Category: 2021 Spring – Diabetes Focus eMag

energy

How to overcome energy dips

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Energy dips are most often experienced mid-afternoon. You may have rushed to the vending machine and grabbed a chocolate or packet of crisps in the past. But read what Tammy Jardine has to say first before grabbing that snack.

There is a myriad of reasons for energy dips that make you feel like you have hit a wall that you can’t climb, and if you have diabetes it’s important to see if you really are having a blood glucose dip before noshing on that high-energy snack.

Feeling fatigued can be related to eye strain, dehydration, stress and tension, hunger, illness, low blood pressure, low blood glucose and high blood sugar.

Test your glucose levels

If you have diabetes, it is important to test your blood glucose to double check what is happening. Your blood glucose reading will determine what kind of snack to choose.

If your blood glucose is lower then normal then choose a carbohydrate snack but if it normal or high then choose a snack that is low in carbohydrate.

Most people with diabetes may be able to tolerate 15g of carbohydrates for a snack. Having more carbohydrate between meals often will mean that your blood glucose is high before the next meal.

If you typically have low blood glucose before meals or experience hypos during the day, you should have a carbohydrate snack of 15g between meals.

If you do not have hypos or drop blood glucose quickly between meals then you should stick to low carbohydrate snacks (less than 5g carbohydrate).

You may also need a carbohydrate snack if you have a very long gap between meals.

Carbohydrates per portion food label

Use the food label to determine the amount of carbohydrates per portion. Choose natural foods as snacks as often as possible.

Snacks options containing 15g carbs

 Snacks containing less than 5g of carbs
1 small apple (6,5cm diameter)

100g low-fat fruit yoghurt

4 Salticrax crackers

40g peanuts and raisins

2 cups popcorn

1 large carrot (7,5cm long) and 2 tablespoons hummus

½ an avocado

1 slice low-GI bread with butter or margarine or cheese

 ½ cup berries

100g double cream plain yoghurt

1 Salticrax cracker

40g peanuts

2/3 cup popcorn

1 stalk celery and 1 tablespoon hummus

Sugar-free jelly

Boiled egg

Biltong

Cheese, cottage cheese, Laughing Cow cheese wedge

Olives

¼ avocado

MEET THE EXPERT

Tammy Jardine is a qualified diabetes educator and a registered dietitian. Living with diabetes for over 15 years means that she knows first-hand how difficult it can be to achieve and maintain optimal blood glucose control with good lifestyle habits. She believes that diabetes affects every person differently and takes the time to understand how it’s affecting the individual and to help them manage it effectively. With more than 20 years of experience working as a dietitian in the UK and SA, she has a passion for helping people live a better and happier life with good food. Tammy currently works from Wilgeheuwel hospital.

Ask Tammy

Do you have a question for Tammy?
Email your question to tamjdiet@gmail.com
PLEASE NOTE: Not all questions can be answered, click here to read our Q&A 
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ghrelin

How to tame ghrelin your hunger hormone

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Ghrelin, the hunger hormone, is not your enemy and can be tamed in productive ways. Dietitian, Retha Harmse, explains further.

Hunger is often seen as the enemy and therefore by association the hunger hormone, ghrelin, is demonised and ostracised. The name ghrelin doesn’t do itself any favours though, as it sounds like a gremlin. The Oxford dictionary even defined gremlins as:

  • In early use: a lowly or despised person; a menial, a dogsbody, a wretch (obsolete).
  • Later: a mischievous sprite imagined as the cause of mishaps to aircraft.
  • More generally: such a creature is imagined as the cause of any trouble or mischance.
  • Hence also: an unexplained problem or fault.

But let us take a closer look at this misunderstood and underappreciated hormone.

Meet the hormones

A host of hormones, insulin, leptin, adiponectin, and ghrelin, among others, communicate with the brain’s control centre called the hypothalamus to manage a person’s intake and weight. These regulatory hormones regulate feeding in response to signals from body tissues.

  • Insulin controls the amount of glucose in the blood by moving it into the cells for energy.
  • Leptin, which is produced mainly by fat cells, contributes to long-term fullness by sensing the body’s overall energy stores.
  • Adiponectin is also made by fat cells and apparently helps the body respond better to insulin by boosting metabolism.
  • Ghrelin, the hunger hormone, is produced primarily by the stomach and tells the brain when the stomach is empty, prompting hunger pangs and a drop in metabolism. Ghrelin also increases our cravings and affinity for sugar- and carbohydrate-rich foods (which is a problem for glycaemic control).

Getting to know how the hunger hormone works

This communication of the stomach with the brain happens via the vagus nerve, part of the autonomic nervous system that travels from the brain to the stomach. When filled with food or liquid, the stomach’s stretch receptors send a message to the brain indicating satiety.

It seems easy enough then to lose weight, right? There should just be a drop in ghrelin levels. Unfortunately, it is much more complicated than that. Ghrelin levels are highest in lean individuals and lowest in the obese. Increased levels are seen in people who are dieting. In fact, traditional dieting tends to boost ghrelin levels.

The reasons for this can be debated until the end of time but the short and not at all in-depth explanation is to always remember that our bodies try their utmost best to protect us and keep us alive and safe. In the case of ghrelin, the real threat and danger we are being protected from is starvation. So, what can we do?

How can we tame the hunger hormone?

It is also worthy to mention at this point that interfering with hormones can be extremely dangerous, therefore we would be looking at lifestyle factors instead of hormone-altering treatments.

Carbohydrates

Low concentrations of glucose in the blood showed an increase in ghrelin secretion. However, interestingly though, insulin was also shown to affect ghrelin levels (which might seem contradictory if we understand the link between glucose and insulin production). Further research is needed to fully understand the link, but from what we know now is that instead of the insulin itself, the insulin-sensitivity might be more important to regulate ghrelin levels.

Regular meals that are high in fibre and low in glycaemic index that provide a slower release of glucose into the bloodstream is recommended.

Protein

The connection between protein and ghrelin is less clear. One study found that the ingestion of essential amino acids leads to a continuous rise in serum ghrelin levels, which unexpectedly contradicts other studies that found an inhibitory effect of protein on ghrelin.

Although the connection isn’t clear, adding healthy lean proteins are always beneficial for meals to be more balanced.

Fat

Healthy fats also helped reduce the ghrelin levels in the plasma. Thus adding healthy fats to your meals are recommended as well. Foods that contain omega 3 like fatty fish, chia and flax seeds and nuts will boost leptin and keep ghrelin in check.

Fasting

Total ghrelin level increases at night and decreases after breakfast in humans. Circulating ghrelin concentration rises before a meal and falls after a meal and serum ghrelin increases steadily during long-term of fasting in humans. Eating regular meals and snacks per day will keep ghrelin and leptin levels stable. During crash dieting or calorie restriction, ghrelin levels increase and poor food choices and cravings will increase.

Therefore, fasting is not recommended and regular balanced meals are better for ghrelin-regulation.

Good quality and uninterrupted sleep

There have been numerous studies showing the importance of good quality sleep on weight loss and maintaining a healthy weight. Participants with less than 7 hours of sleep were shown to have higher BMIs and were thought to have increased appetites. The mechanism of leptin and ghrelin might explain those results. To gradually reduce ghrelin, aim for 7-9 hours of sleep each night.

Stress

As stress levels get elevated, ghrelin levels tend to increase (hello sugar cravings during stressful times). Circulating ghrelin levels have been found to rise following stress. It has been proposed that this elevated ghrelin helps the animals in the study to cope with stress by generating antidepressant-like behavioural adaptations, although another study suggests that decreasing the central nervous system ghrelin expression has antidepressant-like effects. 

Engage in activities that help you to rest and relax: spending time outside in nature, engaging in exercise you enjoy, arts and crafts that help you be creative and lastly get feelings off your chest and allow yourself to feel and heal your emotions.

Be friends

  • The hunger hormone is called ghrelin.
  • Ghrelin is not the enemy; it is made to protect your body and protect you against starvation.
  • Traditional dieting and fasting tend to upregulate ghrelin levels.
  • Fasting is also not recommended as it also tends to increase ghrelin levels.
  • Ghrelin levels can be modulated by:
    • Eating a balanced diet with sufficient complex and low glycaemic index carbohydrates, healthy fats and lean proteins.
    • Ensuring regular and adequate meals to prevent hypoglycaemia.
  • Aim for 7-9 hours of sleep per night. Good, uninterrupted sleep is very important.
  • Reducing stress levels in any way that feels good for you.
Retha Harmse is a Registered Dietitian and the ADSA Public relations portfolio holder. She has a passion for informing and equipping the in the field of nutrition. She is currently in private practice in Saxonwold, Houghton and believes that everyone deserves happiness and health and to achieve this she gives practical and individual-specific advice, guidelines and diets.

MEET THE EXPERT

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

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immune system

Support your immune system with good nutrition

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How our bodies fight off diseases has gained more attention recently since the unprecedented global pandemic hit. The immune system is the intricate mechanism your body uses to fight off diseases and foreign invaders. Your diet and lifestyle can greatly affect your immune system, Jessica Pieterse tells us how.

Vitamin D

Vitamin D has always been a large role player in immune health. Receptors of vitamin D have been identified on several immune cells; in addition, they regulate the immune system by suppressing the pro-inflammatory molecules.

To improve your vitamin D levels, spend 15-20 minutes daily in the sun with as much skin exposed as possible. It must be from direct sun exposure and not through any windows. To get as much vitamin D, avoid applying sun cream, however, being sun smart is just as important. Eat more foods that contain vitamin D, such as liver, mushrooms, whole eggs, salmon, mackerel, and cod liver oil. Take a supplement if you know you are deficient. It is best if your health practitioner monitors your vitamin D levels annually and regulates your supplementation.

Gut bacteria

We have billions of bacteria making their home in our gut. Gut bacteria can be helpful or harmful depending on the type of bacteria. If a person has a healthy balance of the good bacteria, it can be vital in supporting immune health. Good bacteria fight harmful foreign substances that enter the body by detoxifying them and easing their elimination. Bacteria can also stimulate immune cells and affect gut lining integrity.

Ways to improve your gut bacteria balance is to take a good quality probiotic supplement, increasing prebiotic fibres, adopting a balanced healthy diet, reducing stress and improving sleep.

Good quality probiotic supplements contain several different strains of bacteria, have high doses of bacteria (at least 1 billion CFUs) and are stored in the refrigerator to keep bacteria alive. Take probiotics on an empty stomach so the bacteria are released further down the gut system and not in the stomach.

Most fruit, vegetables and wholegrains (barley, brown rice, oats) are sources of prebiotic fibres. Eating more of these foods will improve your gut bacteria balance. People suffering with IBS, be cautious. Some prebiotic fibres can worsen IBS symptoms so it’s best to seek individualised advice from your health practitioner.

Antioxidants, vitamins and minerals

Many supplements marketed to improve your immune system will contain a variety of vitamins, minerals and antioxidants. Antioxidants help by reducing oxidative stress. Eat more cocoa, red grapes, berries, herbal teas, turmeric, olive oil and pomegranates to boost your antioxidant intake.

The main vitamins and minerals that support your immune system are vitamin A, C, E, D, selenium and zinc. They each play a unique role. One vitamin or mineral is not a magic pill for avoiding getting sick. To clean your house, you can’t just use a broom; you also need a mop, cloth, water, and a bucket to do a good thorough job. Your immune system is the same. Many different vitamins, minerals and substances are needed to protect your body. They all play a part in the big picture.

Eat more beans, chickpeas, lentils, salmon, pilchards, fish, oysters, nuts, seeds, sweet peppers, strawberries and orange fruit and vegetables to improve your intake of these key nutrients.

Exercise

Being active can improve your immune system. It is interesting to note that very high amounts of exercise can potentially strain your immune system and have the opposite effect. That is why it is common to hear of many Comrades runners getting sick right before the race as they are extensively exercising at that point.

Aim for 30-45 minutes of exercise 3-4 times a week of varying intensities as a gauge. Exercise that lowers stress levels will have further beneficial impacts.

Sleep

Most people are told when they are sick to sleep more. This is not just an old wife’s tale but is correct. While you sleep, your body releases certain immune and inflammation molecules which affect your immune health.

Aim to improve how long you sleep and the quality of your sleep. Make these changes to improve your sleep.

  • Avoid digital devices an hour before sleeping.
  • Make your room dark and cool enough.
  • Avoid drinking liquids too late at night.
  • Reduce your caffeine intake.
  • Be more active.

Do a relaxing activity before sleep like reading, deep breathing, prayer or mediation.

MEET THE EXPERT

Jessica Pieterse is a registered dietitian and owner of Dish Up Dietitians. She practices in Edenvale, Johannesburg and has a special interest in women’s health and gut health.

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kidney

How is your kidney function?

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Kidney function is one of those things that we seldom pay attention to in diabetes, until it’s too late and costly. This is why Dr Paula Diab advocates preventing kidney disease as early as possible.

Recent data published by the International Diabetes Federation (IDF) shows that there has been a dramatic rise in the prevalence of diabetes in South Africa over the last 10 years from 1,2 million to 4,5 million people.

In addition, it estimates that 52,4% of people living with diabetes are undiagnosed and that by 2030, the prevalence would have risen to over 6 million people. Every year diabetes complications claim the lives of about 90 000 people in South Africa and many of these people are under the age of 60.

Amongst these complications, kidney disease is one of the biggest contributing factors, especially in the African population. It is a costly complication and one that is difficult to diagnose and treat therefore it is really important to prevent kidney disease as early as possible.

What is kidney disease?

Kidney disease (diabetic nephropathy) is caused by damage to small blood vessels in the kidneys, leading to the kidneys becoming less efficient or failing altogether.

Kidney disease is much more common in people with diabetes than in those without diabetes. Although other diseases, such as hypertension, may also contribute towards the development thereof. By maintaining near normal levels of blood glucose and blood pressure, you can greatly reduce the risk of kidney disease.

Why is it so difficult to diagnose and treat kidney disease?

Firstly, kidney disease has almost no symptoms until almost all kidney function is lost. What this means is unlike a respiratory infection, for example, where within days of being infected you develop symptoms of a blocked nose, temperature, sore throat; kidney disease begins insidiously in the body without any noticeable symptoms.

When symptoms do start to develop, they are very non-specific. Common indications are fatigue, weakness, nausea, difficulty concentrating or poor appetite. All of these symptoms have multiple other causes which are often far more common and, even more often, are disregarded by healthcare professionals and patients alike as being of no consequence.

The symptoms that generally alert us to specific kidney problems only tend to occur very late in the disease process when very little preventative therapy can be offered. However, they are important to be aware of and include problems, such as a reduced urine output, shortness of breath, dry, itchy skin and puffy feet and face.

Our other indicator of disease is often blood or urine tests. Once again, in kidney disease, these are non-specific, and changes often only tend to occur very late in the disease. Those people who have diabetes or hypertension should make sure that they have regular (twice a year) blood and urine tests to look for changes in kidney function.

End-stage kidney disease is expensive

“Prevention is better than cure” is an old adage used in medicine, but it has never been more relevant than when talking about kidney disease.

Kidney dialysis is an extremely expensive and time-consuming way of treating kidney failure and yet it’s often inevitable if you don’t pay attention to kidney disease early on. It involves multiple visits to hospital every week and leaves people feeling very tired and weak. Although most medical aids will fund dialysis treatment, the amount of money spent on kidney dialysis annually is enough to provide continuous glucose monitoring to each person living with diabetes in South Africa. Imagine how much better we could control diabetes with such technology!

What can be done?

For many reasons, kidney disease has always been one of those forgotten complications of diabetes that we tend to ignore. Possibly because there wasn’t much that could be done to preserve or treat kidney function. Thankfully, much has changed!

  1. Lifestyle adaptations

Yes, I’m talking about those horrible things like exercise, eating correctly and stopping smoking. It is difficult and involves planning, educating yourself and commitment but it’s still the most effective way of preventing kidney disease. In fact, stopping smoking is probably the single most effective thing you can do to prevent the majority of complications associated with diabetes.

  1. Avoid excessive over-the-counter medication

Many OTC medicines that we all take on a regular basis can have a negative impact on the kidneys especially if they are taken in excess. Be careful of many herbal preparations and ‘health supplements. Other medications that can be implicated are pain medications, some antibiotics and medications for heartburn or reflux. Please rather get these medications scripted by your doctor who can assess if the benefit of the medication outweighs the risk and ensure you are taking the correct dose.

  1. Make sure you take your chronic medication regularly

Diabetes medication is unlike any other chronic disease and requires regular updates and alterations. Please don’t be lulled into taking the same medication year after year and allowing your glucose levels to become uncontrolled. Don’t just expect to have a script rewritten every six months with the same medication; regular updates and changes may be necessary.

Check your glucose levels throughout the day and contact your diabetologist regularly to reassess your condition. Blood pressure medication also needs to be taken daily and re-assessed at regular intervals. Newer medications are now available that can be protective to the kidneys and are highly effective at preserving kidney function so talk to your doctor and find out what is best for you.

  1. See your doctor and healthcare team regularly

When you take your car for a service, you don’t expect the mechanic to repair the dent in the bumper, do the wheel alignment and change the windscreen. These are all specific jobs that all require specialists. The same teacher doesn’t teach all matric subjects and one shop doesn’t necessarily sell all your clothing and grocery needs. Diabetes requires a team approach for the best outcomes to be achieved. Dietitians and diabetes nurse educators play an extremely vital role in complementing and augmenting the services that a doctor can give. Working together as a team also allows for more regular check-ups and preventing diabetes complications from a number of different pathways.

  1. It’s a good investment

As our kidneys have some of the smallest blood vessels in the body, by ensuring those small vessels are well perfused and healthy, you will also be taking care of other small vessels in the body, such as the eyes, nerves and heart. Taking care of the small vessels also ensures that the larger vessels in the heart, muscles and brain are also kept healthy.

Final say

In conclusion, treating kidney disease is costly. It can be difficult to diagnose and may only be picked up in the late stages of the disease. But, it can certainly be prevented through good lifestyle choices and preventative medication. Take control of your own health and well-being and speak to your doctor about what can be done to ensure that you prevent any further damage to the kidneys.

Dr Paula Diab

MEET THE EXPERT

Dr Paula Diab is a specialist family physician who enjoys the challenges that diabetes management has to offer. She runs a multi-disciplinary practice in Kloof, KZN, where she works with patients with diabetes and their families to allow them to gain control of their disease rather than being overwhelmed by the complexities and complications often associated with diabetes.

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Type 2 diabetes

Can Type 2 diabetes be reversed?

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The good news is that Type 2 diabetes can be reversed; Dr Angela Murphy expands on the ways reversal can be achieved.

In short – yes, Type 2 diabetes can be reversed. However, it is neither easy nor possible for all patients. The word reversed somehow implies that diabetes will disappear never to be seen again. Most of my patients will ask this at some point, especially when the diagnosis is new, and I must emphasise that we do not have a cure for diabetes. It is possible to have remission of diabetes if certain criteria are met.

According to the American Diabetes Association these criteria are:

  • Full diabetes remission – fasting blood glucose (FBG) < 5,56mmol/L and HbA1c < 6,0% on no diabetes treatment.
  • Partial diabetes remission – FBG is 5,56-6,9mmol/L and HbA1c 6,0-6,5% on no diabetes treatment.

To consider whether it is possible to achieve remission, we need to take a step back and review what factors caused Type 2 diabetes to occur.

What factors caused the diabetes?

The human body requires an exquisite balance of systems to keep blood glucose in the normal range. Insulin produced by the beta-cells in the pancreas must be delivered throughout the body to do this. It is insulin that controls the amount of glucose produced by the liver when the body is in the fasting state, and insulin that regulates the uptake of glucose derived from food into the cells.

When a person gains excess weight, extra fat deposits in the liver and pancreas. This fat creates insulin resistance in the liver and so glucose production goes unchecked. In the pancreas, the fat interferes with normal beta-cell function. Eventually, the combination of increased insulin resistance and decreased insulin secretion causes diabetes. Although, there are always genetic influences, the main factor seems to be the excess fat.

Can the factor be removed?

Yes, most definitely with weight loss interventions. These are as follows:

Dietary

In 2011, the Counterpoint study showed that extreme calorie restriction could normalise blood glucose in a group of patients with Type 2 diabetes. The 11 study volunteers were given a liquid shake (Optifast – available in South Africa) and non-starchy vegetables totalling 600kcal per day. After the first week blood glucose levels dropped on average from 9,2mmol/L to 5,9mmol/L and remained there for the duration of the eight-week study. There was a significant improvement in insulin sensitivity in the liver and pancreas. This meant that the production of glucose in the liver decreased, and the pancreatic beta-cells could do their work again to control blood glucose. The average weight loss to achieve these changes was 15% of initial body weight.

The Counterbalance study, published in 2016, showed similar results in a larger group of patients with Type 2 diabetes who achieved normal blood glucose values for up to six months.

The DiRECT Trial, conducted in a general practice setting in the United Kingdom, showed diabetes remission in 46% of patients after a year and 36% of patients were still in remission after two years.  This showed that a calorie-controlled diet could induce diabetes remission. There is similar evidence for the use of a low carbohydrate diet as a dietary intervention to induce diabetes remission. There is still some debate whether it is the low carbohydrate intake per se or the associated overall drop in total calories that produces the benefit. In my experience, I like patients to follow diets they prefer as reducing calories is always hard work.

Surgery

Bariatric surgery has been used to treat obesity for many years. The sleeve gastrectomy, Roux-Y-gastric bypass and biliopancreatic diversion are the three main procedures.

The Swedish Obese Subject study followed several hundred patients with Type 2 diabetes who underwent bariatric surgery for over two decades. At the end of the second year, 72,3% of patients were in remission. This number decreased to 30,4% at 15-years post-surgery which is still significant.

We now talk about metabolic surgery which is defined as gastrointestinal surgery with the intent of treating diabetes and obesity. The improvement in glucose control post bariatric surgery occurs within days so it is not entirely dependent on actual weight loss. The significant drop in calories decreases the fat in the liver and pancreas restoring normal function in these organs. In addition, the levels of the gut hormone, GLP-1 (glucagon like peptide 1), increase which also increases insulin secretion from the pancreas. These changes lower insulin resistance and increase insulin production which decreases blood glucose. Many medical and scientific societies now endorse bariatric surgery as an effective treatment for Type 2 diabetes and a means to achieve diabetes remission.

What factors affect remission?

It has been shown that patients with longer diabetes duration, poor glucose control and low endogenous insulin production are less likely to achieve diabetes remission despite the above suggested interventions.

Patients choosing bariatric surgery will be assessed with one or other scoring method. The DiaRem score considers patient age, current HbA1c, the number of oral diabetic medications being used, whether the patient is on insulin and the duration of the diabetes. The higher the score, the less likely remission will occur, and this must be discussed with the patient prior to making any decision regarding surgery.

The type of bariatric surgery also affects the rates of diabetes remission with the more complex, malabsorption procedures (such as a biliopancreatic diversion) giving better results. The possibility of diabetes remission must be balanced against the possible risk of complications, especially long-term vitamin deficiencies.

Summary

The good news is that Type 2 diabetes can be reversed, and it is important that healthcare professionals discuss this possibility with patients. For many this will be information they can and will act on.

Bariatric surgery offers an excellent chance of diabetes reversal, but it is invasive and expensive. This makes it less accessible for most patients with Type 2 diabetes.

Lifestyle intervention should be a simpler option, but the calorie restriction is significant and for many people difficult to sustain. This is where newer medications, such as the GLP-1 receptor agonists (exenatide, liraglutide, dulaglutide and semaglutide) may help in the long-term use of very low-calorie diets.

It is vital to remember that good diabetes control decreases the risk of diabetes complications. It is much more beneficial to have good control with diabetic medications than fail at attempts to reverse diabetes and end up with poor control. To achieve diabetes remission is possible but not easy. To achieve diabetes control is possible and usually easier.

References:

  1. Lim, E.L., Hollingsworth, K.G., Aribisala, B.S. et al. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 54, 2506–2514 (2011).
  2. Steven S, et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care 2016; 39: 808– 15
  3. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med (2002) 346(6):393–403.

MEET THE 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 and has a busy diabetes practice.

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Meditation

Meditation – more than just gongs and incense

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Daniel Sher explains how meditation can improve the mental and physical well-being of people with Type 1 and Type 2 diabetes.

What comes to mind when you think about meditation? If you’re envisaging a Buddhist Monk poised in the lotus position, levitating just above the ground, you’re not alone. However, meditation is more than just gongs and incense. 

In my clinical psychology practice for people with diabetes, meditation is one of the most effective and transformative tools that I use to help people learn to thrive with diabetes.

What is meditation?

Quite simply, it is a way of calming the mind through techniques, such as focused breathing and visualisation. There are many different types, including Mindfulness, Transcendental Meditation, Mantra Meditation and Progressive Muscular Relaxation.

Meditation has been practiced for centuries by people all over the world; and it often forms an important part of various ethnic and spiritual practices. However, in the context of health sciences, most people use meditation as a brain-training exercise for improving health, rather than a spiritual practice.

How can meditation help people with diabetes?

Meditation (Mindfulness in particular) is a skill which people with diabetes can use to build up their resilience toolbox. Research has shown, for example, that meditation can help people with diabetes to:

Improve

  • blood glucose control;
  • sleep;
  • overall quality of life

Lower

  • risk of high blood pressure and cardiovascular disease

More generally, meditation is a really powerful tool for people with diabetes, as it can help them to manage the emotional aspects of this condition. For example, diabetes burnout is a situation in which we feel overwhelmed and exhausted by the demands of living with this condition.

Most people with diabetes experience burnout at least once, often more. Meditation can help us to recognise the signs of burnout. Beyond this, meditation gives us a tool to process and move through the feelings of overwhelming frustration that we often feel as a result of living with this condition. What else?

Meditation is a highly effective way of lowering stress. Why is this important for people with diabetes? For starters, stress hormones (such as cortisol) lead to higher blood-glucose levels. Through meditation, therefore, you help your body to lower blood glucose levels naturally. Furthermore, people who are good at managing their stress are also better at making healthy decisions in terms of their day-to-day lifestyle.

Meditation is also a really great way of helping people with diabetes to regulate their emotions. Why is this important? As with stress, uncomfortable emotions (such as fear, worry, anger, sadness or hopelessness) can raise blood glucose.

Uncontrolled emotional fluctuations can also lead to emotional binge-eating, substance use, avoidance of injections and other problematic behaviours. Furthermore, meditation is a great tool for helping people to move through denial, in order to truly accept their condition.

What about people with diabetes and a diagnosed psychiatric condition?

As people with diabetes, we are far more likely than most to have a diagnosed psychiatric condition, such as clinical depression (or Major Depressive Disorder), anxiety disorders, eating disorders and bipolar mood disorder. These disorders can be effectively treated through psychological therapy techniques which draw on meditation.

For example, Mindfulness Based Cognitive Therapy (MBCT) and Acceptance and Commitment Therapy (ACT) are both evidence-based approaches for treating mental illness, which blend Mindfulness with other psychotherapy techniques. A 2020 paper has also shown that Mindfulness-based therapy, in particular, is an effective way for people with diabetes to get better HbA1C levels and treat depression at the same time.

Your brain on meditation

Brain scan technology shows us that certain forms of meditation (including Mindfulness) can actually change our brains. We know, for example, that practicing Mindfulness can lead to changes in parts of the brain that control fear, panic and self-soothing responses. In this sense, the practice can help you ‘rewire’ your brain in a way that promotes health, calm and well-being. Another 2012 study found that practicing Mindfulness can help you grow your hippocampus (often referred to as the memory centre of the brain) thereby helping you to improve your thinking skills.

Summing up

In recent times, rigorous scientific trials and sophisticated brain-scan technologies have shown that meditation can have real benefits for your brain and body. In particular, meditation is a powerful tool for people with diabetes who are looking to live a happier and fuller life. Best of all: meditation can be practiced by anyone, anywhere. In other words, it’s not only for mystics, monks and hippies.

References

Gainey, A., Himathongkam, T., Tanaka, H., & Suksom, D. (2016). Effects of Buddhist walking meditation on glycemic control and vascular function in patients with type 2 diabetes. Complementary therapies in medicine, 26, 92-97.

Greenberg, Jonathan, et al. “Reduced interference in working memory following mindfulness training is associated with increases in hippocampal volume.” Brain imaging and behavior 13.2 (2019): 366-376.

 Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging, 191(1), 36-43.

 Keyworth, C., Knopp, J., Roughley, K., Dickens, C., Bold, S., & Coventry, P. (2014). A mixed-methods pilot study of the acceptability and effectiveness of a brief meditation and mindfulness intervention for people with diabetes and coronary heart disease. Behavioral Medicine, 40(2), 53-64.

 Ni, Y., Ma, L., & Li, J. (2020). Effects of Mindfulness‐Based Stress Reduction and Mindfulness‐Based Cognitive Therapy in People With Diabetes: A Systematic Review and Meta‐Analysis. Journal of Nursing Scholarship, 52(4), 379-388.

 Varghese, M. P., Balakrishnan, R., & Pailoor, S. (2018). Association between a guided meditation practice, sleep and psychological well-being in type 2 diabetes mellitus patients. Journal of Complementary and Integrative Medicine, 15(4).

MEET THE 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 them thrive. Visit www.danielshertherapy.com

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COVID-19

How to boost your immune system while recovering from COVID-19

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Omy Naidoo, a registered dietitian, shares four immune-boosting nutrition tips for people with diabetes and obesity when recovering from COVID-19.

People with diabetes and who are obese are part of the vulnerable group whose immune system is easily compromised, making them vulnerable to contracting COVID-19. If someone has been exposed to or contracted the virus, healthy nutrition is essential for recovery in boosting their immune system.

The impact of COVID-19 is greater for people with diabetes and are obese. People who have diabetes and are obese, are more likely to have serious complications from COVID-19. In general, people with diabetes are more likely to have more severe symptoms and complications when infected with any virus. On the other hand, obesity has emerged as a strong and independent risk factor for severe infection and death due to COVID-19.

According to the World Health Organisation, obesity significantly increases the chances of severe outcomes for COVID-19 patients. Likewise, extra healthy nutritional measures need to be taken for people with diabetes.

Those recovering from the coronavirus should eat a variety of fresh and unprocessed foods every day to get the vitamins, minerals, dietary fibre, protein and antioxidants their body needs. They should also drink enough water, avoid sugar, fat and salt to significantly lower their risk of diabetes and obesity.

Four immune-boosting nutrition tips for people with diabetes and obesity when recovering from COVID-19:

Proteins

Protein is an important nutrient for cell growth and regeneration. It is the building block of life and is required by our body for faster recovery. When suffering from COVID-19 it is recommended to eat a high protein diet.

Eating 75-100 grams of protein is essential every day. Add more foods like lentils, legumes, milk and milk products, soya, nuts, seeds, meat, chicken, fish and eggs.

Vitamins and minerals

  • Fresh fruits and vegetables are loaded with immune-boosting, antioxidants, vitamins and minerals. These can be an excellent addition to your diet for faster recovery and strengthening your immune system.
  • Aim for five portions of fruits and vegetables a day.
  • Citrus fruits are packed with vitamin C, which helps in the formation of antibodies and fights infection, while green and root vegetables help to strengthen the immune system.
  • Also, spend some time outdoors to get a sufficient amount of vitamin D.

Less sugar and salt

  • When cooking and preparing food, limit the amount of salt and high-sodium condiments (e.g. soya sauce and fish sauce).
  • Limit your daily salt intake to less than 5g (approximately 1 teaspoon), and use iodized salt.
  • Avoid foods (e.g. snacks) that are high in salt and sugar.
  • Limit your intake of soft drinks or sodas and other drinks that are high in sugar (e.g. fruit juices, fruit juice concentrates and syrups, flavoured milk and yoghurt drinks). Choose fresh fruits instead of sweet snacks, such as cookies, cakes and chocolate.

Fluids

  • Water is an essential element for life as it carries nutrients in the blood, regulates body temperature, and flushes out toxins from the body. Besides, an infection can dehydrate the body.
  • Try to drink at least two to three litres of water every day. You can also consume herbal concoctions, coconut water, milk and fresh juice.
  • Avoid packed juice, caffeine and fizzy drinks.

MEET THE EXPERT

Omy Naidoo is a registered dietitian and founder of Newtricion Wellness Dieticians. He has been in practice for 13 years. He worked within the government sector and then moved into the pharmaceutical industry. His key focus is on diabetes products. This enabled him to further his knowledge and skills in diabetes management. Thereafter he went into private practice.

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workplace

Diabetes in the workplace: speak, prepare, feel

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Type 1 diabetic, Gabrielle Mixon, shares the pitfalls and peaks of managing her condition in a new workplace.

Managing diabetes at your workplace can be daunting or you can use it as an opportunity to share more about your condition. I’ve always chosen the easy, take-it-in-your-stride-approach and in all honesty, that hasn’t led to outcomes that really benefited me. Sharing that I have diabetes at a new job is something I’ve battled with, however, I have become bolder over the last couple of years and with certainty I can now say the best advice is to develop these simple habits: speak, prepare, feel (SPF).

Speak

My mistake was that I did not like speaking about the fact that I am  a Type 1 diabetic. This was for a number of reasons that don’t make sense to me anymore. One reason was that I just wanted to be as normal as the next person and not draw any special attention to myself by referring to myself as a diabetic.

My lesson learnt was to speak about the chronic condition openly. Seeing as I have to live with it, I ought to live with it more openly, even in the workplace.

One of the first things is to let the HR team or person know that you have a chronic condition. Should anything happen to you while at work that information is vital to know and for the purposes of office etiquette and catering to your health requirements, conditions should be made known to HR. It also saves you a great deal of pressure if you are in a meeting and need to excuse yourself because you have a low sugar and need to treat it.

You become a floodlight into the life of a person with diabetes who makes several hundred more decisions everyday than the average person, according to research. One decision you can make to manage your diabetes in a new work environment is to speak openly about having it. Tell your team or colleagues your story and how it has impacted your lifestyle and how you got diagnosed. The only way to overcome the nerves you are feeling is to open up about it. You’ll be astounded by the support and ease that comes with opening up.

A large portion of our population are undiagnosed diabetics. So, in speaking about it you can simultaneously raise awareness and perhaps help another colleague who is undiagnosed.

Prepare

One of my mistakes: taking the previous night’s dinner for lunch. Usually I enjoy higher carb content meals at night because it sustains my blood glucose level through the night and prevents me waking up with a low blood glucose at early hours of the morning. The problem with this easy lunch is that my blood glucose and energy level suffer because of it.

My lesson: Prepare lunches that are proven to not affect my blood glucose and energy level negatively. Your well-being is of the utmost importance, as the saying goes ‘’health is your wealth’’ and you can’t be a productive worker without first taking care of yourself, diabetic or not.

A little extra time used to prepare your lunch will result in great energy and productivity at work. Plus, your successful health management will be to your benefit in adjusting to your new job more efficiently.

Feel

My mistake was that in a previous job, I got used to eating cake on every birthday and whenever there was a reason to celebrate in the office. The pressure and natural desire to belong and fit in socially was more important than the guilt I felt for having a high glucose after eating the cake.

Not only did I feel terrible physically which resulted in lower productivity but I’d emotionally beat myself up for having failed at controlling my blood glucose level. Double trouble.

My lesson is to simply get used to feeling comfortable with having the conversation with yourself about how low glucose makes you feel or how high glucose makes you feel. When you can honestly say something makes you feel bad and come to terms with the empowering belief that only you are responsible for making yourself feel otherwise, you change your behaviour, which changes everything.

No one knows the impact of the condition if they do not have it or have not experienced it before through people close to them. Still, nothing compares to actually going through it yourself. As people with diabetes we go through highs and lows, literally and figuratively.

Over the last two years, speak, prepare and feel are habits that I’ve picked up and have really begun to work for me greatly. I urge you to take what you need from this and begin applying or share it with someone.

I believe in the below affirmations more now than ever:

  • It’s normal for you to feel nervous
  • It’s okay to snack in meetings
  • It’s okay to take time away from your work to test your glucose
  • It’s okay to drink a lot of water and use the restroom. Some people need smoke breaks, others need bathroom breaks. As a person with diabetes I need the latter.
  • It’s okay to take a break when you have low blood glucose and to use the time to readjust to normalcy.
  • It’s okay to take a bit of time preparing a considered lunch whether at home or in the work kitchen.
  • It’s okay to be different to your co-workers and have different needs.
  • It’s okay to say no.
  • It’s okay to say yes

With affirmations that empower you to prioritise your diabetes in your new work environment, you can thrive in your occupational spaces despite having to deal with the unexpected and unique experience that comes with being diabetic.

Gabrielle Mixon is advocate for T1 Diabetes.

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Gabrielle Mixon is an advocate for T1 diabetes.

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Intermittent fasting

Intermittent fasting – is it for everyone?

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Intermittent fasting has become one of the world’s most popular health and fitness trends. People are using it to lose weight, improve their health and simplify their lifestyles. But is it for everyone?

Fasting has been around for decades and many different religions practise some sort of fasting during holy periods.

However, intermittent fasting (IF) is a type of weight loss strategy in which the person undergoes a voluntary fast for a specific period of time. The benefit of this fasting is that after 12 hours your body starts to break down fat through a process called lipolysis; as opposed to storing fat, which is typically seen after eating a meal. Scientists refer to this process as a way to flip your metabolism’s switch.

The benefits of IF include weight loss, some improvements in blood glucose levels, anti-aging effects, reduction in cardiovascular risk, as well as cancer.

 

May not be good for everyone

Whilst there is growing evidence that IF has its benefits, it’s crucial to remember it may not be an approach that works for everyone. It’s important to work with an expert, such as a registered dietitian, to determine which strategy would be the best for you. This could be IF, low-carb diets, Keto diet, Calorie restriction, Very Low-Calorie diets (800kcal), etc. Remember, it is not a one-size-fits-all approach.

The best approach for IF would be the 16/8 whereby you consume all your calories in an 8-hour window. This would mean having supper at 6pm and then your next meal at 10am the next morning. The best results have been seen when you combine IF and a calorie restriction; this means one should still be mindful of the types of foods being eaten in the 8-hour window.

Some research shows that IF actually helps with fat loss, as well as fat redistribution whereby the fat around the tummy is redistributed in the body, thereby reducing the risk of cardiac disease.

Intermittent fasting is not for everyone, since it does not always yield positive results and can cause hypoglycaemia for people with diabetes and low blood glucose levels in pregnant women.

Although intermittent fasting can seem convenient to do, it is advisable that you consult your medical practitioner before implementing it, especially if you have a medical condition.

MEET THE EXPERT

Omy Naidoo is a registered dietitian and founder of Newtricion Wellness Dieticians. He has been in practice for 13 years. He worked within the government sector and then moved into the pharmaceutical industry. His key focus is on diabetes products. This enabled him to further his knowledge and skills in diabetes management. Thereafter he went into private practice.

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diabetic gastroparesis

What is diabetic gastroparesis?

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Diabetic gastroparesis is a severe complication resulting from uncontrolled diabetes that impairs quality of life. Dr Louise Johnson expands on this debilitating condition.

Gastroparesis definition

Gastroparesis is characterised by delayed gastric (stomach) emptying in the absence of mechanical obstruction. This is associated with uncontrolled diabetes. It is more prevalent in Type 1 diabetes than in type 2 diabetes.1

Clinical

The prevalence of diabetes associated gastrointestinal symptoms are 5-12%. In a study, done in Olmsted County, Minnesota, the prevalence of gastroparesis in Type 1 diabetes was 5% and in Type 2 diabetes the prevalence was 1%. 2

Gastroparesis is a form of autonomic neuropathy (nerve damage) and is most common seen in people with diabetes longer than 10 years. They usually have microvascular (small blood vessel) complications to the eye, kidney and feet as well.

The most common symptoms are nausea, bloating, abdominal pain and vomiting. The reason for these symptoms is due to delayed pass through of food and liquids from the stomach to the bowel. This is usually due to long-standing poor glycaemic control.

What causes the delay?

In the stomach there are specialised cells called Cajal cells that function as the electrical pacemaker of the stomach. Due to high blood glucose these cells are damaged, and this leads to gastroparesis.

The symptoms of gastroparesis can range from mild to severe and incapacitating. The diagnosis is not always easy as early on a person may be asymptomatic. Early symptoms are early satiety, weight loss, abdominal pain, bloating, nausea and vomiting.

Pain is under-reported and up to 75% of patients with gastroparesis experience abdominal pain.

In a study3 that looked at gastroparesis trends from 1995 to 2004, a 53% increased risk of diabetes-related hospitalisations was attributed to gastroparesis. This condition may also indicate a higher risk of other diabetes-related complications.

Some patients with diabetes may not realise that they experience delayed gastric emptying but exhibit unpredictable responses to mealtime insulin. These responses result from a mismatch between food absorption from the stomach that is slowed down and insulin absorption that is not slowed down. The result is hypoglycaemia early after a meal and a few hours later an unpredictable hyperglycaemia.

In Type 2 diabetes patients who take Glucagon-like peptide-receptor agonists (GLP1 RA), such as exenatide, liraglutide, dulaglutide, semaglutide, the symptoms may be exacerbated since these drugs cause gastric (stomach) delay. This is used in Type 2 diabetes that have increased stomach emptying and tend to overeat and pick up weight.

Diagnosis

The typical complaint associated with gastroparesis is a feeling of excessive fullness after eating, which can last for hours or even overnight. Patients may also complain of feeling full or satiated sooner than expected. When symptoms progress some may even vomit undigested food hours after eating. These symptoms can occur after any meal.

The first test to do is a gastroscopy (swallowing of the camera) to rule out stomach outlet obstruction. Once a mechanical obstruction is ruled out the next step is to measure the time it takes for food to move from the stomach to the small bowel. This is called a gastric motility test.

Patients fast overnight and are not allowed to drink alcohol the night before. Blood glucose should also be below 15 mmol/L. The patient then eats a low-fat egg-white sandwich and special images of the transit time of the food are taken up to 4 hours after eating. When the test is completed and there is more than 10% food left in the stomach after 4 hours, the diagnosis of delaying gastric emptying or gastroparesis is made.

Treatment of diabetic gastroparesis

Non-pharmacological

The first line of treatment for gastroparesis includes dietary modification, glucose control and restoration of fluids and electrolytes.

Foods that are spicy, acidic and fatty should be avoided or minimised because they may worsen symptoms. Carbonated beverages can aggravate the distension of the stomach. Smoking and alcohol slow down stomach movement and should also be avoided. It is suggested to visit a dietitian and eat smaller, more frequent meals.

In more severe cases, feeding needs to be substituted by liquid feeds and in very severe cases hospitalisation and feeding via an intravenous line (drip).

It can be quite challenging to control blood glucose in a person with gastroparesis. It may be necessary to change the mealtime insulin by giving it after a meal to prevent hypoglycaemia. In certain cases, the use of an insulin pump and sensor is very effective by giving small doses of insulin as needed and suspend insulin when blood glucose will go low.

Pharmacological

  1. Metoclopramide before each meal will help with faster emptying of the stomach.
  2. Domperidone before each meal will help with faster stomach emptying.
  3. Erythromycin three times a day before each meal help with stomach emptying but this can’t be used longer than four weeks. It can also aggravate nausea.
  4. Surgically there is a pacemaker that can be implanted in the stomach to help restore the stomach functions. This is unfortunately very expensive and still very new therapy.

Diabetic gastroparesis is a severe complication resulting from uncontrolled diabetes that impairs quality of life and increases comorbid conditions and mortality. Remember that good glucose control can prevent this complication. It is important to take care of your diabetes and know your numbers (HbA1c). Seek the help of a specialist team to optimise your health and all your diabetes complications.

References

  1. Krishnasamy S, Abel TL “Diabetic gastroparesis principles and current trends in management.” Diab Ther 2018;9 p1-42
  2. Jung HK, Choung RS et. al. “The incidence, prevalence and outcomes of patients with gastroparesis in Olmsted County, Minnesota from 1996 to 2006” Gastroenterology 2009;136: 1225-1233
  3. Wang YR, Fisher RS et. al. “Gastroparesis -related hospitalizations in the United States: trends, characteristics, and outcomes, 1995-2004” Am J Gastroenterology 2008;103:313-322
Dr Louise Johnson

MEET THE 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.

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