Why glucose is the go-to

Jessica Oosthuizen explains why pure glucose is the preferred treatment for hypoglycaemia (low blood glucose).


“To fix a low blood glucose reading you need time, not more food.”

Hypoglycaemia remains a worry for many people living with diabetes and parents with children who have diabetes. It’s also one of the major limiting factors towards achieving good glycaemic control.

In diabetes management, when you are aiming for a blood glucose target of between 4 – 10mmol/L, it’s almost impossible to prevent hypoglycaemia all the time.

Hypoglycaemia can happen at any time of the day. Though, it may be more likely to occur before meal times, at the peak of insulin if the dose is incorrect, and during or after exercise.

Type 1 diabetes patients frequent hypoglycaemia the most. Followed by people with Type 2 diabetes managed by insulin and then people with Type 2 diabetes managed by sulfonylureas (antidiabetic drugs).

What is hypoglycaemia?

Hypoglycaemia means low blood glucose levels. It can be defined by:

  • A low blood glucose reading below 3,5 mmol/L. In children under six, this reading is below 4 mmol/L  because children may not be able to recognise symptoms or communicate with you.
  • Adrenergic and autonomic symptoms. These are symptoms caused by the body attempting to raise the blood glucose level. They include trembling, palpitations, sweating, dizziness, anxiety, hunger, nausea and tingling. These symptoms tend to start happening at a reading of between 2,8 and 4mmol/L.
  • Neuroglycopenic symptoms. These symptoms originate in the brain as a result of a deficiency of glucose in the central nervous system. These include difficulty concentrating, confusion, weakness, drowsiness, blurred vison, difficulty speaking, headache and dizziness. These symptoms are likely to occur at a reading below 2,8mmol/L.

Classifications

Hypoglycaemia can be classified as mild, moderate or severe.

In mild hypoglycaemia, self-treatment is possible and blood glucose can easily be rectified to normal values.

With moderate hypoglycaemia, your body will react with warning signs, involving autonomic symptoms. You will be able to self-treat to bring blood glucose levels up.

When having a severe hypoglycaemic episode, you will require assistance from another person to give you something to eat or drink, or a glucagon injection.

In severe cases, you may lose consciousness and have seizures. Glucagon is a naturally occurring substance, produced by the pancreas, which supports the production of glucose to correct the hypoglycaemic state. This response may be slightly defective in Type 1 diabetes.

What causes hypoglycaemia?

Low blood glucose is caused by an imbalance between the factors that raise and decrease blood glucose levels. Those causing an increase in blood glucose include food and counter-regulatory hormones (glucagon, adrenaline and cortisol) and those causing a decrease include insulin or oral medication and physical activity.

With new technologies, such as flash glucose monitoring systems and continuous glucose monitors (CGMs), we get a clearer picture of what the blood glucose levels are doing over a 24-hour period.

This is compared to the traditional self-blood glucose monitoring (SBGM) system whereby with a prick of the finger you get your blood glucose reading of that given moment. In the case of SBGM, if you test your blood glucose and see that your levels are low, you have no idea where they may be going from there.

With CGMs and flash glucose monitoring systems, we can see in the form of an arrow which way the glucose is trending. And, with some of the newer CGMs, the rate at which it is trending up or down.

Common reasons for a low blood glucose reading:

  • Delayed or skipped meal.
  • Eating too little carbohydrates at a meal.
  • Overestimated the carbohydrates eaten, if using carb counting.
  • If you have exercised or been physically active.
  • Taken too much insulin in relation to what your body needs.
  • New injection site, therefore, avoiding lumpy tissue where insulin absorption is unpredictable.
  • Consuming alcohol.

How to treat hypoglycaemia?

This will depend on various factors, such as the rate at which the blood glucose is decreasing by, how much active or unused insulin is on-board, and when you last ate something carbohydrate-based.

Active insulin is the time that insulin remains working in your body, it refers to a bolus injection and this is usually 3-4 hours.

Having pure glucose is the preferred treatment for hypoglycaemia. However, any carbohydrates that contains glucose will raise blood glucose levels.

It is important to test blood glucose first, treat with the correct amount of rapid-acting carbohydrates, wait 15 minutes and then retest your blood glucose. If you are still not feeling better and your blood glucose has not risen, then you should repeat with the same amount of glucose. 0,3g of glucose/kg will increase the blood glucose reading by approximately 2 mmol/L.

Studies have shown that 15g of glucose is required to get an increase in blood glucose of approximately 2,1mmol/L within 20 minutes.

Examples of 15g of carbohydrate for the treatment of mild to moderate hypoglycaemia:

  • 15g of glucose in the form of glucose or dextrose tablets.
  • 15ml (3 teaspoons) of sugar.
  • 150ml of regular soft drinks.
  • 15ml (1 tablespoon) of honey.

Danger of over-treating hypoglycaemia

Over-treating hypoglycaemia should be avoided as much as possible because this can lead to rebound hyperglycaemia (high blood glucose) and weight gain.

To fix a low blood glucose reading you need time, not more food. It is important to note that the liver is also responsible for glucose output and rebound hyperglycaemia.

Glucose has a quicker effect on the blood glucose compared to other types of carbohydrates. You should avoid food and drinks containing fat, such as chocolates, biscuits or milk. The fat in these food items will delay digestion in the stomach and the glucose will therefore take longer to reach the bloodstream.

Fructose (the fruit sugar naturally found in fruits) is absorbed more slowly from the intestine and is not as effective as glucose in raising blood glucose levels.

Why can’t hypoglycaemia be treated with ‘real food’?

Treating hypoglycaemia with ‘real food’, for example, a banana will completely depend on the situation at hand. With the use of CGMs, we may be able to use ‘real food’ more frequently to treat a lower blood glucose reading before reaching the hypoglycaemic range.

With SBGM, we are limited because we only have that one reading for that specific time and no other information to tell us where we are going. Because of this, eating something like a banana (without any active insulin), may cause an undesirable rise in blood glucose.

Diabetes is an extremely unpredictable disease and it may be impossible to prevent all future hypoglycaemic episodes. It is important to evaluate your current diabetes management plan with your endocrinologist, diabetes nurse educator and registered dietitian to reduce and prevent large fluctuations in blood glucose readings.


References:

  1. Wherret DK, Ho J, Hout C, et al. 2018 Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents. Can J Diabetes 2018; 42: 234 – 246.
  2. Yale JF, Paty B, Senior PA. 2018 Clinical Practice Guidelines: Hypoglycemia. Can J Diabetes 2018; 42: 104 – 108.
  3. Barnard K, Thomas S, Royale P, Noyes K, Waugh N. Fear of Hypoglycemia in parents of young children with type 1 diabetes. BMC Pediatrics 2010, 10:50.
  4. Hanas, R., Type 1 Diabetes in children, adolescents and young adults. 6th Class Publishing: Bridgwater, 2015.

MEET OUR EXPERT


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


Diabetes: where science, art and education meet

Louise Johnson explains that the art of living skilfully with diabetes in the new millennium is possible with your own skill, science and the help of a team.


The Oxford Dictionary defines art as “the creation of beautiful or significant things” and “a superior skill that you can learn by study and practice and observation.”

In the new millennium, diabetes patients can acquire this art or superior skill by diabetes education. This can be in any form of information from your diabetes nurse educator, doctor, internet support group or books on the subject.

Insulin saves lives

Historically, diabetes mellitus was a deadly disease in people living with Type 1 diabetes. Prior to 1921, when insulin was first given to Leonard Thompson, people living with Type 1 diabetes died.

There has been a radical change and growth in information and technology since 1921. People living with Type 1 diabetes now have basal and bolus analogue insulin.

An analogue is an insulin that works as close as possible to normal human insulin. Recently two new basal second-generation insulin were launched in 2018: Toujeo (glargine U300) and Tresiba (degludec).

Both have a working time of more than 24 hours. This is truly a once daily long-acting insulin without any peaks or intra patient variability. In practise, this mean that the sugar values will stay the same if you eat the same food every day. Thus, it allows for suitable background insulin to build on.

The short-acting analogues currently available are all very effective. NovoRapid, Humalog and Apidra all have a working time of approximately four hours and start to peak after 30 minutes. There is a new shorter-acting analogue in the pipeline and will be available later this year in South Africa.

Science and art meet at carb counting

Most people living with diabetes complain, from time to time, that they want to eat something ‘naughty’, without all the consequences of high sugars and feeling terrible.

The answer (if you don’t know it yet) is carbohydrate counting aka carb counting. This method calculates the carbohydrates per meal and establishes the correct amount of insulin via an easy mathematical calculation. Carb counting should be practiced by all diabetes patients on rapid insulin.

This scientific method both establishes the correct amount of insulin per carbohydrate meal as well as the correct dosage to correct sugar to a glucose target. Your doctor will determine this target value. The before meal and two-hour after meal values are important for good sugar control.

This art of food/insulin calculations are only possible with blood glucose values. Previously, the only method was finger prick. The more pricks and sugar measures, the better the sugar control.

The past few years have brought about five glucose sensors that can now do this for you. No more or very little finger pricking needed. This is made possible by continuous glucose monitoring.

It is a sensor that measures interstitial fluid sugar values every five minutes. This data is sent via a transmitter regularly. This data can be seen on cell phone apps or a reader specifically for this purpose.

The CGM system has arrows on the screen that gives an indication of sugars going up, down or staying stable. The real positive of this device is the reduction of finger pricking, accompanied with better hands on evaluation throughout a 24-hour period of the trend of the glucose.

All this technology is great but it is imperative to follow the correct procedure.

Insulin injection – the basics:

  1. Keep insulin in a cold area/fridge.
  2. Make sure it has not expired.
  3. Secure an insulin needle on a pen every second or third day. If you still use syringes then ensure you replace every second or third day. Blunt needles cause damage to the injected area. This can later lead to lipodystrophy (fat cells that are unresponsive and not functioning anymore, very lumpy).
  4. Rotate insulin injections areas every time to prevent this.
  5. Do not inject on scars or tattoos.
  6. Insert the needle at 90 degrees into fat tissue and not muscle. Be careful of upper arms and thighs if you are very thin. Make sure to pinch fat tissue between thumb and finger and not muscle.
  7. After the insulin dosage is injected, keep the plunger in for 10 seconds to get the whole dosage delivered.
  8. Do not clean with alcohol since this can interact with insulin. Soap and water is more than enough.

Glucose testing – the basics:

  1. Make sure your hands are clean.
  2. Check the machine and strips, to be sure they are the same brand, and that the strips are not expired.
  3. Replace lancets frequently to prevent damage to fingertips.
  4. Do not test on other sites than fingertips.
  5. Always keep a spare machine or battery at hand.

Other artful skills to learn:

  1. Adopting a diabetic diet.
  2. Regular aerobic exercises, such as walking, swimming, or running.
  3. Yearly visit to the eye specialist for a retina examination.
  4. Yearly visit to the podiatrist to examine feet and help with removing of corns, calluses, and abnormal nails.
  5. Visit a specialist physician once a year for heart and kidney evaluation. This is important to ensure all your values are on target.

Targets to achieve:

  1. Normal weight with a waist circumference below 80cm for a woman and 98cm for a male.
  2. Blood pressure equal to or below 130/80 mmHg.
  3. HbA1c below 7% (people with heart and kidney problems can have a value up to 8% but your doctor will establish your correct value).
  4. Triglycerides less than 1,2 mmol/L.
  5. LDL (bad cholesterol) less than 1,8 mmol/L.
  6. HDL (good cholesterol) more than 1,0 for a male and 1,2 mmol/L for a female.
  7. Urine albumin: creatinine ratio less than 30 mg/min. 

Type 2 diabetes

The tablet arena has increased dramatically over the past five years. The basis to all Type 2 diabetes treatment protocols should still be metformin.

The options in cases where metformin is not sufficient depend on the patient’s risk factors for heart attack, weight problems and cost.

  • DPP4i (Galvus, Onglyza, Januvia)

These dipeptidyl peptidase-4 inhibitor (DPP4i) drugs work on the incretin in the gut of diabetics and cause food to stay in the stomach. This causes increased satiety. In addition, the liver and pancreas secrete less glucose. The pancreas secretes the correct amount of insulin. This group of drugs makes patients sensitive to their own insulin.

  • GLP-1RA (Victoza, Byetta)

This glucagon-like peptide-1 receptor agonists (GLP-1RA) class of drugs are injectable incretins. They work the same way as the DPP4i but cause a greater loss of weight.

  • SGLT2i (Forxiga, Jardiance)

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is the newest class of drugs, especially for type 2 diabetes. They work in the top part of the kidney loop and prevent the reabsorption of sugar. This causes more sugar in the urine as well as lower blood sugar, lower blood pressure and 3 to 6kg weight loss.

In both Forxiga and Jardiance, there is sufficient data that showed improvement in mortality (risk to die) to both diabetics with previous heart attacks, strokes and heart failure and the group that only have the risk factors.

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.


Fighting fit: exercising with diabetes

Prof Martin Schwellnus gives us a rundown of how to form a safe exercise regime when living with diabetes.


Preventing and treating diabetes requires a lifestyle approach, of which exercise is a vital component. Before you start exercising, the first, and most important, step is having a full medical check-up. The main reason for this is to make sure that the prescribed exercise “dose” is safe.

Types of diabetes

Diabetes mellitus is a group of chronic diseases classified into four broad clinical classes:

  • Type 1 diabetes is characterised by the destruction of pancreatic β-cells, leading to insulin deficiency.
  • Type 2 diabetes is characterised by insulin resistance and a relative insulin deficiency.
  • Gestational diabetes is diagnosed during pregnancy.
  • Other types of diabetes may be caused by genetic defects, disease of the exocrine pancreas, and drug- or chemical-induced causes.

Preventing and treating diabetes requires a lifestyle approach, of which exercise is a vital component. But it also includes nutrition, psychosocial support, smoking cessation and education. So, don’t forget the other important elements of your strategy for managing diabetes.

Benefits of exercise in diabetes patients

Exercise improves many factors important in the prevention and management of diabetes. These include improved glucose control, muscle and liver insulin sensitivity and muscle glucose uptake; reductions in HbA1c; improved weight management, blood pressure, and overall cardiovascular health.

Before you start exercising, the first, and most important, step is having a full medical check-up. The main reason for this is to make sure that the prescribed exercise “dose” is safe Any treatment plan should be patient-centred, not disease-centred, which means you should be assessed and treated holistically.

Identifying any other health concerns is important. Since these may influence how you manage your overall health, and your ability to exercise safely and effectively. Once you have the full picture, a plan can be created that suits your specific needs.

This lifestyle intervention programme is usually directed by a physician trained in sport and exercise medicine and a physician specialising in diabetes management, together with a multi-disciplinary team. This team includes dietitians, biokineticists, endocrinologists, physiotherapists and others.

Your exercise/activity plan

Structured exercise is an important part of your lifestyle, and the FIT principles below give you an idea of the type of exercise you could include in your regime.

Having said that, your activity/exercise plan needs to take various things into account, including type of diabetes, age, activity done, medication use and the presence of any complications.

As such, your plan needs to be tailored to your specific needs. So, speak to a sport and exercise physician about the strategies you will need to adopt. You may be advised to participate in an out-patient setting, or you may be able to train by yourself. In most instances training is initially conducted in small groups, where sessions (usually three per week) are supervised by members of the lifestyle intervention team.

In addition, try to increase the amount of unstructured activity you do. This is the activity you typically do during your day, such as shopping, errands, household tasks, walking your dog and gardening.

If you feel you are not ready for a structured exercise programme, start by increasing your daily activity, and then start including short bouts of structured exercise. Since any activity will increase energy expenditure and improve glycaemic control, this is a great step in the right direction.

Recently, more attention has been paid to prolonged sitting as this has a negative effect on health, irrespective of how active you are. So, be aware of how long you sit during the day, and try to stand up and do some light activity for a few minutes every 30 minutes.

General exercise guidelines for adults with diabetes and pre-diabetes: 

F

I

T

Type of exercise Frequency Intensity Time

Progression

Aerobic

(cardio – walking, swimming, cycling)

3-7 days per week, with no more than 2 days without exercise.

Moderate (your breathing and heart rate is increased slightly) to vigorous (only do if already active, your breathing is heavy and heart rate increased). Build up to at least 150 minutes per week of moderate-intensity. For those already active, 75 minutes per week of vigorous intensity.

If you are starting an exercise regime, start with bouts of 10 minutes at moderate intensity. Increase intensity, frequency and durations slowly over time to at least 150 minutes per week of moderate intensity.

Resistance 

(body weight exercises, free weights, resistance machines or bands)

At least 2 (preferably 3) non-consecutive days per week.

Moderate (using weights that allow you to do up to 15 repetitions) to vigorous (using heavier weights allowing you to do up to 6-8 repetitions). At least 8-10 different exercises, doing 1-3 sets of 10-15 reps, to near fatigue.

Start with weights that allow you to do 10-15 reps per set. Increase weight only once you can do 15 reps consistently. When you increase the weight, reduce the reps to 8-10, then increase reps again over time.

Flexibility & balance

(stretching, yoga, tai chi, balance exercises)

2-3 days per week.

Stretch to point of slight discomfort, not pain. Balance exercises of easy to moderate difficulty. Hold static stretch, or do dynamic stretch for 10-30 seconds, 2-4 reps per stretch.

Increase duration and/or frequency slowly over time

Exercise guidelines during pregnancy with gestational diabetes:

 

Aerobic exercise:

Resistance Exercise:

During pregnancy with gestational diabetes: check with your doctor Up to 30min of moderate-intensity (if sedentary before pregnancy, start at a lower intensity). No more than 2 consecutive days without exercising.

 

5-10 different exercises, 1-2 sets of 8 -15 reps, up to 60 minutes. At least 2 but ideally 3 times a week, at moderate-intensity.

Monitoring and follow-up

All patients participating in a lifestyle intervention should be assessed regularly during exercise training sessions by a member of the healthcare team. Before each exercise session symptoms of diabetes mellitus (polyuria, polydipsia), other symptoms (cardiac, infectious disease), resting heart rate, resting blood pressure and blood glucose concentrations should be taken.

During the training session, rating of perceived exertion, peak heart rate, and peak blood pressure should be monitored.

After exercise, a blood glucose measure may also be taken.

All the measurements that were recorded during the initial assessment, before starting the lifestyle programme, should be repeated two to three months later. These results should be discussed and a revised strategy created for the subsequent few months. All patients with diabetes should be re-assessed at least once a year.

Cautions to keep in mind when exercising

  • Blood glucose responses are influenced not only by the type, timing, intensity, and duration of exercise, but also by many other factors. This variation in the way blood glucose responds to exercise makes it difficult to give generalised recommendations for the management of food (carbohydrate) intake and insulin dosing during and after exercise. Speak to your sport and exercise physician, doctor and/or dietitian about the strategies you will need to adopt.
  • Adults with diabetes are frequently treated with multiple medications for other conditions. Some medications may have a negative interaction with exercise and therefore dosage may need to be adjusted.
  • Older adults or anyone with autonomic neuropathy, cardiovascular complications, or pulmonary disease should avoid exercising outside on very hot and/or humid days to prevent heat-related illnesses.
  • Patients with autonomic neuropathy should undergo cardiac screening before starting exercise, and be monitored for hypoglycaemia and abnormal thermoregulatory responses during training.
  • High-intensity endurance and resistance training, jumping, jarring, head-down activities and breath-holding are not recommended for patients with proliferative diabetic retinopathy or severe non-proliferative diabetic retinopathy, due to the increased risk of triggering vitreous haemorrhage or retinal detachment.
  • Patients with peripheral neuropathy should practise proper foot care during activity. Non-weight bearing exercise is recommended, to decrease the risk of skin breakdown, infections and joint destruction.
  • During pregnancy, avoid sports with a risk of forceful contact or falling (basketball, rugby, horseback riding, gymnastics), exercising in a supine position after the first trimester, scuba diving, and prolonged intensity workouts that increase body temperature and perspiration. Stop exercising immediately if your experience vaginal bleeding, dizziness, headache, chest pain, muscle weakness, preterm labour, decreased foetal movement, amniotic fluid leakage, calf pain or swelling and dyspnea without exertion.

What does the Sport, Exercise Medicine and Lifestyle Institute (SEMLI) offer?

SEMLI at the University of Pretoria has a team of specialist sport and exercise physicians, qualified to assess your current health status and advise you on an activity programme that will suit you.

The multi-disciplinary approach of SEMLI means you have access to a variety of healthcare professionals, including biokineticists, physiotherapists, dietitians and psychologists, as well as sport scientists who can assist you along your journey to good health.

For more information contact us at:  info@semli.co.zaor 012 484 1749.  www.up.ac.za/sport-exercise-medicine-and-lifestyle-institute/


References:

  • Schwellnus MP, Patel DN, Nossel C et al. Healthy lifestyle interventions in general practice
  • Part 4: Lifestyle and diabetes mellitus. SA Fam Pract 2009; 51(1): 19-25
  • Colberg SR, Sigal RJ, Yardley JE et al. Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39: 2065–2079
  • Padayachee C, Coombes JS. Exercise guidelines for gestational diabetes mellitus. World J Diabetes 2015; 6(8): 1033-1044

MEET OUR EXPERT


Prof Martin Schwellnus is the director of SEMLI. He is a specialist sport and exercise medicine physician who regularly consults with athletes of all levels. He is passionate about promoting safe physical activity for all, as part of a healthy lifestyle.


What fruit is best for you?

Dietitian, Donna Van Zyl, explains the considerations for diabetes patients when eating fruit.


There is often concern as to eating ‘sweet fruit’ if you have diabetes. However, this does not mean that you should avoid eating fruit completely.

Fruit can be classified under the macronutrient, known as carbohydrates. Carbohydrates, or fruit, are digested and converted by the body into glucose and therefore should be counted as part of a carb-counting regimen.

What needs to be considered when eating fruit is: the type of fruit and the quantity consumed as both these influence blood glucose control.

If we look at the type, fruits are classified according to their glycaemic index, which will further have an impact on the spike of the blood glucose level.

Type of fruit: The glycaemic index

What is the glycaemic index (GI)?

It is a numerical measure of the rate i.e. how fast and to what extent the intake of carbohydrate rich foods may affect your blood glucose levels. An item of food with a high GI raises blood glucose levels more than an item of food with a medium or low GI.

Glucose has been given a numerical value of 100, because it is absorbed immediately into the bloodstream. All carbohydrate-containing food, such as fruit, are compared to the reference of glucose.

The low-GI index food items fall below the reference range of 40 (<40) and are given the green to go. Whereas intermediate-GI food items falls within the reference range of 56 – 69; the orange for slow down and proceed with caution. The high-GI food items, with a reference range of above 70 (70+), gets the red for halt.

Though, high-GI fruits can be consumed with exercise, depending on blood glucose levels, and in combination with other foods products, especially protein or fat, or even to correct a hypoglycaemic event.

The GI Foundation uses the following icons to indicate the GI of foods:

Absorption and digestion factors

Factors affecting the absorption and digestion of fruit, which in turn may influence the GI of foods include:

  • The amount of cooking (cooked apple versus raw apple).
  • Processing (fruit versus fruit juice).
  • Ripeness and storage time: the riper a fruit, the higher the GI.
  • The type of fibre (soluble – citrus fruits).
  • The more acidic a food is, the lower the GI value. e.g. lemon juice lowers the GI of the food or meal.
  • The presence of fat, protein or low-GI foods consumed with the GI carbohydrate.

When eating a higher GI fruit, you can combine it with other low GI foods, or protein and fat to balance out the effect on blood glucose levels. For example, eating a fruit salad and yoghurt (plain).

The GI of fruit commonly eaten

Fruit GLYCEMIC INDEX (glucose=100)  Serving size in gram
Apple, average 39 120
Banana, ripe 62 120
Grapefruit 25 120
Grapes, average 59 120
Orange, average 40 120
Peach, average 42 120
Peach, canned in light syrup 40 120
Pear, average 38 120
Prunes, pitted 29 60
Raisins 64 60
Strawberries/Berries 40 120/125
Watermelon 72 120

When looking at the GI of specific fruits above, a variety of low GI fruit should form part of a balanced dietary intake. Fruits are not only delicious, but a good source of fibre which helps aid in regulating blood glucose levels. Fruits are also a good source vitamins, minerals or phytochemicals which aid bodily functions and help fight against disease.

Give preference to apples, berries, peaches or citrus throughout the day and consume with meals to ensure that the rise in blood glucose is covered by the insulin injected i.e. part of carb-counting.

Whereas your high-GI fruit, such as watermelon or grapes, can be used to prevent hypoglycaemia, especially after exercise, or to correct a hypoglycaemic event.

Quantity

Be mindful of your portions too. You will see the above-mentioned GI of fruit is indicated per quantity. Remember, the more fruit you eat at once, the more fruit sugar is also consumed which will affect blood glucose control.

One small apple provides approximately 15g of glycaemic carbohydrates. So, eating two apples in one go will naturally provide you with up to 30g of glycaemic carbohydrates, which will lead to a spike in blood glucose levels due to quantity consumed.

Take home message

Fruits form part of a healthy balanced intake. A variety of low-GI fruit should ideally be consumed and distributed throughout the day. Be cautious with high-GI fruits, however. they can be useful especially in picking up blood glucose levels.

MEET OUR EXPERT


Donna van Zyl is a private practicing dietitian for Nutritional Solutions, Bloemfontein. She is growing in the field of paediatrics and plays a key role in individualising nutritional therapy for Type 1 diabetics. Her special interest is in optimising health, managing chronic lifestyle related diseases, and sports nutrition. She lectures part-time at the University of the Free State, which she enjoys thoroughly.


Should you really be eating that?

Daniel Sher educates us and shares practical advice on how to make peace with the food police.


Who are the food police?

People who feel they have the right to comment on your dietary choices.

As a person living with diabetes, here are steps can you take to stop the food police from ruining your day.

Empathise

One way of coping with the food police is to put yourself in their shoes. Often, they truly are coming from a place of care and concern. Even if their response is inflammatory enough to make you want to pull your (or their) hair out.

Recognise that often, when someone asks, “Are you allowed to eat that?”, the subtext of their question is: “I’m really freaked out by the fact that you have this illness. So, I’m making these comments to help me feel in control”.

Diabetes is tough for us who live with it, but it’s also taxing for our loved ones. Recognise that food policing might simply be a family member’s coping strategy. Once you’ve made peace with this idea, you’ll be better placed to educate and set boundaries to stop food policing for good.

Educate

Often, the food police lack an understanding of what people with diabetes can and can’t eat. For example, you may be shocked to learn how many people think that managing diabetes is simply about avoiding sugar. If only it were that simple!

If you’re feeling in a good enough mood, you can use your loved one’s display of ignorance as an opportunity to help them learn more about a) what managing diabetes is really about; and b) what sort of responses are and aren’t helpful.

Ultimately, however, the food police often leave us feeling angry and hurt; and we’re usually not in the right sort of space to educate. This is perfectly okay. In such situations, it’s important to own your anger so that you can set healthy boundaries.

Own your anger

Many of my clients are surprised when I tell them that anger is a good thing. Specifically, anger is a healthy indicator that something is off in a relationship. It’s a catalyst for important interpersonal change. Your anger lets you know that a loved one has overstepped a boundary.

If you’re able to channel your anger into a healthy response (discussed below), you’ll be using your emotion to help you establish appropriate boundaries.

To do this, it’s important to own your anger: acknowledge and accept its presence. Allow yourself to feel it; but give yourself some time to calm down before you act on what you’re feeling!

Set boundaries

Your job, should you choose to accept it, is to set healthy boundaries. It’s possible to do this in a kind way, but you need to be firm and assertive at the same time.

This is where ‘owning your anger’ comes into play. Connect with whatever the food police make you feel – anger, sadness or frustration. Tell them frankly what you feel when they speak to you in this way. This will help them to understand that what they are doing is not helpful or appropriate. The phrases below may be helpful in such circumstances:

  • “I know you’re coming from a place of concern, but what you’re doing is not really helping.”
  • “My body, my health, my choices. Please respect that and ease off.”
  • “If you really want to support me, you’ll stop making me feel ashamed and guilty.”

As a friend or family member of a person living with diabetes, how can you avoid becoming a member of the food police?

Educate yourself

If you believe that the most important aspect of managing diabetes is avoiding sugar and carbohydrates at all costs, you should educate yourself before making potentially harmful comments.

This is a common trap that the food police frequently fall into. You see your loved one eating a delicious muffin and you make a critical comment based on the assumption that they’re mismanaging their condition.

A good place to start would be to read articles on www.diabetessa.org.za on managing diabetes. However, even if it turns out that your loved one is making a ‘wrong’ or ‘unhealthy’ choice, it’s important to make peace with the fact that, ultimately, it’s their choice to make. Not yours.

Control your urge to control

When we ask someone whether they should really be eating that slice of carrot cake, it’s usually coming from a place of genuine concern. However, it’s not having the intended effect, because it’s likely to infuriate and annoy, rather than encourage healthier food choices.

So, what’s the solution? We need to recognise the fact that our loved one having diabetes elicits, in us, an overwhelming sense of being out of control. By acknowledging this feeling, we see that it leads us to try to control our loved one’s behaviour by constantly monitoring and commenting on their choices.

We need to learn to start accepting the fact that much of life itself is uncontrollable. There are certain things, such as our loved one’s dietary choices, that we need to let go and allow. This doesn’t mean, however, that you can’t do anything to support your loved one in making healthy choices. Read on to learn how to do this in an appropriate manner.

Offer your support

How can you convert your desire to help into a response that is truly useful for your loved one? Stop speaking and start listening. Stop advising and start asking questions. Show your loved one that you are curious and that you care.

Instead of trying to tell them what they should be doing, ask them what you can do to support them. Make yourself available to understand; and be non-judgmentally curious about their difficulties and decisions.

Research shows that social support is incredibly important for us diabetes patients. In most cases, your loved one will benefit simply by knowing that you are there and that you care, in a respectful and non-intrusive manner. Sometimes, your loved one will ask you to back off. In such cases, it’s important to give them their space.

MEET OUR EXPERT


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


My art of living with diabetes

When you think of art, what comes to mind? Creative art, colourful art, abstract art, black and white art? Art is different to every person, therefore, the art of living with diabetes is different to every person living with diabetes.


There are many different arts (ways) of living with diabetes. My art of living with diabetes include lifestyle, foodstuff and sports. I ensure my sugar readings stay under control so that I can be healthy and live a long and happy life.

I keep my blood glucose levels under control by making sure that I eat the correct foods. I include a large amount of fresh vegetables and fruit and, of course, protein. My favourite proteins are chicken and pork.

By doing this, my sugar readings do not get too high. By eating correctly, I don’t need to inject myself with insulin too many times a day.

In our household, we only drink sugar-free cool drinks and water, which means less sugar and less insulin injections for me. We also eat mostly home-cooked meals, which is healthier and better for my blood glucose readings.

I play a lot of sport which keeps me active and keeps me healthy and in shape, both physically and mentally. I’m a cricketer and a golfer. It takes at least four to six hours to complete a cricket game or a round of golf. So, I always keep healthy snacks and water with me to ensure my sugar level remains stable. However, I enjoy any sport as I enjoy being out in the fresh air.

My lifestyle also includes not watching too much TV, etc. and trying not to stress too much about school and exams. Stress can affect my sugar readings too.

I realise that different people have their own art of living with diabetes. It is your choice what art you use and how you use that art.

MEET OUR EXPERT


Aiden Nel lives in Port Elizabeth. He is 15 years old and has Type 1 diabetes.


Too much blood sugar, too bad for your ears

Audiologist, Sakhile Nkosi, unpacks whether there is a link between diabetes and hearing loss.


Every person living with diabetes worldwide knows upon diagnosis that there are different types of diabetes e.g. Type 1 and Type 2 diabetes. Your doctor likely provided rigorous counselling, explaining all the clinical manifestation present in diabetes, such as loss of sensation in the feet (neuropathy), vision disturbances, kidney problems, etc. and the importance of taking medication and maintaining a healthy lifestyle to prevent these complications.

Most research conducted, so far, gave concrete evidence on what can possibly go wrong with an individual living with diabetes. Though, one of the unfamiliar complications that the diabetic community isn’t often made aware of, is the effect of diabetes on the ear structure. Hence, hearing and balance.

The ear

The ear is one of the most important organs in the human body. It provides two basic functions: hearing and to balance. Hearing itself is a special sense, just like vision; it forms basis of communication.

Hearing loss occurs as a result of damage either in the outer, middle or inner (retro-cochlear) part of the ear. If hearing loss is left untreated, it can have negative consequences on an individual’s life. This includes physical, emotional and social health and can cause disturbing effects in relationships with colleagues, family and friends.  In children, hearing loss can cause a delay in speech and language development.

The link between diabetes and hearing loss and balance

Current research reveals the link between diabetes and hearing loss. As early as 2008, the National Health and Nutrition Examination Survey results found that individuals with diabetes are at risk of developing hearing loss compared to those without diabetes.

The results of the survey revealed that individuals with diabetes are prone to a degree of hearing loss ranging from mild to moderate. The type of hearing loss common in diabetic patients is sensorineural in nature, implying the hearing loss is caused by damage to the inner ear or the hearing nerve that carries sound to the brain.

In terms of balance, patients who are diagnosed with diabetes may be at a higher risk for falls. This happens because of how diabetes affects the normal function of vision, sensation in feet, ankles, knees, hips, and inner ears.

As you may be aware, diabetes can affect the normal function of the retina of the eye. If the retina is damaged by diabetes and vision is distorted, the brain is deprived of information and needs help to maintain your balance.

Diabetes also can affect whether you have sensation in your feet. If your feet are numb (due to diabetes), you’ll not be able to sense when you are leaning forward, backward or side to side. In darkness, this becomes a larger problem because you lose the help that you normally would get with vision. This becomes a larger problem, a fall risk, if you also lose function in the inner ears.

Signs and symptoms of hearing loss

One might experience a few or a combination of symptoms.

  • Speech and other sounds are perceived muffled.
  • Difficulty understanding words or speech in a presence of background noise or crowd.
  • Frequently asking other to speak more slowly, clearly and loudly.
  • Constantly turning the TV/radio volume up.
  • Often withdrawing from conversations.
  • Avoiding certain social settings.

How to protect your hearing and balance?

You might have not yet experienced symptoms related to hearing and balance, but prevention is better than cure. Take charge of your diabetes by:

  • Controlling your blood sugar by taking your prescribed medication.
  • Noise can damage your hearing. At home, wear ear plugs when you are running the lawn mower or any other loud appliance. Take ear plugs with you when you attend concerts and sporting events that may be too loud.
  • Have your hearing tested by an audiologist on a regular basis. At least annually or sooner if you notice changes.
  • If you have a hearing impairment, your audiologist might fit you with hearing devices that will improve your ability to converse with others (e.g. hearing aids and assistive hearing devices).
  • Reduce background noise when you have a conversation (radio, TV, etc.)
  • Your doctor may recommend that your inner ears be evaluated by an audiologist to diagnose why you are dizzy and whether it is vertigo. Referrals will be made to other professionals, such as physiotherapists and occupational therapist.
  • Work with your doctor to determine whether changes in your medications might explain changes in your balance.

References:

The Audiology Project https://www.theaudiologyproject.com/

Bainbridge, K., Hoffman, H., & Cowie, C. (2008). Diabetes and Hearing Impairment in the United States: Audiometric Evidence from the National Health and Nutrition Examination Survey, 1999 to 2004. Ann Intern Med

Akinpelu, O., Mujica-Mota, M., & Daniel, S. (2014). Is type 2 diabetes mellitus associated with alterations in hearing? A systematic review and meta-analysis. Laryngoscope, 767-76.

Arlinger, S. (2003). Negative consequences of uncorrected hearing loss – A review. International Journal of Audiology, 42(2), S17–2 S20.

Hlayisi, V., Petersen, L., & Ramma, L. (2018). High prevelance of disabling hearing loss in young to middle-aged adults with diabetes. Int J Diabetes Dev Ctries, 39(1), 148-153. doi:10.1007/s13410-018-0655-9.


MEET OUR EXPERT


Sakhile Nkosi is an audiologist in the public sector. He has been exposed to lots of conditions that are in line with the global burden of diseases, one of them is diabetes. Currently, Sakhile holds a portfolio as a public sector representative at the South African Association of Audiologists (SAAA) and is also part of The Audiology Project (TAP), South African Cohort.