Category: 2018 Summer – Diabetes Focus eMag

Screen for life – know your score

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We hear why diabetic retinopathy screening, Screen for life, is so important for diabetes patients.

Modern technological advances have made it possible to detect the earliest signs of diabetic disease by taking a photograph of the retina at the back of the eye. A new appreciation of the importance of the detection of any retinopathy has changed the way doctors are managing the disease.

The detection of retinopathy, done by human and artificial intelligence graders, informs the risk of future disease, including blindness. This makes it imperative for people living with diabetes to know their retinopathy score while there is still time to change it by looking after themselves better.

#Redflag communication system

The Ophthalmology Society of South Africa (OSSA) has developed the Screen for life programme to help communicate these important messages, using three red warning flags. The #Redflag communication system is communicated using the patient held record:

  • Screen for life, #Flag 1: Detection of any retinopathy determines the person to be retinopathy positive. This increases the risk of future complications, especially heart attack. The primary care giver needs to be informed of this.
  • Screen for sight, #Flag 2: Detection of sight-threatening retinopathy, glaucoma, and age-related macular degeneration. Referral to an ophthalmologist is indicated for this.
  • Screen for progression, #Flag 3: Progression of retinopathy disease means that the steps to control the disease are not working and more help is needed to prevent severe disease. This will require more urgent intervention by the primary care giver and may require referral to a diabetologist.

All people living with diabetes should be screened to determine whether retinopathy is present. If no retinopathy is detected, the person is advised to be screened in one year’s time. Diabetic patients are encouraged to keep looking after themselves well to stay retinopathy negative. When retinopathy is present, review is advised based on the severity of disease detected. This may be yearly, six-monthly or three-monthly. Once retinopathy is more severe, referral to an ophthalmologist is indicated.

MEET OUR EXPERT

Stephen Cook is an ophthalmologist and works at the Eye Centre which strives to provide a comprehensive eye service to people in the region. He is also a part-time consultant at the Frere Hospital and supports the registrar training programme for Walter Sisulu University. His special interests lie in making medical services more accessible and communication regarding conditions more understandable. He has developed the Screen for life diabetic retinopathy screening programme on behalf of the ophthalmology society (OSSA).

The Screen For Life programme helps communicate these important messages, using three red warning flags.
coconut

Coconut oil – is it what it is set out to be?

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The claimed health benefits of coconut products are in abundance, but how much of this information is true? Dietitian, Jessica Oosthuizen, tells us.

Coconut products are abundant on the shelves of supermarkets and health stores. These products promise so many health benefits. Apart from coconut oil, you will find coconut milk, coconut water, coconut yoghurt and coconut snack bars just to name a few.

If you Google the health benefits of coconut oil, the websites and lists will be endless. Claims for coconut oil will vary from increasing fat burning; reducing hunger therefore help you to eat less; ability to raise your ‘good’ HDL cholesterol; protection of skin, hair and dental health; reducing inflammation; and stimulating organs, such as the thyroid and the brain, to assist in weight loss. Let’s take a further look at the health claims.

  1. Coconut oil lowers your risk for heart disease

There are claims stating that populations who eat a lot of coconut oil are healthy. Such as those in India, Sri Lanka and countries in the South Pacific area. However, when evaluating these claims, it’s important to remember that there are various factors other than cholesterol that contribute to one outcome, such as heart disease.

The overall diet will play a key role towards how nutrients influence health outcomes. The diet consumed by these populations will contribute to their minimal risk for developing heart disease, as their diet is mostly unprocessed, and rich in wholegrains, fish and fresh fruit and vegetables. This type of diet contrasts with the typical Western diet – high in refined carbohydrates, sugars and saturated fats.

Clinical trials comparing the direct effect on cardiovascular disease (CVD) of coconut oil have not been reported. Therefore, there is no scientific evidence stating that coconut oil can reduce your risk for CVD.

Many studies have evaluated the effect of consuming a variety of fats and oils on blood lipid profiles, including coconut oil, butter, coconut butter and unsaturated fats (olive oil, sunflower oil, safflower oil and corn oil). Coconut oil raised both HDL and LDL cholesterol.

Numerous studies have shown that you can lower your risk of heart disease by replacing saturated fats with unsaturated fats in the diet. Individuals who adopt the Mediterranean style of eating that includes nuts, olives and olive oil had a lower risk for developing heart disease, stroke and death compared to those who follow a low-fat diet.

  1. Coconut oil is healthy as it contains medium-chain triglycerides (MCT)

All dietary fats consist of a variety of fatty acids. Depending on the length of the fatty acid chain, fatty acids are classified as short-, medium- or long-chain fatty acids. MCTs are easily digested and absorbed by the body.

The truth lies in the fact that lauric acid, which is the predominant property in coconut oil, has a higher molecular weight and is metabolised differently to the lower-molecular-weight triglycerides, such as caprylic and capric acids.

Most MCT fats are made up of caprylic and capric acids and not the lauric acid found in coconut oil. Since the triglycerides that are present in coconut oil cannot biologically or functionally be classified as MCTs, it is incorrect to apply these health benefits of coconut oil as the research is not relevant.

  1. Coconut oil is better to use for cooking

It’s imperative to understand the smoke point of certain types of oil when determining if it is suitable for cooking. The smoke point refers to the temperature that the oil can be used in cooking. The higher the smoke point, the more cooking methods it can be used for. The smoking point of coconut oil is 177°C compared to healthier options, such as virgin olive oil which has a smoking point of 210°C; sunflower oil (227°C) and canola oil (204°C).

The conclusion on coconut oil

The evidence showing an association between coconut consumption and risk factors for heart disease is mostly of poor quality. However, it does show that coconut oil compared to unsaturated plant oils raises total cholesterol, HDL cholesterol and LDL cholesterol. There is no convincing evidence to support the benefits of consuming coconut oil. Research suggests that replacing coconut oil with unsaturated fats, such as olive oil, could reduce your CVD risk.

With this said, it does not mean that all coconut products need to be completely avoided. They can add flavour to the occasional Thai or Indian dish.

When selecting an oil to use every day, it would be best to choose an unsaturated fat, such as olive oil. The World Health Organisation (WHO) recommends reducing saturated fats to <10% of total energy intake. Practically speaking for a man following an 8400kJ (2000kcal) diet, 10% of this would be 22g of saturated fat per day. One tablespoon of coconut provides 12g of saturated fat. Therefore, you can get an idea of how easy it is to reach your saturated fat intake for the day if using coconut oil. As a comparison, 1 tablespoon of olive oil only has 2g of saturated fat and 10g of monounsaturated and polyunsaturated fatty acids.

References

  1. Sacks et al. (2017). Dietary fats and Cardiovascular Disease. A Presidential Advisory from the American Heart Association. Circulation. 135 : e00-23.
  2. Clifton, P.M. & Keogh, J.B. (2017). A systematic review of the effect of dietary saturated and polyunsaturated fat on heart disease. Nutrition, Metabolism & Cardiovascular Diseases. 27:1060-1080.
  3. Eyres, L., Eyres, M.F., Chisholm, A. & Brown, R. C. 2016. Coconut oil consumption and cardiovascular risk factors in humans. Nutrition Reviews. 74(4):267-280.
  4. World Health Organisation. Practical advice on maintaining a health diet : Fats. 2018.

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.

NHI

The PMB Review and NHI: healthcare funding unfolding

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In the fourth and last article of a series aimed to empower patients on their rights in the funding of healthcare, Elsabé Klinck looks at the most recent proposed developments in healthcare funding, namely changes proposed to medical schemes, and the National Health Insurance (NHI).

Development in healthcare funding

We have, in the third article of this series, addressed managed care as practised within the medical scheme environment. We have also referred to the prescribed minimum benefits (PMBs) and designated service providers.

Now we are looking at proposals to change the PMBs, as well as other aspects in the medical schemes law, such as agreeing to only go to a designated service provider. We will also look at the health system changes envisaged. This proposed law aims to create a national, countrywide health insurance system, which will include both the public and private sectors.

It must be noted that what we discuss below are only proposals, and no changes to any of the laws or health funding systems are in place yet. It will still be many months, if not years, before such changes are brought into effect.

The review of the PMBs

A process to amend the current PMBs started at the Council for Medical Schemes two years ago. According to the law, the PMBs must be updated every two years. This is to ensure that it keeps pace with developments in technology and healthcare.

These updates have, unfortunately, not been done as the law requires. As a result, many of the descriptions and treatment, or diagnostic options available, are not always recorded as part of the PMBs in the list attached to the regulations.

For example, newer types of diabetes treatments are not included in the treatment descriptions for diabetes, and newer forms of blood glucose monitoring, such as continuous blood glucose monitoring systems, are also not considered for inclusion.

The PMB review process includes representatives from patient groups, as well as doctor and medical scheme groups.

What is significant is that the PMB review process will include consideration of primary healthcare, as well as an alignment with what is envisaged as benefits under the NHI.

The NHI benefit list does not specifically include all the conditions currently listed as part of the PMBs. Requiring, for example, all (or more) primary care chronic conditions to be funded, will necessitate some cuts in the level and types of diabetes benefits. So, to fund more conditions, fewer treatment options in diabetes care may be available.

Therefore, an expansion of what must be covered by medical schemes would necessitate trade-offs, should medical scheme budgets remain the same. More would have to be covered with the same amount of money.

The Medical Schemes Amendment Bill

The Health Market Inquiry, investigating price increases and competition in the private healthcare sector, have found (as recorded on page 456) in their draft report released in July:“Ideally the trustees of schemes should be interceding on behalf of members to ensure that they receive value for money and that administrators are delivering the best possible value to scheme members. But, the governance of schemes is problematic,”

The Medical Schemes Amendment Bill now tightens the responsibilities that rest on the trustees and principal officers of medical schemes, to act in the best interests of the beneficiaries of the scheme.

Other changes are proposed in this draft law. One of these changes will support the creation of two registers, or lists. One for people who belong to medical schemes and one for healthcare providers.

  • The beneficiary register will help the Council for Medical Schemes determine what the health status and needs of patients are. This will assist with planning on the resources needed to render healthcare services.
  • The healthcare provider register will be a list of doctors, hospitals and other healthcare providers.

Both lists will be provided to the NHI Fund. It seems that the medical scheme amendments will assist in the transition into a national health insurance system.

Proposed changes

The Bill also proposes a new system of benefits to replace the current PMBs. These benefits will be “service benefits”. This is not described in the law, and it seems that schemes will no longer have to pay for certain diagnoses, such as diabetes, but rather for a certain number of doctor visits, specific medicines, specific tests, and so on.

The Amendment also creates a new type of medical scheme option or plan, called “efficiency discounted options”. If a person agrees to belong to such an option or plan, the person and all their beneficiaries agree to only use preferred or network providers. This means one would not be free to choose one’s provider. In return, however, there will be a reduction in medical scheme monthly contributions or premiums.

Other changes brought about by the proposed law relates to contributions or premiums. If the main member’s contribution is expressed as 100%, the main adult dependent(s) would pay 50% of that, adult children (up to the age of 30 years) 40% of that, and child dependents 20% of that.

The idea is to create an incentive for younger adults to stay on medical schemes, to address the fact that young people often do not belong to medical schemes. Having young, healthy people on medical schemes is important, for the cross-subsidising effect it has.

Many stakeholders have expressed concerns about many aspects of the Bill, such as the income that will be lost by the flat-structure premiums, etc. A key concern has been the proposed amendments to benefits as service benefits. What will happen to persons with diabetes who have certain benefits as part of the PMB rules, where such benefits are no longer prescribed in law? If more conditions must be funded, medicines and other treatment options will be limited, as the same budget would now have to stretch to cover more. This would mean that patients may no longer have all their diabetes treatments funded as in the past. 

NHI

The NHI Bill has been lauded as the solution to many problems facing the health sector. It proposes that the NHI structure to be set up, called the NHI Fund, become the only entity that will buy services and goods. Currently goods, such as medicines, are bought by the various provinces and other entities, such as the military and correctional services. It is hoped that by centralising the funding of healthcare, many of the current problems on financial ability to pay for medicines and to ensure sufficient supply could be addressed.

However, the South African Constitution currently makes provinces legally responsible for rendering healthcare, and compels the treasury to make sure that monies are allocated to provinces to fulfil this mandate.

Shift from current system

What the NHI Bill proposes is a fundamental shift from the current system. Under this system general tax money is provided to the provinces, and with that money they create, maintain and fund public hospitals and clinics with staff being paid, with medicines, and so forth, to render the healthcare services.

The NHI system will separate the service providers (i.e. the public hospitals, clinics and their staff) from the funding model. So, all public hospitals and clinics will be service providers contracted to the NHI Fund. They will then get paid according to the patient population they are generally looked after. They will therefore no longer get a general budget from the national treasury through their province. Medicines and medical devices will then also not be supplied from the province, but bought by the NHI Fund and provided directly to the hospital or clinic.

Another fundamental change is that, whereas provincial health allocations are done based on the extent of how rural the province is, as well as how large the population is, the new allocations will be on the disease- and incident (e.g. accident) profiles in the feeding area of that hospital.

So, a diabetic patient who suffers a hypoglycaemic event and goes to hospital, will be covered by that hospital based on calculations that was made on the estimated numbers of similar patients in that area who are likely to require hospitalisation due to hypoglycaemic events.

Clinics

Clinics, who render primary healthcare, and where diabetes care will be based, will be funded on a capitation basis. That means, if that clinic renders services to a thousand patients, that clinic will receive a flat per patient per month fee to look after that patient, irrespective of how sick or well the patient is.

Private general practitioners, nursing practitioners and other primary care providers could, under the new proposals, join forces and collectively contract with the NHI authority on a district level to provide primary care. The idea is that servicing uncomplicated patients could be done by, for example, nursing professionals, whereas more complicated care could be rendered by a GP, etc.

Private sector

The NHI Bill also makes it clear that private sector hospitals and specialists could contract into the NHI, but is not clear on how they would be paid for rendering services to NHI patients. No private sector provider would be permitted to “opt out” of the NHI. To receive a certificate to practice, a person must be accredited by the NHI, and therefore render services to NHI patients.

Supply chain unknown

It is not known exactly how the supply chain will work, and how a diabetic patient will receive medicine under the NHI. If the patient goes to their primary care provider in their area, the cost of that visit will be covered by the capitation agreement between that provider and the NHI Fund. The patient will then get a prescription for, for example, an insulin. The patient will then get that specific insulin from the pharmacy in their area if that insulin is part of the NHI Fund’s benefits. This raises the question that if the patient’s specific insulin is not available from the NHI Fund – can that patient obtain their insulin from their medical scheme, or pay out of pocket?

As the Medical Schemes Amendment Bill proposes that medical schemes do not provide duplicative cover, it is not clear whether it would be possible for a patient to get their consultation for a specific condition from the NHI, but their medicine from a medical scheme.

Conclusion

There are still many uncertainties as to how, practically, the proposed changes to the PMBs, the Medical Schemes Amendment Bill and the NHI Bill will affect the delivery of diabetes care.

It is, however, important that patients living with diabetes are involved in the discussions around these changes. They need to make their voices heard as to how various proposals would, practically, affect their right of access to healthcare, and the availability of services, medicines and medical devices, which are required to ensure optimum health outcomes.

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.

Type 1.5 diabetes

Type 1.5 diabetes – a new diagnosis?

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Dr Angela Murphy tells us about Type 1.5 diabetes, commonly known as latent autoimmune diabetes.

Mrs JM came to see me about her new diagnosis of Type 1.5 diabetes. She was concerned that she had never heard of this before and that it may represent a more dangerous type of diabetes. She specifically wanted to know if she was receiving the correct treatment. To be able to explain this diagnosis, let us go back to the very beginning.

Back to the beginning

Diabetes mellitus, a condition where blood glocose is high, has been described for thousands of years. It was initially diagnosed by testing for the sweet (mellitus) taste of urine.

Over time it became clear that not all diabetes is the same and so began attempts to classify the various types. This classification has changed over the years and we now categorise diabetes according to the cause of the diabetes. The four main types are:

  • Type 1

In this type, there is significant destruction of the insulin producing beta cells of the pancreas. This is usually due to an autoimmune process that attacks these cells but may occur without any sign of autoantibodies. The latter variant has a very strong family history and is more common in African and Asian populations.

  • Type 2

This is the most common form of diabetes occurring in 90-95% of cases. Usually there is a background of insulin resistance and then progressive loss in insulin secretion from the beta cells.

  • Type 3

This group has over several major subtypes with over 40 individual causes described. The group includes the maturity onset diabetes of the young (MODY) conditions which are single gene mutations; pancreatic diseases such as cystic fibrosis; endocrine disorders; side effects of drugs, such as HIV treatment or other rare genetic conditions.

  • Type 4

By definition, this is hyperglycaemia (high blood glucose) first detected in the second or third trimester of pregnancy. This type is better known as gestational diabetes.

LADA

As you can see, there is no Type 1.5 diabetes. The more accepted term for this type of diabetes is latent autoimmune diabetes in adults (LADA). LADA is a condition that occurs in adults between the ages of 30-50 years. Like Type 1 diabetes, there is autoimmune damage to the pancreatic beta cells. However, this seems to be at a much slower rate than in the young, typical Type 1 diabetes patient. Hence, the term latent.

Why is LADA called Type 1.5 diabetes?

LADA has features from both Type 1 and Type 2 diabetes, so it seems reasonable to call it Type 1.5. However, the cause of LADA is autoimmune beta cell destruction. So, for that reason it must be considered as a subtype of Type 1 diabetes.

We should always consider a diagnosis of LADA in a normal weight patient who has reasonable glucose control, using lifestyle interventions and/or oral medication only. It would be reasonable to test for LADA in such a patient.

LADA/Type 1.5 diabetes symptoms

Initially, patients may experience non-specific fatigue, decrease in concentration and hunger pangs after eating. More typical symptoms, such as weight loss, thirst and blurred vision, develop gradually over months, sometimes even years. Patients are often of normal weight and usually there is no family history of diabetes. They may have another autoimmune condition, such as thyroiditis, rheumatoid arthritis or coeliac disease. The patient is advised on a healthy lifestyle and usually started on oral medication to control glucose, which seems to help for a period. Ultimately, there will always come a point when insulin needs to be initiated.

Confirmation tests for LADA

The only way LADA can be confirmed is to do specific tests to look for the antibodies causing the damage, specifically the glutamic acid decarboxylase (GAD) antibody. A C-peptide level test can also be done to measure how much insulin the pancreas is still producing.

These are not routinely tested and it can be argued that doing these tests, does not necessarily change management. If the patient is having regular check-ups, including HbA1c measurement and testing glucose regularly at home, any deterioration in the diabetes will be detected. The decision to initiate insulin can then be made timeously.

However, we should consider the advantages of doing the antibody testing and establishing if LADA is present as seen below.

Protecting beta cell function

Some of the oral medications available to treat high blood glucose work by stimulating the beta cells of the pancreas to increase their insulin production.

In LADA, this may have the negative effect of speeding up the deterioration of the beta cell and shortening the latent period: patients would need to start insulin sooner.

Metformin is the best oral diabetic medication to begin with as it has no pancreatic action. Rather, metformin decreases the production of glucose in the liver.

Preserving beta cell function

There is evidence that early insulin treatment may assist the beta cells so that they can continue producing insulin for longer periods. A Japanese study looked at 4000 patients with LADA and found that those treated with early insulin took longer to be fully dependent on insulin compared to those patients on oral medications.

Prevention of ketoacidosis

Ketones are formed by the body when fat is used for fuel. The body does this when there is not enough insulin to move glucose out of the blood stream and into the working cells of the body. Unfortunately, these ketones cause the body to become acidotic which is very dangerous.

Patients with LADA could be made aware that a persistent increase in their blood glucose might be heralding the time to start insulin. In this way, there would be less delay and thus, less chance of developing ketones.

Table 1 – Comparison of Type 1 and Type 2 diabetes

DIABETES ADULT ONSET AUTOIMMUNE DIABETES TYPE 2
Type 1 Latent Autoimmune
Autoantibodies YES YES NO NO
Insulin required at diagnosis YES NO NO VARIABLE

MEET OUR EXPERT

Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence as well as a specialist with the Centre for Diabetes Excellence (CDE) network.

Tshwane Insulin Project

The Tshwane Insulin Project

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Prof Paul Rheeder tells us more about the five-year research programme, the Tshwane Insulin Project (TIP).

About TIP

The University of Pretoria (UP) and Eli Lilly and Company will embark on a five-year research programme called, the Tshwane Insulin Project (TIP).

The aim of TIP is to optimise the control of blood glucose, blood pressure and lipids in people with diabetes, with specific reference to initiation and up-titration of insulin by both primary care nurses and/or primary care clinic physicians.

TIP is designed to fit into the National Department of Health’s Integrated Chronic Disease Management (ICDM). ICDM is a model of managed care that provides for integrated prevention, treatment and care of chronic patients at primary healthcare level, to ensure a seamless transition to assisted self-management within the community.

The TIP programme is a collaborative effort between the Departments of Internal Medicine, Family Medicine, Human Nutrition and the School of Health Systems and Public Health of UP, national and local health authorities, external experts and Eli Lilly.

The programme uses Lilly’s global health framework, which includes studying key research questions, reporting what works and what doesn’t, and then using the data to advocate for the scale up of the most effective solutions. The programme will contribute to Lilly 30×30. This is the company’s goal to create new access to quality healthcare for 30 million people in resource-limited communities every year by 2030.

Major challenge in SA

In SA, initiation and up-titration of insulin in primary care has been identified as a major challenge in diabetes care and achieving optimal insulin control. This is related to scarcity of resources, lack of healthcare practitioners trained in insulin use as well as patient-related factors, such as psychological insulin resistance

TIP is a much-needed project aimed at integrating diabetes care and especially initiation and up-titration of insulin by both primary care nurses and clinic physicians. Integrating prevention and effective treatment of diabetes and optimal glucose control is a crucial component of strengthening health systems and vulnerable communities where the impact of non-communicable diseases, like diabetes are often hardest felt.

UP has been involved in diabetes research in primary care for several years and through its research and training workshops, it has become clear that many patients in primary care are very poorly controlled.

One of the challenges with initiation and up-titration of insulin stems from the fact that insulin may legally only be prescribed by a doctor and not a nurse. Depending on the province and the district, many primary healthcare clinics do not have primary care physicians available full-time or even one day a week.

Many primary care physicians are also not confident in initiating and up-titrating insulin which leaves diabetes patients incredibly vulnerable and unable to access quality care close to their home.

Pathways to be taken

This programme is designed to explore the feasibility of using telemedicine or phone apps to assist the nurse or even the primary care physician to better serve the needs of people living with diabetes in underserved areas. It’s well-recognised that the major achievement of getting millions of people onto anti-retroviral treatment in SA was due to successful task-shifting using primary care nurses.

Inclusion of home visits by community healthcare workers will also be evaluated as they potentially could enhance compliance and patient education. TB care was also decentralised in a similar way and care and treatment was made available to patients as close to their homes as possible. We believe that the same can be achieved with diabetes care and we can avoid the current tragedy of people presenting at hospitals with advanced stages of diabetic co-morbidities and complications due to poor glucose control.

Comments from Eli Lilly

Evan Lee, Senior Director Global Health Programs and Strategy of Eli Lilly Global Health says diabetes is a major contributor to poverty and a barrier to social and economic development in developing countries like SA.

Diabetes is a growing problem worldwide, and its costs to society are high and escalating. It’s alarming when one considers that of the 10 leading causes of death in SA in 2016, five were non-communicable diseases and all had increased in 2016 compared with 2014. In fact, diabetes, which ranked third in 2014, moved to being the second most common natural cause of death in 2016, responsible for 5,5% of all deaths by natural causes. That’s 25 255 lives lost in 2016 alone, 69 deaths each day. Diabetes is ranked second only to tuberculosis and ahead of HIV, and in women, diabetes is the leading cause of death¹.

The importance of getting quality diabetes care embedded at a primary care level can’t be emphasised enough. Evidence shows that good diabetic control reduces the risk of diabetes complications and co-morbidities. This is a crucial aspect of the quality of life that a patient living with diabetes can expect to enjoy.

Therefore, finding new approaches to the detection and management diabetes, and bringing access to quality care to the community is so important. SA has been a pioneer in enabling care and management of complex diseases, like HIV and MDR-TB. So, it should be feasible to do so for diabetes.

By working closely with the UP and local municipal clinics, we aim to transfer the learnings from this research project to other regions in SA. By rigorously documenting, monitoring and evaluating the intervention, we hope this project will be shared nationally and the massive impact of diabetes, especially on vulnerable communities, can be halted.

References:

http://www.statssa.gov.za/publications/P03093/P030932016.pdf, Appendix M

MEET OUR EXPERT

Professor Paul Rheeder is a trained specialist physician with a PhD in clinical epidemiology obtained from Utrecht University, the Netherlands. He occupied the Medihelp Chair in clinical epidemiology at UP for 10 years. He is past acting head of the School of Health Systems and Public Health, UP. Currently he is employed as senior specialist physician at the Steve Biko Academic Hospital, Department of Internal Medicine. His main research interest is in improving management and outcomes of patients with diabetes mellitus.

EASD

Highlights from EASD 2018

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Dr Louise Johnson gives us a brief overview of what was presented at the European Association of the Study of Diabetes (EASD) Annual Meeting 2018.

From fear to hope

The meeting started with a lecture titled From fear to hope. The lecture was about Dr Banting who discovered the first insulin and moved through the history of insulin up until till where we are now with the second-generation basal (long- acting) insulin. Both insulin glargine U300 (Toujeo) and degludec insulin (Tresiba) are available in South Africa.

The new direction in diabetes with insulin is not only the HbA1c (average three-month blood glucose value) but also glucose variability. Glucose variability is the time spent within target range. This is established with the help of a continuous glucose monitor (CGM) sensor that measure blood glucose every five minutes and displays it on a screen or a cell phone app. Currently, there are five different CGM monitors available in South Africa.

The target range would be a variation of blood glucose between 5 and 10 mmol/L in a 24-hour period. The more time spent within this range, the less likely the appearance of complications.

The lecturer, Dr Rosenstock, showed data from Diabetes Care (2017, 40 :554) that correlates the time in range and the presence of retinopathy complications. 

The BRIGHT study

The results of The BRIGHT study – the first head-to-head randomised clinical trial comparing the two new basal insulins: Toujeo and Tresiba – were released.

The results showed no difference in HbA1c over a 12-week period. The glucose variability between the two groups were the same.

It is important to remember with these second-generation basal insulins to only adjust the insulin dosage once every week, due to the long-onset of action. Toujeo is 32-hours and Tresiba is 42-hours. This gives the advantage of flexibility and less hypoglycaemia, especially at night time.

Diabetes – a diverse and heterogeneous disease

Another highlight was a talk, by Dr James Gavin III, titled Diabetes – a diverse and heterogeneous disease. The core message was that our current diagnosis of Type 1 and Type 2 are not correct anymore since there are a lot of overlapping. The importance of a diagnosis is to be able to predict, prevent complications, and plan correctly.

The new diagnoses are in clusters:

  • Cluster 1 – Severe autoimmune diabetes (previously most of Type 1 diabetes). This has early onset of disease at a young age, relatively low BMI, poor metabolic control, insulin deficiency and the presence of auto-antibodies (GAD antibodies).
  • Cluster 2 – Severe insulin deficient diabetes. This is early onset of diabetes with a relatively low BMI and poor metabolic control. There is low secretion of insulin but the auto-antibodies are negative.
  • Cluster 3 – Severe insulin resistant diabetes (most of Type 2 diabetes fit in here). These patients have high insulin levels and a high BMI.
  • Cluster 4 – Mild obesity-related diabetes. These patients are obese but not insulin resistant.
  • Cluster 5 – Mild age-related diabetes. These are older patients that are not insulin resistant

The importance of the new diagnosis classification is to not only focus on blood glucose control but also on disease modification. It was also stressed to get blood glucose to target early in the disease and this will prompt the legacy effect. The body will remember the good control for years afterwards and prevent complications.

What is new on the drug scene?

The new wonder drug in the Type 2 diabetes arena is the class of drugs called sodium glucose co-transporter 2 inhibitor (SGLT2). This class works on the proximal (first) part of the kidney tubule and blocks the absorption of glucose back into the body. The result of this is glucose in the urine. But there is more:

  • Three to six kg weight loss.
  • Blood pressure reduction.
  • Better blood glucose control.
  • Most important is reduction in the mortality of heart attack and heart failure.

In South Africa, we have dapagliflozin (Forxiga) and empagliflozin (Jardiance).

There is a new drug in this class that is now being tested in Type 1 diabetes. It is called sotagliflozin and works mostly on the gut. It prevents absorption of sugar from the gut and improve glucose in Type 1 diabetes, especially after meals. This drug is still under investigation and is not available yet anywhere in the world. The preliminary data shows the same reduction in mortality.

Can Type1 diabetes use the SGLT2 class?

The two SGLT2 inhibitors, Forxiga and Jardiance, currently available in South Africa are not registered for Type 1 use. The reason is the increase in diabetic ketoacidosis(DKA).

DKA can be fatal if not picked up early and it’s not suggested for Type 1 diabetes. Rather wait for the appearance of sotagliflozin that works mainly on the gut.

Focus on other targets

During the meeting, it was reiterated that diabetic patients should not only focus on glucose control but also blood pressure target below 130/80mmHg, LDL cholesterol below 1,8 mmol\L and not smoke at all. Regular, light exercise was also emphasised. It was shown that if more of these goals are met, the cognitive improvement, especially in older individuals, is achieved.

Does pneumopathy exist?

The last day ask the question Does pneumopathy exist? Pneumopathy is the presence of lung disease without other factors, such as smoking or lung infection being present.

There are only 64 papers worldwide but there is enough evidence to show that a restrictive lung function pattern does exist in long-standing diabetes. The data showed an incidence of 25%. The best predictor for lung disease is the presence of kidney disease. The treatment currently seems to be good control and regular exercise to improve lung function.

The microbiota in diabetes

The final but most riveting session was: The microbiota in diabetes. The microbiota is the normal microorganisms that stay in the gut in the faeces (stool). It was shown how the organisms differ between disease states.

The current thought process is that the microbiome first change to that of Type 2 diabetes and only later does the blood glucose rise. This is a fascinating area since correct diets could have the potential to prevent diabetes. This is unfortunately still early days but keep your eyes peeled.

In summary

Healthy diet, especially if you or your loved ones do not have diabetes yet, is important. Plus, low blood pressure, low cholesterol, low blood glucose and regular exercise are important.

Talk to your healthcare provider about the new drugs and monitors.Remember that the scientists are working diligently around the clock to find to a cure!

Dr Louise Johnson

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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

support

My family support

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Aiden Nel, a teenager with Type 1 diabetes, tells us the highlights and challenges of the support from his family concerning his diabetes.

My family tries to support me with my diabetes as much as possible. Most of the time their support is good, but to be honest there are times that the way they go about supporting me does upset me.

The positives

One of the positive ways that my mother supports me is when she cooks; she tries to cook with the least amount of sugar, and as a family, they try their best to not have more carbohydrates than necessary.

As a family, we also only drink sugar-free cold drinks. It’s very rare that we will have a sugar cold drink, like Coke or Cream Soda, in the fridge.

My sister likes sweets, but she is very considerate and won’t eat them in front of me. I still do eat sweets, but not as much as other non-diabetic children. I just need to have my insulin immediately.

The negatives

One thing that does upset me though, is that we don’t often eat dessert. I sometimes feel that this is because of my diabetes and what child wouldn’t be upset if they could not have pudding?

The biggest bugbear is the constant asking of what my reading is. Every night, before I go to bed, they ask me what my reading is. Before I leave for school, in the morning, they ask me what my reading is. Sometimes I do get irritated by all the asking and checking of my readings. However, I do know that it is for the best and they are asking out of concern and love for me. So, I do not stay upset for long. I just go and test myself, and then everyone is happy again.

Even if my family sometimes upsets me, they still do their best to help me, and I am very grateful for their support and love.

Aiden Nel lives in Port Elizabeth. He is 14 years old and has Type 1 diabetes.

flexible family

The flexible family

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One of your family members has diabetes, but in a way, the whole family has diabetes because each of you experiences this chronic disease in one way or another. Rosemary Flynn expands on the flexible family.

A family can be a single parent family or a large family, including others like a grandmother or a cousin.

The ups and downs of diabetes can bring emotional highs and lows that each of the family members must deal with, and that requires flexibility.

Family stressors, like arguments, divorce, or loss of a family member, can make blood glucose levels higher and that will negatively affect diabetes control in the long run. The family needs to be able to work together to resolve the problems and also to manage the diabetes.

In any family, the spouse or parents often worry about the person with diabetes. Have they eaten right? Are they managing their control enough to prevent complications? Have they exercised enough and safely? Are they losing weight as has been advised by the diabetes team? Worrying is a natural response in families, because they love each other.

The family worries a lot less when the person with diabetes takes responsibility for their diabetes and practises good management. It works the other way around too: if the person has family support, he or she worries a lot less.

Each family member must understand diabetes well

On the medical side, for the family to be supportive, each member needs to understand diabetes well. They need to know how to deal with hypoglycaemia and high blood glucose levels, the eating plan, the exercise plan, the medical plan and the management plan. Even the young ones can have an understanding at their level of development.

Understand that if the person with diabetes is a child, siblings can be resentful of all the attention given, or feel guilty, or feel anxious for their brother or sister. So, give them the space to talk about their feelings.

A balanced family

Family balance goes a long way to making diabetes self-care successful. Creating a balanced family can be done in the following ways:

  • Have family meetings to talk to each other about the things that concern you (include all who live in your home, even the little ones). Give everyone a turn to speak and respect what each family member has to say. Any diabetes information can be discussed this way. It allows for creative solutions to the problems to be found.
  • Talk to other families who 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 give good ideas on how to deal with family issues that arise because of diabetes.
  • Spend time with your family, doing things you all enjoy, and listen to what is going on in each member’s life. This makes each member feel they belong.
  • If you need to speak to one family member, set aside a special time to do this.

Create a flexible family by:

  • Having clear limits, expectations and rules which can be adapted to different situations.
  • Being committed to the decisions that are made in the family, but carry these out in a reasonable, flexible way.
  • Being respectful and kind to each other.
  • Solving problems together.
  • Valuing each member’s feelings.

Having a flexible family means that each person feels valued, understood and secure in their relationships at home. They can develop confidence and positive self-esteem both at home and outside of the home. They are less likely to struggle with anxiety and depression.

A flexible family will enable both the person with diabetes and all the other members of the family to go into the future in a positive way.

Rosemary Flynn

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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.

Albany Bread-A-Betix Super Citrus Chicken Sarmie

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INGREDIENTS

  • 2 slices Albany Bread-A-Betix Low G.I. White Bread

For the citrus mayo:

  • 60ml mayo
  • 5ml lemon zest
  • 5ml lemon juice
  • 5ml orange juice
  • 5ml orange zest
  • 1 chicken breast
  • 2,5ml ground ginger
  • Olive oil for frying

For the cucumber pickle:

  • 80ml apple cider vinegar
  • Black sesame seeds
  • 15ml brown sugar
  • ¼ cucumber, shaved
  • Fresh watercress

METHOD

  1. For the chicken breast, toss in the ginger and pan fry until cooked through and golden. Slice.
  2. For the pickle, mix together the vinegar, sugar, and black sesame seeds and then toss in the shaved cucumber. Leave to pickle for 15 minutes.
  3. For the citrus mayo, mix together the lemon and orange zest, juice, mayonnaise and season to taste.
  4. For the sarmie, spread the 2 slices of bread with citrus mayonnaise, top with watercress then place sliced, grilled chicken on each slice.
  5. Top with cucumber pickle and extra zest!

Understanding the steps to diabetes self-management

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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.