Carb counting

Diabetes Nurse Educator, Christine Manga, helps us understand the need for carb counting if you have diabetes.


What is carb counting?

Carbohydrate (carb) counting is a meal management tool for people with both Type 1 and Type 2 diabetes who use insulin. The aim of carb counting is to balance the mealtime insulin injected with the amount of carbs eaten at each meal. Insulin is the hormone responsible for getting sugar from the blood stream into the cells where it can be used. So by carb counting, you will have better glucose control and more meal flexibility.

What are carbs?

Carbohydrates is the nutrient that affects your blood glucose the most. They are one of the main nutrients found in food. The other main nutrients are fat and protein.

Carbohydrates are found in starches and sugars. There are healthy and unhealthy carbs. Healthy carbs include whole grains, vegetables and fruit. These carbs contain energy, and nutrients, such as fibre, vitamins and minerals.

Unhealthy carbs are food and drinks containing added sugars. These foods are often energy dense but have low amounts of nutrients.

Carb exchange

A ‘carb’ or ‘carb exchange’ is a portion of food that contains 15 grams of carbohydrates. In order to carb count, you’ll need to know what foods contain carbohydrates. The following foods contain carbohydrates:

  • Rice, pasta, oatmeal, corn and grains.
  • Breads, cereals, biscuits and crackers.
  • Most snack foods.
  • Dried beans and lentils.
  • Starchy vegetables, such as potatoes, sweet corn, peas and sweet potatoes.
  • Fruit – both fresh and dried as well as fruit juice.
  • Dairy products including milk and yoghurt.
  • Honey, syrup, sugar, sweets and desserts.

Generally speaking, a ‘carb’ is:

  • ½ a cup of cooked rice, pasta, oats, pap, beans or lentils.
  • ½ a cup of cooked starchy vegetables like potatoes, peas, corn or a mealie.
  • ½ a hamburger or hotdog roll, one slice of bread, one small tortilla.
  • 2 cups of popcorn.
  • 3/4 cup of breakfast cereal.
  • ¼ cup of muesli. It is best to read the label for this type of cereal as some contain more dried fruit than others.
  • 1 small to medium fresh fruit (about a handful).
  • ½ cup of fruit juice.
  • ¼ cup dried fruit.
  • 1 cup of milk.
  • 100ml flavoured yoghurt.

Read food labels

To get the exact carb content of a food, you will need to read the nutritional label. Carbohydrates will be measured per 100g and per serving size. Weighing your food may be necessary as you get used to portion sizes. It is important to count the carbs for your full portion.

Apart from food labels, other sources of nutritional information can be found at www.fatsecretsa.co.za or www.carbsandcals.com.The book South African Glycaemic Index and Load Guide book by Liesbet Delport and Gabi Steenkamp is also helpful.

How many carbs should you have a day?

You can average on 30-60 grams per meal and 15 grams for two snacks a day. This would be adjusted according to sex, activity levels, weight goals and personal preferences.

Carb/insulin ratio

To find out how much insulin you would need for 15 grams of carbs to be transported into your cells (carb/insulin ratio), visit your doctor or educator.

This ratio is calculated on your total daily dose of all insulins you use. It will change if the amount of insulin you are using increases or decreases drastically.

Carb counting will seem tedious initially, but with time and practice you will also gain experience-based estimation that will guide you.

eating time budget

MEET OUR EXPERT


Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.


Why do I always cheat?

Whether it’s for general well-being or specific to weight loss, there are many fad diets out there. What’s common among them all is that there is always a timeline which promises rapid results with minimal effort. So, then why do we always cheat? The reasons below are key factors that lead us to stray from our diet plan.


Restriction and deprivation

Going on a strict temporary eating plan leaves you feeling deprived and unsatisfied. This type of quick fix does not teach you healthy eating habits. Rather, you are cutting out food groups entirely and creating an energy deficit, which is one of the reasons why you may drop a few kilograms in the first week or two.

With this restrictive way of eating there are often lists of ‘forbidden’ foods leading to overindulgence when having ‘cheat days.’ These days can include excessive eating of unhealthy ‘bad’ foods and can undo all the work that you have done to get to that point.

Poor planning

If we don’t plan our meals for the week then we tend to lean on convenience options. Take away or ready-made meals are generally extremely high in kilojoule content. By visiting the shops more frequently, you are more likely to throw the unhealthy snacks into the shopping basket because you are more exposed to the temptation.

Temptation

The power of habit is stronger than we think. Often, we grab that chocolate after dinner because last night we had some chocolate and we have created the expectation of having it again. By keeping unhealthy snacks at home or in our desk drawer, we are constantly being tempted and this of course increases the likelihood of indulging even when we aren’t hungry.

So, what can we do to prevent this?

The best solution is to move towards adopting a healthy lifestyle mind-set as opposed to following a strict temporary plan.

  1. Make an appointment to see a dietitian on a regular basis. He/she can help educate and train you to adopt a healthy lifestyle by creating an eating plan that suits your individual needs and circumstances.
  2. Follow the 80/20 rule, it calls for a mindful approach to the foods you eat 80% of the time and allows flexibility for the other 20%. This empowers you to make better choices whilst still enjoying your life without being restrictive.
  3. Pre-plan your meals and do as much meal preparation as you can over the weekend. Do weekly grocery trips as opposed to a quick stop after work each day.
  4. Remove the temptation and create a healthy food environment at home and at work. Leave your wallet in your car so you aren’t tempted to go to the vending machine when it hits late afternoon. Rather save your treats for special occasions, such as birthday parties or when meeting up with a friend.
  5. Practise mindful eating to improve your relationship with food. The next time you want to grab that chocolate bar or bag of crisps, ask yourself if you are really hungry, or just eating for the sake of eating as per habit.

Healthy food swops

We need to keep in mind that there is a big difference between general healthy eating and eating for weight loss. It is never solely about what foods you are eating as other factors such as portion control play a huge role.

Are these swops really a healthier option?

  1. Potato ➡️ Sweet potato

These two starchy vegetables have approximately the same amount of carbohydrate and energy content, which is around 15-17g carbohydrate and 311-354kJ per 100g. However, sweet potatoes have a lower glycaemic index (GI) and glycaemic load (GL). They are an excellent source of vitamin A in the form of beta-carotene and they have a higher vitamin C content.

  1. 4 Finger KitKat  ➡️ Woolworths Nutty Almond Snack Bar

As a disclaimer, this is a sole comparison of kilojoule content, but believe it or not these ‘health’ bars contain more kilojoules (1177kJ) than a KitKat chocolate bar (868kJ).

  1. Crisps ➡️ Popcorn

Popcorn comes in as a much healthier alternative with a total energy of 1400kJ per 100g compared to 2320kJ for a 100g bag of crisps. The total fat content in crisps is 36g compared to 8g for popcorn.

  1. Salticrax ➡️ Ryvita

One of the biggest difference between these two cracker options is the fibre content. Salticrax has almost no fibre coming in at 0,3g per serving (2 biscuits) compared to Ryvita which has 3g. Salticrax are also higher in added fats with 3,2g per serving compared to Ryvita with only 0,2g. Here we can see that products containing similar energy contents (267kJ vs 289kJ) can have a very different nutritional composition.

Remember that following a healthy eating plan is a lifestyle and not a quick fix. We need to be conscious about including a variety of foods from all the food groups and eating regular, structured and balanced meals. Moderation is key.

MEET OUR EXPERT


Jessica Oosthuizen RD (SA) is a Type 1 diabetic herself (since the age of 13) She 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. Her experience includes working in the clinical hospital setting as well as experience with a variety of chronic diseases of lifestyle, such as obesity, hypertension and Type 2 diabetes.


Making insulin work for the diabetic, and not the other way around

Michelle Carrihill educates us on how to use various insulins with their unique actions to meet the desired requirements.


There is no ‘easy-peasy’

As a student, I remember being taught that the only thing wrong with a Type 1 diabetic is that they are deficient in insulin. So, the treatment is simple – replace the insulin, and all is returned to normal. Easy-peasy.

Except it is not. Each person is an individual. Each person has variable insulin requirements, and these may change minute-to-minute, hour-to-hour, day-to-day, week-to-week, and especially year-to-year as the body grows and changes.

Very few people have predictable, regular lives. Nevermind predictable regular metabolic rates. Add the variability that is introduced with different amounts and types of carbohydrates, plus protein and the altered absorption with fat in a meal; throw in exercise, emotions and stress, and it might feel almost impossible to exactly figure out which insulin and how much of it should be given at any one time.

Another factor is that each individual may respond slightly differently to a brand or type of insulin, and that the individual’s response may not be the same at each injection.

Also, unlike the insulin produced naturally, once insulin is injected in the body, it cannot be switched off. Once it is in the body, it will continue working, whether needed or not!

Individualise insulin treatment

The most important thing is to individualise the insulin treatment regimen to best fit the individual’s needs. Obviously, the available insulins, the budget and the willingness of the diabetic (or their carer) to test sugar levels and adjust doses are important to take into consideration when designing insulin replacement therapy.

To understand this, let’s look at the available insulins, and their action times. This information is provided by each of the manufacturers.

 

Type of Insulin & Brand Names

Onset

Peak

Duration

Role in Blood Sugar Management

Rapid-Acting

Lispro (Humalog) 15-30 min. 30-90 min 3-5 hours Rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection.
Aspart (Novorapid) 10-20 min. 40-50 min. 3-5 hours
Glulisine (Apidra) 20-30 min. 30-90 min. 1-2 1/2 hours

Short-Acting

Regular (R)

Actrapid

Biosulin R

Humulin R

Insumam R

30 min. -1 hour 2-5 hours 5-8 hours Short-acting insulin covers insulin needs for meals eaten within 30-60 minutes

Intermediate-Acting

NPH (N)

Biosulin N

Humulin N

Insumam N

Protophane

 

 

1-2 hours

 

 

4-12 hours

18-24 hours Intermediate-acting insulin covers insulin needs for about half the day or overnight.

Long-Acting

Insulin glargine (Basaglar, LantusToujeo, Optisulin) 1-1 1/2 hours No peak time. Insulin is delivered at a steady level. 20-24 hours Long-acting insulin covers insulin needs for up to one full day.
Insulin detemir (Levemir) 1-2 hours 6-8 hours Up to 24 hours
Insulin degludec (Tresiba) 30-90 min. No peak time 42 hours

Pre-Mixed*

Humulin 30/70

Actraphane

30 min. 2-4 hours 14-24 hours These products are generally taken twice a day before main meals.
NovoMix 30 10-20 min. 1-4 hours Up to 24 hours
Humalog mix 25 15 min. 30 min.-2 1/2 hours 16-20 hours
*Premixed insulins combine specific amounts of intermediate-acting and short-acting insulin in one bottle or insulin pen. (The numbers following the brand name indicate the percentage of each type of insulin.)

If you combine these insulin profiles, and superimpose them over what the individual’s insulin requirements are, you then get to understand when the insulin will be working for them, and which combination will suit their needs. These needs may vary from time-to-time and over time, so it is important they monitor their sugars, either with finger-prick tests, or if viable, a continuous glucose monitor.

Let’s look at some regimens:

Twice a day insulin

Benefits: Disadvantages:
Easiest regimen Must be given 30 minutes before the meals.
Only two injections a day Midmorning snack required.
Lunch carbohydrates may not be adequately covered.
No flexibility in meal component of the insulin (if using a premixed insulin combination).
The intermediate-acting insulin given before an early dinner may mean inadequate basal cover by the early morning – a risk of waking up with a high fasting sugar, and some ketosis.

 Three times a day insulin

Benefits: Disadvantages:
Covers overnight requirements better by the later injection of the intermediate insulin, decreasing the chance of morning high levels. Regular insulin must be given 30 minutes before the meals.
Midmorning snack required.
Lunch carbohydrates may not be adequately covered.
Requires a bedtime snack.

 Basal bolus regimen

Benefits: Disadvantages:
Flexible dosing for carbohydrates and correcting. In-between meal carbohydrates need to be counted and dosed for. Or carbohydrate free snacks considered.
More frequent injections (and testing) required.
More expensive.

 Long-acting insulin analogues

Benefits: Disadvantages:
Flexible dosage for carbohydrates and correcting. ‘In-between’ meal carbohydrates need to be counted and dosed for. Or carbohydrate free snacks considered.
Fasting is possible. More frequent injections (and testing) required.
Flexibility in the timing of the meals/snacks. Much more expensive.
Less risk of nocturnal hypoglycaemia.
No need for night time snack.

Continuous sc insulin infusion

Benefits: Disadvantages:
Built in calculator for carbohydrate counting and corrections. Only rapid insulin is used, so any disruption in delivery can rapidly lead to ketoacidosis.
Insulin can be suspended. Very expensive.
Basal rates can be individually set. Needs high quality training and ongoing interaction.
Dawn phenomenon can be covered. Permanently attached to a device.
Fasting easy to achieve.
Temporary increase or decrease in basal requirements easy to achieve.

Mix and match

Mixing and matching of insulins is also possible. For example, a child attending primary school might do well on regular and intermediate-acting insulins half an hour before breakfast, without requiring any insulin for their school break; a rapid insulin analogue for after-school lunch and dinner; and then a long-acting basal analogue for their basal insulin overnight.

As mentioned already, monitoring the blood glucose then opens the eyes to the effect of the insulin doses – both for the individual dose, as well as for the pattern of dosing. Fasting sugars reflect the long-acting doses and post-meal levels reflect the bolused doses for carbohydrates and corrections.

Carbohydrate counting affords the closest-to-physiology use of mealtime insulin, and is to be encouraged. Even if using a fixed-dose insulin regimen, knowing how much carbohydrate is in a meal allows for consistency of insulin to carbohydrate dosing – which then helps prevent sugar variability after meals.

Monitoring sugar levels before and after activities and sports helps with planning of extra carbohydrates or a change in insulin dose for the meal before or after the exercise.

The message is that getting sugars to target is possible by knowing what the individual needs, and using the available insulins to suit those needs. Monitoring sugars and adjusting doses and types of insulin along the way will keep the person with diabetes healthy, and able to get on with living their lives.

MEET OUR EXPERT


Dr Michelle Carrihill is a paediatric endocrinologist working with children and adolescents with diabetes and chronic endocrine and metabolic conditions. She runs the adolescent sub-speciality ward at Groote Schuur Hospital and has a large ambulatory service for the chronic medical needs of these patients.


The challenge of change

Rosemary Flynn explains the four changes needed when diagnosed with diabetes.


When you are diagnosed with diabetes, you have to make some important changes in your lifestyle to remain healthy. The main changes will be: to eat differently, to be more active and to take medications (whether they are tablets or injections).

All people find it difficult to change and it usually takes a whole lot of effort to establish the new way of living and thinking. As Einstein said, “We can’t solve our problems with the same thinking we used when we created them.”

So, what changes do you have to make with your thinking?

The first change:

Find out all you can about diabetes and how to apply the treatment you are given. That means you have to both gain knowledge and apply the new knowledge. You will have to unlearn some things and relearn another way to do it.

The second change:

You need to know that although a doctor can support you and prescribe the right treatment, diabetes is a condition that you have to manage on a daily basis, and you will need to practise a lot of ‘self-healing’.

With Type 1 diabetes, you have to figure out how much insulin to take for the meal you are about to eat. You have to know how to test your blood glucose and work out your dose of insulin. You have to know how to treat high or low blood glucose. You have to know how to exercise safely so that you don’t have hypoglycaemia.

With Type 2 diabetes, you have to know what food is good for you and try to stick to those foods. If you are usually a sedentary person, you have to become more active to keep your circulation healthy and reduce your insulin resistance. If you are overweight or obese, you have to make an effort to lose weight. You have to be conscientious about taking your medication.

The doctors and others on your diabetes care team can help and guide you, but you will have to practise these things on your own and take responsibility for managing your diabetes. Diabetes is not a condition where the doctor tells you what the recommended treatment is and fixes it for you. You have to work on your own body on a daily basis, making decisions that will keep your body as healthy as possible. You can’t just live from a previous appointment to the next appointment to care for yourself.

The third change:

This change, you need to make, is in your attitude towards having a chronic condition. You have to move onwards from the disappointment and distress of having diabetes, to accepting it and learning to work with it. Then, you will develop the right attitude towards it which will enable to manage it successfully.

The fourth change:

Develop a working relationship with your doctor, so that you feel free to discuss your pitfalls and problems without feeling judged or criticised.

If your doctor does too much, you will not do enough. If your doctor is too critical or judgemental about your control, listen to what he/she is criticising. If he/she is right, work on the first three changes and try to achieve better control. If he/she is wrong or does not understand your situation, or involve you in decision making, tell him/her the truth about the matter. If he/she remains critical and judgemental after you have addressed the situation, change doctors, but remember that ultimately, you are your own best doctor.

Changes worth making

It can take many months to feel comfortable with the new lifestyle, and you will be able to develop internal motivation to continue your new lifestyle. You will feel less distressed about your diabetes and you will be able to act on your knowledge to manage well even in difficult times. There may be occasions when you feel like giving up, but these will become fewer as you become more resilient and able.

Success feels good and when you feel healthy, you feel good. Now you are ready to develop a new appreciation for life and your purpose in it. It really is worth making the changes!

Rosemary Flynn

MEET OUR EXPERT


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.


Managed care: tools to manage the cost of healthcare services

In this third article in the series aimed to empower patients on their rights in the funding of healthcare, Elsabé Klinck discusses managed care.


Managed care

We have, in the second article in this series, referred to the prescribed minimum benefits (PMBs) and how medical schemes can manage the cost thereof by entering in to contracts with designated service providers (DSPs). 

They can also manage cost by implementing “managed care” strategies. These include, for example, having medicines lists, requiring pre-authorisation before certain procedures can be undertaken or before one can be admitted into hospital, or setting certain financial caps up to which the scheme will pay.

It must be noted that “managed care” applies to both PMBs, and non-PMBs.

Medicines list and treatment protocols

Medicines lists, or formularies, are ways by which medical schemes state that they will only pay for certain medicines, and not for others. Treatment protocols are step-by-step “recipes” that states how the doctor should manage a certain condition. 

One would assume, because managed care is about managing cost, that the law would say these must be set on price. However, healthcare is more complex than just what is cheap or expensive. It is about:

(a) What is, in healthcare terms, appropriate for a patient; and

(b) To cater for cases where not all patients are equally well, or well at all, on the same medicine.

In terms of what is appropriate for a patient, the medical scheme must set its medicine lists and treatment protocols based on evidence-based medicine (EBm). 

What is EBM?

EBM is defined in the law as considering, in an honest and ethical way, what’s the current best ways of treating patients with a certain condition. It then also considers the individual circumstances of the patient and the doctor’s experience in managing such diseases. Then one must also consider what research says, i.e. clinical research on patients, treatments and various products. This includes considerations that may come to light during a clinical trial, e.g. that patients with certain other conditions cannot take a specific medicine, or that in some groups, the medicine has a bad reaction. 

Scenario cases in the interest of the patient’s health

So, to cater for the patients who are not well on the medicines on the list, the law, in Regulations 15H(1)(c) of the General Medical Schemes Regulations, states that the scheme must deviate from their medicine list, in the interest of the patient’s health, under the following situations:

  • Where the medication that the scheme is willing to pay for, did not work for the patient (this is called “treatment failure”). In diabetes, this can be proven by showing that the medicine is not bringing one’s blood glucose levels within the right range. 
  • Where the scheme-recommended treatment causes, or would cause an adverse reaction. This means that the patient has experienced a side effect on the medicine on the list, or that we know, often from research and experience, that certain patients will experience a side effect. 

If the above cases are proven, the scheme must, by law, fund an appropriate alternative medicine, even if that medicine is not on their list, without a co-payment.

The same principles that apply to medicines lists or formularies, also apply to treatment protocols (regulation 15H(1)(c)). Where the patient is not well on the treatment as set out step-by-step, the scheme must pay for a deviation from the protocol. This is also in cases where the step-by-step approach is not working for the patient and his/her condition is not getting better (i.e. “treatment failure”) or where following those steps would cause, or have already caused, the patient to suffer harm.

Other important aspects of managed care to remember

One sometimes hears that a scheme says: “We are only making a funding decision, it is not a decision about your care.” This is not true where the medical scheme, or the entity that administers the scheme, is a registered managed care organisation. 

Managed care, in the law, is defined to include both the financial, and the clinical (i.e. healthcare) management of a scheme beneficiary. When they make a funding decision they must consider not only the financial impact of that decision, but also the impact on your health.

Get your healthcare providers support

Also, where the scheme has, as part of its managed care, appointed “network” doctors or hospitals, who agree to adhere to certain principles and protocols, the law set criteria aimed at protecting patients. It says that even in these cases the scheme is responsible towards its beneficiaries. The scheme or the contract may never prevent the doctor or other healthcare provider from telling the patient what care they need, and what would be best for them. Even if the managed care agreement requires adherence to a formulary or protocol. 

The scheme may also not terminate the agreement because of the provider saying they disagree with a scheme decision or when the provider assists the patient to lodge a complaint or an appeal. Patients should therefore not hesitate to:

  • Ask their doctors and healthcare providers as to whether the care is appropriate, or the best care for them; and
  • Ask for their doctors or providers’ supporting in taking up cases with the scheme and even the Council of Medical Schemes (CMS).

No kick-backs for healthcare providers

When appointing or selecting providers, medical schemes may not unfairly discriminate against any provider, and must base such selection on a clearly defined and reasonable policy which furthers the objectives of affordability, cost-effectiveness, quality of care and member access to health services.

Regulation 15J prohibits practices where the provider is rewarded for recommending inappropriate care. For example, paying a pharmacist a higher dispensing fee for switching the patient from one medicine to another where the second medicine then is not appropriate, or paying a doctor a higher fee for refraining from using care that would be medically appropriate (e.g. starting a certain type of treatment or referring the patient to a specialist) would be prohibited under this regulation.

Capitation

The managed care regulations also provide for “capitation”. It literally means “per head”. So, the scheme would pay an average amount per head, for all diabetic patients, irrespective of what that patient actually costs. 

So, if a patient has complex diabetes, the amount may be too little, but if the patient is easy to treat, the amount may be more than what is required to treat the patient. However, the decisions on how to treat the range of diabetic patients, then is up to the doctor, who then undertakes the assessment as to what would be possible for each patient. 

However, if this is done, regulation 15F sets the following criteria for these capitated contracts namely:

  • It must be in the interests of the members of the medical scheme;
  • There must be a “genuine transfer of risk” from the scheme to providers, which means they must truly empower the provider to make the decisions on appropriateness per patient and to take the risk of more complicated patients; and
  • The capitated payment must be “reasonably commensurate with the extent of the risk transfer”, which means it must be certain that, overall, the doctor is able to appropriately treat all patients, even if s/he has more complicated patients than someone else to manage.

Conclusion

Managed care is an important aspect in medical schemes, and many patients are not aware that there are rules that frame how schemes must set, and enforce, their medicines list, or preferred doctors. 

These rules are important and protect patients who are not doing well on scheme-medicines, who require different care, or who are more complicated patients.

MEET OUR EXPERT


Elsabė Klinck (B.Iuris, LLB, BA Hons (German), BA Applied Psychology) specialises in health law, -policy and -ethics. She owns a successful healthcare consulting firm, serving various clients in the pharmaceutical, medical device, healthcare professional and health facility markets.


Basic benefits: PMBs

In the second article of a series aimed to empower patients on their rights in the funding of healthcare, Elsabé Klinck educates us on prescribed minimum benefits (PMBs) – the basic benefits that all schemes, on all options, must provide.


PMBs as your safety net benefits

The PMBs are benefits that all medical schemes, on all options, should fund. It is a minimum safety net, ensuring that all patients, on all options, at least have these benefits covered. 

It is a key element of what makes medical scheme cover “social insurance” as opposed to regular insurance. It therefore cross-subsidises the funding of care amongst all the members covered by that risk pool. The cover is based on medical need, and not on the contribution to the pool. 

Under the PMBs one obtains cover for certain health conditions, irrespective of how healthy, ill or old one is. In regular insurance, one is penalised for one’s health status, age, etc., i.e. for the risk one poses. PMBs are therefore “social security” benefits. People are therefore, through a mechanism of shared (“social”) pooling of funds, covered or insured for specific conditions.

Standardised set of benefits

The PMBs aim to give everyone a standardised set of health benefits. The explanatory notes to the PMB list, which are attached to the Medical Schemes Regulations of 1999, state the objective of this standardised set of benefits, namely:

The objective of specifying a set of prescribed minimum benefits within these regulations is two-fold:

  • To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals.
  • To encourage improved efficiency in the allocation of private and public healthcare resources.

Implementation

How the PMBs are implemented by schemes should not undermines these objectives. For example, this would be the case where a scheme’s PMB rules require the channelling of patients to the public health sector. This means that one is indeed placing the patient at risk of unfunded care in the public sector. 

It also exacerbates the lack of resources in the public sector system, by requiring private sector patients to join the queue in the public sector, or, worse, to jump the queue because of their private sector, medical scheme status. Medicines and other resources procured for the indigent or uninsured population, now has to be shared with people on medical schemes. 

This means that schemes should not just “transfer” or send patients to an overloaded public sector. Neither should they have the public sector as a designated service provider (DSP) without a proper contract or, in circumstances, where they cannot render the services. They can also not only appoint the state as a DSP, and not have other DSPs. This matter was definitively addressed in the well-known Genesis case in the Supreme Court of Appeal. 

What is included in the PMBs list?

There are 270 diagnostic and treatment pairs (DTPs) that make up the PMBs, and 25 chronic diseases which all fall within the “must be funded” category. All emergency care is also included in the list of conditions that must always be funded. The PMB list can be accessed here:

Because a scheme must fund the PMBs, and one often hears that “PMBs are too expensive”. The 2017 Council for Medical Schemes Annual Report sets the costs of the PMBs as follows:

  • It costs, on average, R680 per beneficiary per month to provide the full set of PMBs; and
  • PMB costs amount to only 54% of the total scheme risk pool, i.e. 46% of risk pool (i.e. shared) spend goes towards non-PMB conditions. 

This is separate from savings and other pools of money in the scheme (what one could term “non-core care”). 

There are therefore significant portions of medical scheme expenditure that are discretionary to the scheme, and it appears strange that one would aim to erode the core and safety-net of benefits and increase the proportion of non-core, scheme discretionary spend.

Ensuring your PMBs are noted

On a practical level, patients should ensure that the PMB code (an alpha-numerical code appearing to the left of the list of PMBs) are included on accounts and motivations to medical schemes. This is important as it indicates to a medical scheme that the diagnoses (e.g. tests), treatment (e.g. medicines, consultations or operations) and/or care (e.g. by a hospital or therapist) provided, is for a PMBs condition. 

DTP example

The PMBs are listed in DTPs. An example of a DTP is as follows, with the PMB Code on the left and specific type of healthcare to be funded, indicated next to the code and diagnosis:

915 is the PMB Code, “… diabetes mellitus with peripheral circulatory disease” is the diagnosis and the minimum care is described in the last column as “medical and surgical management, including amputation”.

The PMBs also include the Chronic Disease List (CDL), which includes conditions, such as diabetes mellitus Type 1 & 2, hypertension (high blood pressure) and hyperlipidaemia (high cholesterol). Instead of a last column describing how it must be funded in general, these conditions are accompanied by “treatment algorithms”, published in the Government Gazette. 

A treatment algorithm is a step-by-step way in which a condition, such as diabetes, is to be treated. So, for example, for Type 2 diabetes, the algorithm says that one should start with lifestyle modification, and blood glucose monitoring is essential. Then, if the condition does not improve, the patient should go onto insulin. 

These algorithms are, however, not cast in stone, and deviations from it must, by law, be made under circumstances set out in the law. We will address these circumstances in the next article in this series.

Patients should not only understand when a condition is a PMB, but also how the treatment of that PMB condition is described.

Funded “in full” and “without co-payment or deductible”

Regulation 8(1) of the Medical Schemes Regulations, 1999 to the Medical Schemes Act of 1998 states that the PMBs: 

  • on “any benefit option”;
  • must be paid by the scheme “in full, without co-payment or the use of deductibles”;
  • and they must pay for the “diagnosis, treatment and care costs.”

For any PMB, it is therefore not only the treatment that must be funded, but also the “diagnosis” and “care”: This includes diagnostic care, such as a glucometer and sufficient strips to ensure that blood glucose level testing can take place. Not paying for an adequate number of strips therefore violates the law.

“Care” includes, for example, feet care rendered by a podiatrist, that may become necessary due to diabetes that affects one’s arteries and circular system. 

Managing the cost of “funding in full”

The PMB law gives medical schemes two mechanisms to control the cost associated with the PMBs, namely (a) appointing designated service providers (DSPs) and (b) by implementation of managed care, such as setting medicines lists.

However, neither of these strategies (i.e. DSPs and managed care), are without limitations, and medical schemes can only use these strategies insofar as it is permitted by law. In the next article, we will address managed care.

The use of DSPs to render health services must be done in line with the law. There should be a formal contract between the service provider and the scheme, which sets out how the services are to be rendered, and what the scheme will pay the DSP. A scheme can, in its rules, say they will only fund a PMB condition or conditions in full, if the beneficiary obtains their healthcare from a DSP. If one freely chooses to not use the DSP, the scheme may impose a co-payment.

However, where one must go to the non-DSP, the scheme may not impose a co-payment. This means that there are exceptions to DSPs. These exceptions are called “involuntary visits to non-DSPs”:

  • If the DSP was not available (e.g. one battles to get an appointment) or the service would not be provided without unreasonable delay (e.g. one must join a waiting list).
  • If you required immediate treatment (e.g. in the event of a hypoglycaemic event that must be managed in hospital) and where the circumstances or the place where this happens means that one cannot get to the DSP.
  • If the DSPs that the scheme has appointed, are too far from your home or work (e.g. you must travel far, or it is expensive, to get to the DSP).

What about choice?

It may seem that, although schemes must fund “in full” the PMBs, they have the power to limit the options and choices that patients have. In this regard regulation 8(5) is important, as it allows patients freedom of choice. The same as a patient can, at the payment of a co-pay, access even a non-DSP and exercise a free choice of a service provider (doctor, hospital, etc.), patients can also exercise choices in terms of treatment.

This part of the law allows patient to choose a medicine that is not on a scheme list. This may be where the patient wants to experience fewer side effects; have a specific preference for a specific product that they were on in the past; have other objectives, such as weight loss; or want to do fewer injections of medicine because of work or school obligations, and so on. This is a free choice, and is not necessitated by medical reasons.

In this case, the patient can decline the medicine that the scheme says it will fund in full, and fund an alternative medicine. So, the patient declines a medicine that they would have been okay on, in favour of something that satisfies other needs. In this case, the scheme may impose a co-payment on the patient. 

This co-payment, as is the case with all co-payments, must be reasonable. This means it must be “reasonable”, i.e. it cannot be exorbitant, and should be close to the real difference in cost.

The opposite of the above is also true: if the scheme medicine is inappropriate for the patient (e.g. the medicine on the list cannot be taken by the patient due to specific circumstances, e.g. pregnancy), the patient should not co-pay to access appropriate care.

Conclusion

Knowing whether your condition is a PMB is important. Also, complications that flow from PMB conditions must be funded. One should also know the rules around DSPs, and the exceptions to DSPs. Most importantly, one should know what the implications are of exercising a free choice, as opposed to choices that one must make on medical necessity.

MEET OUR EXPERT


Elsabė Klinck (B.Iuris, LLB, BA Hons (German), BA Applied Psychology) specialises in health law, -policy and -ethics. She owns a successful healthcare consulting firm, serving various clients in the pharmaceutical, medical device, healthcare professional and health facility markets.


Understanding the steps to diabetes self-management

We explore ways to help you learn and implement self-management practices.


The diagnosis of diabetes

If you or a loved one have just been diagnosed with diabetes, you may be feeling an overwhelming amount of mixed emotions. Diabetes is a complex and serious condition, and living with it every day can be challenging1. Part of that challenge is due to the fact that the management of diabetes will largely rest in your hands. This can be daunting. Be kind to yourself and remember that small positive steps every day will make a difference in the long run.

Getting started with self-management

Ideally, on diagnosis, you should have access to a team of healthcare professionals. This may include the treating doctor, a diabetes educator or coach, and possibly a dietitian.

However, in many cases you might only have access to a doctor and your time spent with him or her in consultation will be limited.

In the beginning, you may feel overloaded with information about what to eat, how much to exercise, when to take your medicine, how to test as well as confusing terminology, such as HbA1c, hyperglycaemia, hypoglycaemia, glycaemic control etc.

To help make sense of it all, diabetes educators have developed some key areas to focus on1:

  1. Healthy eating

Having diabetes does not mean you must give up your favourite foods. Over time and through experience, you’ll learn how the foods you eat affect your blood sugar. You should eat regular meals and make food choices that will help control your diabetes better1.

Work with a dietitian or diabetes educator to develop a healthy, balanced eating plan that suits your lifestyle. Remember that it is okay to treat yourself once in a while. You can also visit the Accu-Chek website and download the Accu-Chek portion plate which will give you some practical tips on healthy eating.

  1. Being active

Guidelines for the management of Type 2 diabetes refer to studies that have proven that regular physical activity significantly improves blood sugar control, reduces cardiovascular risk factors, and may reduce chronic medication dosages2. Regular physical activity may also improve symptoms of depression and improve health-related quality of life2. Try to include a combination of cardio and resistance training into your weekly exercise routine.

  1. Self-monitoring of blood glucose (SMBG)

The International Diabetes Federation (IDF) recommends SMBG as an effective means for patients with diabetes to understand more about their condition and the influence of events – such as exercise, stress, food and medication – on blood sugar levels3.

However, for SMBG to be effective, it’s recommended that you practice structured testing using a tool, such as the Accu-Chek 360 3-Day Profile Tool3 which can be found on www.accu-chek.co.za

Structured testing is testing at the right times, in the right situations, and frequently enough to generate useful information3. Always agree with your doctor or diabetes educator what your individual structured SMBG testing plan is.

Another aspect you should discuss with your doctor will be your target range for your blood sugar levels. In the beginning, understanding this range and what is considered out of range may be confusing, so you may want to make use of a meter such as the Accu-Chek Instant Meter which offers a support tool called the target range indicator (TRI)4.

A study done on the TRI showed that 94% of study participants were able to easily interpret their blood sugar values through the use of the target range indicator4. Furthermore, 94% felt that the support tool will help them discuss their blood sugar values with their doctor4.

  1. Taking medication

You may need to take medication to help keep your blood sugar (glucose) level steady. Diabetes can increase your risk for other health conditions, such as heart or kidney related problems, so you may need to take medicine to help with those too1.

  1. Problem solving

When you have diabetes, you learn to plan ahead to be sure you maintain blood sugar levels as much as possible within your target range goals – not too high, not too low.

As we know, things don’t always go according to plan and a stressful day at the office or an unexpected illness can send your blood sugar in the wrong direction. Days like this will happen from time to time. Here are some tips to cope1:

  • Don’t beat yourself up – managing your diabetes doesn’t mean being perfect.
  • Analyse your day and think about what was different and learn from it.
  • Discuss possible solutions. This can be with your doctor, your diabetes educator or even a face-to-face or online diabetes support group. Try joining some of the online diabetes communities out there, such as the Accu-Chek Facebook page which has over 148 000 members. You can join the conversation at AccuChekSubSahara.

Bigger is sometimes better: medical aid schemes

Craig McLuckie, a father, tells us why he opted for more comprehensive medical aid scheme once his son was diagnosed with diabetes.


Parenting a sickly son

As parents, we all want the very best for our children. When my second son Ethan was born, in 2007, he had a cleft of the soft palate (the soft tissue at the back of your mouth). This was corrected surgically when he was three months old. After the operation, he really started thriving. So, my wife, Rita, and I put it behind us, looking forward to our child leading a normal, healthy life. Unfortunately, a curve ball was thrown our way.

When Ethan was 16 months old, we were visiting family, in Pietermaritzburg, and the little guy took a bit of a turn. We could not keep up with the nappy changes as he was wetting them at a rapid rate. This of course went hand-in-hand with his insatiable thirst.

Life-long chronic condition

For anybody living with diabetes these are classic symptoms of high blood sugars but at the time I didn’t put two and two together. The surprising thing is how quickly his condition deteriorated and by the following day he was lethargic. Unbeknownst to us he was in a ketogenic state due to his body utilising fatty acids as a fuel source and producing acidic ketones as a by-product. We quickly ended up at the paediatrician, who upon diagnosing Ethan as a Type 1 diabetic, referred us to an endocrinologist.

This is really where our journey begins. I remember sitting with the endocrinologist in his office and looking out the window thinking what a lovely day it was, whilst being told Ethan had this life-long chronic condition. It was quite surreal and bewildering – with the introduction to the different types of insulins (long-, medium- and short-acting); the injecting; what to watch out for, such as the highs and lows; and the dietary requirements. We went home with this package of medication, paraphernalia and our little boy. Our lives as parents of a ‘Kid Powered by Insulin’ had begun.

Medical aid troubles

I had to now begin the process of getting the medical aid approval for Ethan’s chronic medications. At the time, I was with a smaller scheme and I quickly realised that their understanding of diabetes mellitus Type 1 was quite skewed. Their diabetic nurse educator told me if Ethan ate correctly he would be cured and would not need insulin!

In addition, they would only cover 30 needles for injecting, the insulins and 100 glucose test strips per month. Anybody living with diabetes will tell you this is nowhere near enough, especially for a young child whose sugar levels can be quite erratic.

Furthermore, all doctors’ consultation fees came out of our savings and thus we incurred numerous of out-of-the pocket expenses. Diabetes is not a cheap condition to live with.

Great discovery

Based on the advice of Ethan’s health carers and friends we ‘discovered’ a medical aid that was much more in tune with a diabetic’s needs – particularly children.

We also registered with the Centre for Diabetes and Endocrinology (CDE) and their management programme. This helps a great deal as we get access to diabetes educators, endocrinologists and dietitians throughout the year without impacting on our medical savings.

Game changers

The primary aim in treating diabetes is to manage it well to prevent complications, both short- and long-term. Every day one is faced with new challenges: What is your child eating? How active are they? Are they ill? These factors will affect blood sugar levels. Being able to accurately dose with insulin is very important.

Here is where the first of our game changers comes in: the insulin pump. Not having to inject your child multiple times during the day and being able to administer very small, accurate insulin dosages is a godsend. It is also imperative that you (or the older child) can monitor blood sugars.

This is where continuous blood glucose monitoring (CBGM) comes in. For us the CBGM has been our second game changer. The system usually consists of a transmitter that attaches to the body and a receiver that gives the readings. Our system gives a reading every five minutes or so and it alarms if the sugars are rapidly rising or dropping. It also allows monitoring of trends. The biggest advantage is the safety factor in being able to avoid low sugar events (and being able to sleep through at night!). The latest technology available can combine the pump and CBGM system.

The right medical aid

For every diabetes patient, it is critical to have the right medical aid and be on the right option. A good medical aid will generally cover the cost of an insulin pump (approximately R30 000; one every three years). Although the consumables do come out of savings. Likewise, with the CBGM system.

The other cost to consider is the test strips as one will still need them as a backup and to calibrate the CBGM system. The insulin is actually the cheapest item.

Holistically speaking there is also the doctor and diabetes educator visits, and dietitians and other specialties if required. I estimate our monthly requirements comes to between R6 000 – R9 000. There is the temptation to buy down and choose a lower option but this means losing out on certain benefits. Affordability is the key issue. As a family, we have sacrificed on other luxuries to ensure we remain on the best option we can afford.

MEET OUR EXPERT


Craig McLuckie lives in Benoni, Gauteng. His youngest son, Ethan, has Type 1 diabetes.


Vaping and diabetes

Electronic cigarette (e-cigarette) or vaping is increasing worldwide. Their use is highly controversial from a scientific, political, financial, and psychological perspective. Louise Johnson examines these controversies.


Smoking

Tobacco smoking is a global pandemic affecting an estimated 1,2 billion people which poses a substantial health burden and cost. With nearly six million tobacco-related deaths annually, smoking is the single most important cause of avoidable premature death in the world7.

Tobacco-related death is mainly caused by lung cancer, coronary heart disease (disease of heart vessels), chronic obstructive pulmonary disease (emphysema), and stroke.

The research is clear on traditional cigarettes. Smoking can have a major impact on your diabetes risk. The Centre for Disease Control and Prevention (CDC) reported that tobacco smokers are 30-40% more likely to develop Type 2 diabetes. In addition, people with diabetes who smoke have an increased risk of complications.

Epidemiologic studies strongly support the assertion that cigarette smoking in both men and women increases the incidence of heart attacks, fatal coronary heart disease, and death. Even low tar and smokeless tobacco have been shown to increase the risk of cardiovascular events in comparison to non-smokers5.

Passive smoking with a smoke exposure about one-hundredth that of active cigarette smoking is associated with approximately 30% increase in risk of coronary artery disease compared with an 80% increase in active smokers4.

Cigarette smoking predisposes the individual to several different clinical atherosclerotic syndromes, including stable angina, acute coronary syndrome (heart attack), sudden death, and stroke. Aorta and peripheral atherosclerosis (plaque in blood vessels causing narrowing) are also increased and lead to intermittent claudication (leg pain when walking) and abdominal aortic aneurysm2.

Differences between smoking and vaping (e-cigarette)

Traditional cigarette smoking contains: nicotine but also tar; carbon monoxide; benzene; formaldehyde; lead; methanol; hydrogen; cyanide; butane; ammonia; chloroform; acetone; nitrosamines; aluminium; carbon dioxide; cadmium; arsenic; ethanol; vinyl chloride; radon; and 3 500 more chemicals and 50 more known carcinogenic substances that cause cancer.

The e-cigarette contains nicotine; propylene glycol (found in food and some medication used as a carry vehicle); glycerine, and food flavouring.

What are the effects of nicotine?

Nicotine stimulates specific receptors in the brain that produce both euphoria and a sedative effect. Individuals who have emotional dysfunction or attention deficits are more likely to start smoking and less likely to quit.

Nicotine is a sympathomimetic drug that releases catecholamine (adrenaline and noradrenaline). This causes a rise in blood pressure, heart rate and an increase in cardiac contractility. It also increases heart vessel constriction and can cause transient ischemia.

After smoking, nicotine raises blood pressure and pulse. It has a deleterious effect on insulin sensitivity in the fact that it decreases insulin sensitivity and can cause or aggravate diabetes.

It has a negative effect on the endothelial (inner lining) of the blood vessels. Increased cardiovascular effects have not been a problem when using nicotine alone and nicotine per se does not cause cancer1.

A suspected adverse effect on reproductive system causes foetal neuroteratogenesis (abnormal babies should the mother smoke or vape during pregnancy).

Though, nicotine has the beneficial effect of increasing attention, concentration, and lifting the mood. Some of these properties cause the addictiveness of nicotine3.

E-cigarette: What about the clinical evidence?

In a pilot study, it was shown for the first time that the smoking habits of smokers changed after using the e-cigarette. This study used 40 smokers that did not want to quit. The results showed significant reduction in smoking and abstinence without withdrawal symptoms.

The overall quit rate was 22%. Moreover, a 50% reduction in smoking was observed. The end results showed an overall 88% decline in the number of cigarettes smoked per day.

The only negative aspect was the initial difficulty in working the e-cigarette. It took considerable training for known smokers to manage the e-cigarette effectively to be satisfied with the results of vaping6.

This study is of significant interest since none of the participants were interested in quitting. This fact needs some more explanation.

Some of the possible answers to this question may be the following options. The e-cigarette replaces the ritual of smoking gestures, the opportunity to reduce a bad smell, to reduce the cost of smoking, and the perception of general well-being might have been responsible for their switching and quitting.

What does vaping do to blood glucose?

The nicotine in vaping can cause a raise in blood glucose due to the effect of increased insulin resistance. Diabetics using insulin may need more insulin to control blood glucose effectively and Type 2 diabetics on tablet medication may need an increase in dosage to prevent the raise in HbA1c (average three-month glucose test).

Conclusive thoughts

  • If you don’t smoke, don’t start vaping since the flavoured nicotine can be addictive.
  • If you do smoke, switch over to vaping to reduce all the other disease causing entities.
  • Remember moderation in all things.
  • An e-cigarette is a good device for quitting and more environmental friendly on people and animals than the traditional cigarette smoke.
  • More studies are still needed on long-term outcomes.

References:

  1. BenowitzNL (2009) ‘Pharmacology of nicotine: addiction, smoking induced disease, and therapeutics.’ Ann Rev Pharmacol. Toxicol. 49 p57-71
  2. Black HR (1995) ‘ Smoking and cardiovascular disease.’ In: Laragh JH, Brenner Bm editors. Hypertension, p2621-47
  3. Gehricke JH, Loughlin SE, Whalen CK et. al. (2007) ‘Smoking to self-medicate attentional and emotional dysfunctions.’ Nicotine Tab. Res, 9 (Suppl4) S523-S536
  4. Law MR, Morris JK, Wald NJ (1997) ‘Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence.’ BMJ, 315 p973-80
  5. Negri E, Franzosi MG, La Vecchia C et. al. (1993) ‘Tar yield of cigarettes and risk of acute myocardial infarction: GISSI-EFIRM Investigators.’ BMJ ,306 p1567-70
  6. Polosa R, Caponnetto P, Morjaria JB et. al. (2011) ‘Effect of an electronic nicotine delivering device (e-cigarette) on smoking cessation and reduction: a prospective pilot study.’ BMC Public Health, 11 p786
  7. World Health Organization (WHO) (2011) ‘Tobacco fact sheet N339’ Geneve, Switzerland.

Dr Louise Loot

MEET OUR EXPERT


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.


Photo credit: www.blacknote.com

The dreaded black toenail – Runner’s toe

If you have decided, this spring, that you want to take up running as your form of exercise, Podiatrist, Dennis Rehbock, helps us understand why runner’s toe occurs.


Most runners are prone to getting the dreaded black toenail, technically called a subungual haematoma. However, it is not only runners who develop this. Anyone can get it, depending on the cause.

This condition is from repetitive trauma to a toenail that causes blistering, bruising or bleeding under the nail. The trauma is usually the toe and toenail hitting the upper and front of the shoe and, eventually, causing bleeding under the nail with pain and swelling.

It mostly occurs in long-distance running but also in other ballistic sports, such as tennis and squash. Trail running and general hiking can also cause this black toenail condition.

What causes it?

The mechanism is very simple. The toenail bashes the shoe repetitively and eventually causes a blood blister to form under the nail. Because there is nowhere for the blood blister to go it creates pressure and pain.

The incorrect fitting of the shoe can also cause this to happen. If the shoe is too short and the toe box is too shallow it can exacerbate the injury. This can allow a too-tight or too-loose fitting and can both cause the injury. Also, when combined with downhill running and long-distance running, it can cause the condition.

Trauma, such as dropping a heavy object on the toe can also cause it. Toenails or fingernails could be affected by this traumatic type.

There are other conditions that can also make a toenail go black, but this is best investigated by your podiatrist if none of the above have occurred.

How to treat it?

A small painless black or blue discolouration under a nail is not serious and can be left alone to resolve itself. The bruise will eventually grow out.

A severe large blood blister under the nail would be painful and would need podiatric intervention. This blood blister needs to be opened and drained. This will automatically relieve the pain. The nail may have to have a hole drilled through it to get to the blood blister. This is best performed by a podiatrist and strict antiseptic protocols need to be followed.

A new nail will grow back in three to six months and then precautions need to be taken so that it does not reoccur. For example, the fitting of a running shoe needs to be looked at. It is best to go to a specialised running shoe store to help in the choice of a running shoe and to ensure the fit is correct. Some running shoe brands, like New Balance, have wider and deeper toe boxes for a better shoe fit. Cutting a hole in the running shoe will also help to prevent the toe trauma.

Prevention is better than cure

If the nail and surrounding area becomes very red and has any pus then it would be infected. See your podiatrist or a healthcare professional as soon as possible.

If the nail is white, yellow, of any other unusual colour there may be more going on there that meets the eye. A proper analysis of the nail, where we clip and biopsy a portion of your nail, is necessary.

For a podiatrist in your area look at the Podiatry Association of South Africa website  or call +27 861 100 249.

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Dennis Rehbock is a podiatrist in private practice in Johannesburg. He has been a part-time lecturer and clinician at the University of Johannesburg Podiatry Department for 37 years. His special interest includes podiatric sports podiatry and the diabetic foot.