship. Things like:

  • family arguments.
  • the loss of a loved member of the family or a friend.
  • the loss of a job.
  • financial strain.
  • a traumatic incident such as a car accident.
  • a violent crime that touches you.
  • excess alcohol consumption.

All of these stressors will have an impact on your relationship while you’re dealing with the difficult circumstances. Both of you will be more anxious and your responses to the anxiety can create uneasiness in the relationship. Add to that, the fact that the stress is pushing your blood glucose levels up and the situation can become quite volatile.

If the difficulty in your relationship with your partner is not resolved in a satisfactory way, conflict and reactions to the dispute can become ongoing. It is so important for you to find a way to normalise your relationship. This is vitally important to your family and to your diabetes! If you need outside help and support to do this, find the help you need.

What can families do to cope with these feelings?

  • Talk to each other about diabetes and things that have happened. Talking can help to strengthen the family bond. The idea is to communicate about the issues that are of concern to each other and the way everyone feels about it. Everyone should have a turn to speak, and each person should feel understood and supported so that the issue can be addressed constructively. Respecting each person’s individuality and situation helps to create an atmosphere of acceptance and allows for creative solutions to problems. Any diabetes information or issues can be discussed in this way.
  • Talk to other families who also have a member with diabetes. Attend family events organised by diabetes organisations or interested parties. This offers you support and helps you feel less isolated as you deal with the day-to-day care of diabetes. Sometimes other families, especially those who have many years of experience, can share good ideas on how to deal with family issues that arise because of diabetes.
  • Be committed to the decisions that are made in the family, but carry these out in a flexible way.
  • Be respectful and kind to each other.
  • Solve problems together.

This way, feelings are valued and the connection between partners and between all family members is restored and maintained.

Also remember that diabetes is in the family genetics, so each member of your family could also be at risk of developing diabetes.  It is helpful to educate your family members on leading healthy lifestyles in order to prevent another member of your family having a diabetes diagnosis.

MEET OUR EXPERT - Rosemary Flynn

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

Toenails – mirrors of your health

Posted on by
Share

Just as they say, ‘your eyes are the mirror of the soul’, so too are your toenails mirrors of your health – revealing information about nutritional status, general health and even an undiagnosed systemic disease.

Discolouration

The primary cause may be from trauma – either from an object dropped onto the toenail or from constant bumping inside a shoe, as suffered by runners and athletes. This discolouration is due to micro-bleeding under the nail, and will grow out with the nail over a period of months (it can take eight to 10 months for the big toenail to grow out completely). If severe bleeding occurs under the nail, the nail may detach while a new nail grows out, provided there is no damage to the nail matrix or the nail bed.

In some instances, in women who have dark skins, it may be perfectly normal for aging to bring about brown or black streaks in the toenails. These are due to changes in melanin (the natural pigment that causes skin and nail darkening).

Changes in consistency, curvature, surface texture, growth and even colour can be signs of a systemic process. For example, blue half-moons or lunulae on your toenails can indicate Wilson’s disease of the liver or silver salts deposition in argyria. In rare instances, discolouration can indicate the presence of a benign glomus tumour beneath the nail, or, even more rarely, malignant melanoma.

Extremely thick toenails (onychogryphosis)

Poor circulation in the feet affects blood supply to the nail matrix and nail bed. It is thought that the stop-start nature of poor circulation (intermittent hyperaemia) triggers the cell replication that can result in thickened toenails. Poor circulation can be present in cardiac conditions as well as in people who have high or low blood pressure, diabetes mellitus, or visible broken and/or varicose veins.

Onychocryptosis with paronychial inflammation

Onychocryptosis with paronychial inflammation

Ingrown toenails (onychocryptosis)

  • Excessive moisture can cause toenails to bend and penetrate the skin.
  • Pressure from shoes or from adjoining toes can shape or mould the toenail into the surrounding skin.
  • Growth spurts in childhood and adolescence can result in a toenail that is wider than the growing toe for a period.
  • Incorrect cutting of toenails can cause ingrown toenails.
  • Fungal infection under the toenail causes weakening of the nail plate and thus structural change in the curvature of the nail, and discolouration. People living with diabetes have an increased risk of fungal infections in the foot.
  • Trauma, such as accidentally dropping heavy objects onto the nail bed and/or the nail matrix at the source of the nail, causes a shape change in the resultant nail growth.

Footwear knowledge to prevent discoloured, thick or ingrown toenails

  • Avoid shoes that are too narrow in the front of the foot as these can restrict blood circulation to your toes.
  • Shoes that are too tight in the toe area may promote ingrown toenails.
  • Avoid shoes that have a shallow tapering toe box as these will constantly rub against the tops of your toenails. Toe muscle action is essential in preventing bunions and corns, hence why you should have enough toe room to be able to wiggle your toes inside your shoes.
  • Choose styles that do not require gripping friction from your toes, such as those that grip around the heel (either closed heel or strap), plus a strap or some form of fastening or closure across the instep of the foot.
  • Heeled shoes tilt body weight onto the ball of the foot. This can lead to toes curling inside the shoe, possibly resulting in hammer toes. Choose flats or lower heels for everyday use and reserve high heels for short one- to two-hour functions or events.

Find a podiatrist:

Podiatry Association of South Africa Toll-free number 0861 100 249

MEET OUR EXPERT - Anette Thompson

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

Diabetes and pregnancy

Posted on by
Share

A question that many women ask is, “Can I have a baby if I have diabetes?” This is a very important question. If the pregnancy is not planned and managed correctly, the pregnancy outcome can be harmful to both mother and baby. Dr Louise Johnson explains further.

There are two types of situations that can occur: healthy pregnant women that develop diabetes during pregnancy or diabetes patients (women) that wish to fall pregnant. It is best to look at these topics separately.

Healthy women that develop diabetes

This type of diabetes is called gestational diabetes mellitus (GDM), and the risk factors for developing GDM are:

  • Being older than 35 years.
  • Having a close family member, such as a mother or father, with Type 2 diabetes.
  • Having had GDM in a previous pregnancy.
  • Being overweight with a BMI (body mass index) of over 30kg/m2.
  • Having polycystic ovarian syndrome (PCOS).
  • Having complications in a previous pregnancy with a baby larger than 4,5kg, a still born baby, or a baby with malformations.
  • Women who are of South Asian descent.

GDM has an incidence of 4% in all pregnancies. It usually develops during the second trimester; in this time, the body changes due to the adjustment in hormones and begins to be more insulin resistant. This is like the insulin resistant state of Type 2 diabetes.

As the pregnancy advances, the insulin resistance becomes worse and patients may need insulin temporarily during the last few weeks before delivery. This need will go away after the birth of the baby. The problem with insulin resistance during the last part of the pregnancy is that the body cannot produce enough insulin to manage the higher glucose levels. This glucose gets transferred to the baby and causes the baby to gain too much weight.

There are recommendations from the American Diabetes Association (ADA) that all pregnant women should be screened for GDM at week 24 with an oral glucose tolerance test (OGTT). This test is where the mother fasts from 10pm at night then at 8am the next morning, blood is drawn, she then consumes 75g of glucose and blood is collected again after an hour and then after two hours. This helps the doctor to pick up GDM early, preventing a big baby.

You will be diagnosed with GMD, if your OGTT test results are as follows:

  • Fasting glucose is more than 5,1mmol/L.
  • First hour value is more than 10mmol/L.
  • Second hour value is more than 8,5mmol/L.

The dangers of GDM are twofold: the mother can develop Type 2 diabetes about six to ten years after the pregnancy. It is important for the mother that had GDM to stay on a diabetic diet and get yearly check-ups to diagnose diabetes early, if she does develop it.

The baby will also have a higher risk to become obese, especially if it was born weighing more than 4,5kg. This baby has a risk of developing diabetes a lot earlier, even in childhood. Again, living a healthy lifestyle is important.

The risk of complications during pregnancy is the same as a mother with Type 1 or Type 2 diabetes, except there is no increased risk of organ malformations in these babies since the organs formed when the glucose levels were still normal. In the healthy female population, the risk of birth defects is 1-4%.

Patients with GDM should have a OGTT six weeks after delivery to determine if the raised glucose levels have returned to normal. Remember, the risk of developing Type 2 diabetes is more than 50%.

The diabetes patient (Type 1 or 2) that wishes to fall pregnant

The most important factor in this pregnancy is planning. Both Type 1 and Type 2 diabetes patients should only become pregnant once they have a HbA1c test result of 6,5% for three continuous months. This is important for healthy eggs and conception.

The first seven weeks are extremely important to have normal glucose control as this is the time that the baby’s organs are formed. Abnormal glucose control during this period increases the risk of birth defects and miscarriages.

More than 50% of women who have diabetes become pregnant without planning. It is vital to use effective family planning to prevent this and to plan for a healthy pregnancy.

Pre-pregnancy examinations:

  • Do the HbA1c test to determine if your result is at the correct target – 6.5% or lower.
  • Test your blood pressure, kidneys and the nerves of the feet.
  • It is important that an eye specialist does a thorough eye examination before the pregnancy and every trimester to prevent eye damage. Laser treatment may be necessary.
  • Check the functionality of the thyroid, especially in Type 1 diabetes. An underactive thyroid can cause a floppy baby.
  • Review all the current medication and stop medication that can be harmful to the baby such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and statins. This should be substituted with ‘baby friendly’ drugs as recommended by your physician.
  • Type 1 diabetes with difficult control will usually be switched to an insulin pump for the period of three months before and during the pregnancy. Type 2 diabetes will usually be started on insulin first, as a baseline, once a day and as time progresses a short-acting insulin will be introduced before each meal. Most oral medications are not safe in pregnancy, except for metformin.

It is important to be vigilant in checking blood glucose often (before each meal and 90 minutes after each meal). There are also devices available, such as Dexcom continuous glucose monitoring, that can help with this.

Type 1 diabetes with difficult control will usually be switch to an insulin pump for the period of three months before and during the pregnancy. Type 2 diabetes will usually be started on insulin first, as a baseline, once a day and as time progresses a short-acting insulin will be introduced before each meal. Most oral medications are not safe in pregnancy, except for metformin.

Blood glucose control is essential because of the risk of complications to the mother and the baby that increases dramatically with poor control.

Risk for mother:

  • Worsening of diabetic eye problems.
  • Worsening of diabetic kidney problems.
  • Increase in infections in the bladder and vaginal area, which can cause early labour.
  • Preeclampsia (a condition in pregnancy characterised by high blood pressure, sometimes with fluid retention and proteinuria).
  • Difficult delivery or caesarean section.

Risks for the baby:

  • Premature delivery.
  • Birth defects (not an increased risk for the GDM mother).
  • Macrosomia (big baby).
  • Possible damage to the nerve of the arms if the baby is big and delivered vaginally.
  • Low blood glucose at birth.
  • Prolonged jaundice.
  • Respiratory distress syndrome (difficulty in breathing).
  • Twitching of the hands and feet due to low calcium and magnesium, which is a direct effect of uncontrolled glucose.

What should the glucose target be during pregnancy?

‱ HbA1c result below 6%. ‱ Fasting glucose 3,5-5,9 mmol/L. ‱ One hour post eating <7.8 mmol/L.

After the pregnancy

Patients with Type 1 and Type 2 diabetes can breastfeed if there is no sight-threatening bleeding or the possibility thereof in the eyes.

Advice for women with diabetes who breastfeed:

  • Breastfeeding will make the glucose a bit more difficult to predict because there are carbohydrates that are going to the baby through breastmilk.
  • Check the glucose before breastfeeding and if below 5mmol/L, eat a 15g snack.
  • Keep a snack ready to eat, to prevent having to interrupt the breastfeeding.
  • Drink enough liquids, especially water or caffeine-free tea, while nursing.
  • Low blood sugars are much more common during night-time nursing. Add a snack or reduce night-time medication. Discuss this with a doctor.

Insulin needs fall dramatically after delivery and medication should be adjusted to prevent hypoglycaemia (low blood glucose). Contraception should also be discussed for future planning.

Another question that is normally asked, “What is my child’s risk of getting diabetes?”

If the father has Type 1 diabetes, the risk is 8-9%.

If the mother has Type 1 diabetes, the risk is 2-3%.

If the father has Type 2 diabetes, the risk is 15%.

If the mother has Type 2 diabetes, the risk is 15%.

If both parents have Type 1 diabetes, the risk is less than 30%.

If both parents have Type 2 diabetes, the risk is 75%.

Final thought

My advice to the diabetic mother and her partner is to follow the rules and consult with the healthcare providers regularly and the beautiful reward for the perseverance will be a healthy baby. I know this is a lot of hard work but there is a silver lining. After this pregnancy, you will have learned how to take control of your health and have had the opportunity to develop healthy habits, which you can take with into your future for you and your family.

References:

  • Amod A, Motala A, Levitt N et. al. (2012) ‘The 2012 SEMDSA guideline for the management of type 2 diabetes.’ JEMDSA, 17 S1-94.
  • Dornhorst A, Banerjee A (2010) ‘Diabetes in pregnancy. Textbook of diabetes 4th edition, Oxford Wiley Blackwell.
  • Metzger BE, Gabbe SG, Persson B et. al. (2010) ‘International association of diabetes and pregnancy study group consensus panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycaemia in pregnancy.’ Diabetes Care, 33 p676-82.
  • Sacks D. (2011) ‘Diabetes and pregnancy: a guide to a healthy pregnancy for women with type1, type 2 and gestational diabetes.’ 1st edition, American Diabetes Association Virginia.

MEET OUR EXPERT - Dr Louise Johnson

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