Category: 2022 Summer – Diabetes Focus Online

Thyroid disease

Thyroid disease and diabetes: a complex relationship

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Diabetes and thyroid disease can have similar signs and symptoms which means the presence of one should alert a healthcare provide to look out for the other. Dr Angela Murphy expands on this.

Thyroid disease and diabetes are both common conditions and so it’s not unexpected that many people may be diagnosed with both. There are genetic and pathological reasons why the conditions may co-exist. In addition, the presence of one condition may make it difficult to diagnose and control the other. This is the challenge the healthcare professional must tackle.

The thyroid gland

The thyroid is a small, butterfly-shaped gland found in the neck that secretes two hormones: T4 (90%) and T3. Most of T3 is made by conversion of T4 in the tissues where it is to be used; thus, T3 is considered the active hormone.

The production of thyroid hormones is controlled by the pituitary gland in the brain which secretes thyroid stimulating hormone (TSH). This feedback loop ensures that all the levels are in the normal range.

The role of thyroid hormones is to regulate all the functions in the body, including heart rate and blood pressure, gut function, and cognition.

When a disease process alters the thyroid hormone levels, specific conditions occur: hyperthyroidism (over active thyroid function) or hypothyroidism (underactive thyroid function).

Thyroid disease

HYPERTHYROID HYPOTHYROID
DEFINITION: Blood tests TSH < 0.01mIU/mL   LOW TSH >10mIU/mL   HIGH
T4 > 22ug/dL             HIGH T4 < 9ug/dL           LOW
CAUSES Autoimmune thyroiditis

(Graves’ disease) *

 Autoimmune thyroiditis (Hashimoto’s thyroiditis) *
Other thyroiditis** Other thyroiditis
Single, toxic nodule or multi-nodular goitre Surgical or radiation damage/removal
SYMPTOMS Weight loss, hunger, Weight gain, fatigue,
tremors, palpitations, cold intolerance, hair loss, dry skin, depression
heat intolerance,
muscle weakness,
anxiety, insomnia
TREATMENT NeoMercazole Levothyroxine
Radioactive iodine
Surgical removal

*Named after the doctors who first described the conditions.   **Viral, environmental toxin.

Autoimmune thyroid disease

Autoimmune disease occurs when circulating antibodies inadvertently attack normal tissue. In the case of autoimmune thyroid disease, different antibodies cause an inflammatory response in the different cells of the thyroid gland. This is called a thyroiditis.  The damage from some antibodies blocks thyroid hormone production causing an underactive thyroid. Other antibody damage results in overproduction of thyroid hormone causing an overactive gland.

Type 1 diabetes

Type 1 diabetes is an autoimmune condition where antibodies attack the insulin producing cells of the pancreas. When considering its association with thyroid disease we must remember:

  • Up to 25% of children with Type 1 diabetes develop autoimmune thyroid disease. Adult females with Type 1 diabetes have a two times increased risk of developing hypothyroidism and males with Type 1 diabetes have a four times higher risk. The combination of autoimmune thyroid disease and Type 1 diabetes is part of the Polyglandular syndrome.
  • Patients should be screened (with blood tests) for abnormal thyroid function annually.
  • All pregnant women should be screened.
  • Hypothyroidism causes hypoglycaemia.
  • Hyperthyroidism worsens glucose control.

Type 2 diabetes

Type 2 diabetes develops when insulin secretion decreases from the pancreas and at the same time peripheral tissues (liver and muscle) becomes resistant to insulin. Thyroid disease has an impact in patients with Type 2 diabetes and so:

  • Screening should start age 45 years or earlier if person is overweight, has had gestational diabetes, has co-morbidities like high cholesterol and hypertension. Screening should be done every three to five years depending on risk.
  • Increase glucose monitoring until normal thyroid hormone levels achieved with levothyroxine.
  • Adjust diabetes regimen as necessary.

Effect of thyroid hormones on diabetes management

Excess circulating thyroid hormones (T4 and T3) increases blood glucose levels by:

  • Increasing absorption of glucose from the gut.
  • Increasing the production of glucose in the liver.
  • Increasing insulin resistance.

This implies that the diabetes regimen might need to be changed and insulin doses adjusted. It’s worth remembering to check for thyroid disease if a patient is reporting a sudden need to increase insulin doses for no apparent reason.

The medications used to treat diabetes can affect thyroid hormone levels. Metformin has been found to reduce TSH levels whereas pioglitazone increases TSH and decreases T4.

This means that the relevant thyroid medication may need to be adjusted to compensate for this. These medications for both hypothyroidism and hyperthyroidism (Levothyroxine and NeoMercazole respectively) tend to lower blood glucose, both fasting and after meals. This increases the risk for hypoglycaemia, particularly in a patient with relatively good diabetes control. It also implies that there may be an improvement in blood glucose levels such that there is a decrease in the risk of developing Type 2 diabetes in certain people.

Subclinical- hypothyroidism and hyperthyroidism

Both hyperthyroid and hypothyroidism can exist in a subclinical form. This is when the bloods are partially outside of the normal range but not in diagnostic range. Usually there are no symptoms (subclinical) at this point.

Subclinical hypothyroidism is associated with high blood pressure and high cholesterol and so may present increased risk of cardiovascular disease in the patient with diabetes.

Subclinical hyperthyroidism can cause cardiac arrhythmias and bone loss (osteoporosis), especially in older adults. As patients with diabetes already have an increased risk of heart disease and osteoporosis this condition may need to be treated.

Diabetes, thyroid disease and pregnancy

The health of both mother and baby are significantly impacted by diabetes and thyroid disease, either hypo- or hyperthyroidism. There is an increased prevalence of hypothyroidism in women diagnosed with gestational diabetes.

It’s important to screen and diagnosis this timeously to avoid pregnancy complications and a low-birth-weight baby. One quarter of women with Type 1 diabetes are at risk of developing hyperthyroidism in the weeks after giving birth. Again, healthcare providers need to be aware of this risk and look out for signs, symptoms, and blood level changes in these women.

In summary

Diabetes and thyroid disease can have similar symptoms and signs: weight changes, water retention, fatigue. Indeed, there is a concern that one condition can mask the other. This means the presence of one should alert a healthcare provide to look out for the other. There is no consistent advice with respect to screening, but general advice would be:

TYPE 1 DIABETES screen for thyroid disease:

  • At diagnosis
  • Annually
  • Six weeks after giving birth

TYPE 2 DIABETES screen for thyroid disease:

  • If an enlarged thyroid (goitre) is found on examination
  • If high blood cholesterol levels and high blood pressure
  • History of gestational diabetes
  • Family history of thyroid disease
  • Repeat screening every three to five years depending on risks

THYROID DISEASE screen for diabetes:

  • At diagnosis
  • Once thyroid function is normal
  • In autoimmune thyroid disease consider annually

Overall, we observe that thyroid disease affects glucose metabolism and abnormal glucose metabolism affects the risk of thyroid disease. This is further complicated by overlap of symptoms and how the drugs for each condition interact with each other. It’s important to be aware that there is an increased connection between the two conditions and screen when appropriate. The influence each condition has on the other can make it challenging to manage both.

Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.

MEET THE EXPERT

Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity.

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Robin Breedeveld

Robin Breedeveld – Living in Africa

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Foreign student, Robin Breedeveld, tells us why she chose to volunteer at Diabetes South Africa and about her adventures in SA so far.

Robin Breedeveld (22) stays in Rondebosch, Cape Town and is currently studying at the University of Cape Town (UCT). S

Studying in SA

Originally from the Netherlands, I completed my bachelor’s degree but moved to Cape Town South Africa to complete a master’s degree in international development studies with a focus on Sub-Saharan Africa.

For this reason I figured that UCT would be the best place to continue my studies, and I moved to Cape Town in February 2022. Cape Town is an amazing versatile city to live in and I’m learning a lot about myself and the world by living abroad. I currently live very close to the university. I like to walk so I try to walk to university, although it’s uphill and my blood glucose always steeply drops after that walk.

Diagnosis

My diagnosis of Type 1 diabetes happened when I was six years old. I remember being incredibly thirsty, and this wouldn’t go away despite all the glasses of water I drank. My parents would put me to bed but I would sneak out of my bed and tiptoe to the tap to drink more, and tiptoe again to the toilet. At first, my parents got mad because they thought I stubbornly wouldn’t go to sleep, but very soon they realised I should see the GP.

After a glucose test, we discovered I had Type 1 diabetes. I started my diabetic journey with injections on a very strict diet. Not necessarily low carb at all, but my doctor had a schedule of how many carbs I should eat every day and exactly how much insulin I should inject for that. I used both long-acting and short-acting insulin.

Insulin pump

The doctors in the Netherlands wanted to get me on the insulin pump for a while, but I refused because I didn’t like the idea of having something permanently attached to my body. But once I turned 12 and puberty hit, my hormones spiked my blood glucose through the roof and the doctors said I had no choice anymore but going on the insulin pump.

That turned out to be one of the best turning points in my life. I no longer suffered from the tender bruises that I had on my legs from injecting, and I was able to pretty much eat anything as long as I correct it with the pump (although pizza and Asian noodles always seem to stay a problem).

Alongside the pump, I was still finger-pricking. Once I turned 19, I was able to get the FreeStyle Libre sensor. This has been so helpful in reducing my feelings of diabetes burnout because it reduces the amount of actions of having to finger-prick so much. It also really helps with exercising and improving my awareness of what my blood glucose levels are doing overall.

Diabetes youth camps

From when I got diagnosed, my parents sent me to diabetes youth camps in the Netherlands. For an entire week, I would be surrounded by other kids with diabetes, even group leaders with diabetes, and there were so many fun activities.

This was a great, eye-opening and empowering experience for me, because I realised that I wasn’t the only child in the world with diabetes. From that first camp experience onwards, I ended up going every year until I turned 12. I made some really good friends at those camps, and still keep in contact with some.

DSA volunteer

I always wanted to go back to one of these camps in my twenties. My friend (who I met at a camp)  and I had the ambition to go together as team leaders one day. Unfortunately, we never got to do that together as she abruptly passed away at 19.

When I moved to South Africa, I decided that both for myself, and in honour of my friend, I would get involved in diabetes youth camps in Cape Town. I googled and came across Diabetes South Africa (DSA) and started volunteering.

It has been a really rewarding experience and I’m so happy I became involved. It was so nice being a group leader at Camp Diabetable that took place recently, and to see the effect it has on kids with diabetes, just like it had on me when I was younger. I aim to stay involved with DSA until I leave Cape Town. The DSA team has also started feeling as my own little family here in South Africa.

The ups and downs

Diabetes has never really affected my work or education. Of course, a bad day of blood glucose levels or a sleepless night because of lows can affect your deadlines, but I have generally found that teachers at UCT and back at home are very understanding. In my experience, they are quite lenient in providing deadline extensions if I need them, although that is rarely the case. I also just try to be kind to myself when that happens, despite how frustrating it may be.

An active life

I love being active; I’ve been playing rugby since I was 15 years old and I also really love hiking. With diabetes, this isn’t always easy. One of my horror stories is that I went on a not very known hike on Table Mountain with a friend and we were completely lost. We couldn’t find the trail anywhere. Initially the hike was supposed to take max five hours, but it ended up taking us nine. And of course, I only took food and drinks for five hours and I ran out of energy bars and juice while we were still climbing up. I even ate all the energy bars from my friends who I was hiking with.

Luckily, my blood glucose level was stable at that moment, but I was afraid of what would happen if it were to drop. I decided to take my pump off completely and just hope for the best. Once we got to the top, we were also unlucky because the restaurant and cable car were far from where we were and we still didn’t see any people on the trail. We decided we would go down slowly and if my blood glucose dropped, we would have to call the Table Mountain emergency line.

Eventually, we saw a couple walk in the distance and we screamed for help. Luckily, they had so much food and sugar on them. We decided to accompany them all the way down and that is how everything turned out well in the end. So, my tip would be, as a person with diabetes, please take food and drinks for three days on any hike, even if it’s only supposed to take two hours.

Rugby

When it comes to rugby, I try to always start training with a blood glucose level of 8 – 12, and in the middle of training I inject a little bit of insulin so that I don’t skyrocket afterwards. This works quite well for me.

Sometimes, rugby coaches don’t really understand my diabetes which can be frustrating. They might not understand that if I’m low, I can’t go back on the field immediately after a sip of juice. They do not understand that I need a solid 15 minutes to feel slightly better.

A few weeks ago, I went on a rugby tournament to Kimberley. After having had a bus ride of 12 hours, only having eaten breakfast and arriving in Kimberley in the evening, the coach spontaneously decided to do an hour training before dinner in 30 degrees. I tried to communicate that this really doesn’t work for me and can cause problematic blood glucose levels, especially after not eaten anything since breakfast, but the coaches failed to understand and didn’t accommodate my needs. It was really frustrating but I’m never afraid to stand up for myself, so that is what I did. In this instance, I recommend young people with diabetes to stand up for themselves, and if people aren’t interested to hear about your situation, you must choose for yourself and make them understand, whether they want to or not. I think diabetes has taught me this skill and has taught me to sometimes be fierce, if really necessary.

Visible pump and sensor

I never feel the need to hide my diabetes from people. I always wear my pump visibly on my trousers, and the sensor is also quite often visible. It has actually resulted in the nicest encounters with other people with diabetes. Once I was walking on the street, and as a guy passed me, he stopped, took his pump out and shouted, “Buddies!”

Last month I went to Rocking the Daisies, a music festival, and a girl came up to me because she saw my sensor. She showed me hers, and we ended up giving each other tips on which alcoholic drinks are best for our blood glucose.

Of course, sometimes non-diabetics ask me funny questions like if I’m recording them (sometimes they think my pump is an old MP3 player), but I’ve never gotten negative comments. Even if I did, I don’t think I would care.

Living my life like anyone else

Diabetes has never stopped me from doing what I want to do. Age 19, I went solo backpacking through Kenya and Tanzania then went back to live in Kenya for three months at age 21, and went wild camping and hiking through the Swiss mountains. I didn’t experience major struggles related to my diabetes doing this, I just made sure I had enough food, pump consumables and insulin with me and a bag to keep my insulin cold.

My diabetes has also not stopped me from pursuing my dream of studying and living abroad. Of course, it always remains an extra challenge. You always have to make sure you have the right stuff with you to make sure you don’t get into tricky situations like what happened to me on Table Mountain.

When I arrived in South Africa I was also really confused with how the medical system works here, because in the Netherlands it works completely differently. It took me months to figure it out, but it has never been a reason to hold me back. I encourage every person living with diabetes to just do the badass things they want to do and to not be afraid! All it requires is a little extra planning.

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Dating

Dating with diabetes

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Dating is hard already but then throw in diabetes too and things can get tricky. Darren Badenhuizen and Paula Thom, a couple who both have Type 1 diabetes, offer advice and share some of their relationship.

Darren Badenhuizen (39) and Paula Thom (33) live in Port Elizabeth and have been dating for two years. They run DSA Young Guns.

How did the two of you meet?

I (Paula) received a message via Instagram by Lundi who wanted to meet up and talk about living with diabetes. She was diagnosed during pregnancy and wanted to get involved with Diabetes South Africa. She brought Darren along to our coffee meeting. Darren was very quiet but always showed up at the Young Guns get-togethers. He was keen to meet other people who live with diabetes. 

How did you each tell the other about your diabetes?

We found out at the coffee shop. Later when we became good friends, we learnt that we both have a passion of helping others with diabetes, especially the youngsters.

Is it best to tell a potential partner about your diabetes?

Definitely. It is a major part of your life and affects your partner’s life as well. 

When best is it to tell a potential partner?

Before you start dating the person and when you feel comfortable enough to share it. Darren and I don’t shy away from telling people that we have diabetes. It’s also a way of spreading awareness in our own little way.

Does having a partner who also has T1D hold accountability in managing it correctly?

We do not think so. We are each equally responsible to look after ourselves, regardless of who we date. There are ups and downs with our health and all we can do is be a support. It definitely helps that we understand every aspect of it with no judgement. This does make it easier to deal with.

If you both have T1D, can you share medication?

No, we have a set amount of insulin prescribed to us and different types. There is no need to share medication and we definitely should not.

Does having T1D add more stress or need for clear communication in a relationship?

Darren and I understand each other pretty well. We both tend to get a bit grumpy or irritable when our blood glucose levels are high. If this is the case, then we will tell the other to test their sugar. It’s something we laugh about, but usually we are right, and the blood glucose level would be the cause of the mood change.

Is there a concern that if both of you have T1D and if you decide to have children that there is a chance that your children might have it too?

This is definitely a concern as it may be genetic.

How has your partner helped you in managing your diabetes?

Paula doesn’t let me eat until I inject as this is my biggest weakness.

Darren reminds me to take my long-acting insulin and test as this is my biggest weakness.

We also help each other figure out what the cause may be of our blood glucose levels being either high or low. So, we will go through the day and talk about what we ate and did and try and eliminate factors and get to the source. This is how we learn what affects it as we go along. We are constantly learning.

MEET OUR EDITOR

Laurelle Williams is the Editor at Word for Word Media. She graduated from AFDA with a Bachelor of Arts Honours degree in Live Performance. She has a love for storytelling and sharing emotions through the power of words. Her aim is to educate, encourage and most of all show there is always hope. Feel free to email Laurelle on editor@diabetesfocus.co.za

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socialise

How to socialise without food

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Dietitian, Estée van Lingen, shares ways to socialise over the December break that doesn’t involve food.

When it comes to the holidays, most people plan their events around food.Unfortunately, with this then comes overindulging and gaining weight. For those of you with diabetes, it can just be plain difficult to then still monitor and manage your blood glucose levels. So, what can you do to still make the holidays fun?

  • Gardening with family and kids.
  • Playing with kids.
  • Painting the house/artwork or furniture (giving them a new look).
  • Art classes with friends.
  • Visit the beach for a swim or go for a long walk on the beach.
  • Cleaning out the cupboards – overdue Spring cleaning.
  • Go for walks with family and/or the dogs.
  • Play board games.
  • Swimming or hanging around the pool (If you need a drink, try sparkling plain water with water flavouring drops and fresh fruit pieces).
  • Take up a sport you haven’t tried before. For example: golf, tennis, table tennis, action cricket or netball, putt-putt, rowing or fishing, surfing, zipline, quad biking, etc.
  • Doing charity work around the town or at old age homes/ animal shelters.
  • Pampering sessions with friends or at your house (foot scrub, face and hair masks, painting nails and lathering on cream).
  • Try out making new healthy recipes.
  • Make decorations for the holidays for your house or for setting the table. Upcycling up your used décor or cans, paper, straws.
  • Cleaning the garden (Raking, pulling out weeds, moving around plants, cutting the grass).
  • Journaling, meditating or reading.
  • Pilates or yoga or just stretching throughout the holidays.

Managing where you eat

Try and eat before or after an event at home or take your own snacks so that you don’t feel obligated to eat at the event or at a restaurant.

When you pack snacks or eat meals before an outing, choose food high in protein, such as boiled eggs, Provitas with low-fat cottage cheese, lean biltong, low-fat chicken mayo on Provitas or brown rice cakes or even snack on raw vegetables, nuts and seeds. Most importantly, include lots of water before, during and after activities to help suppress hunger and prevent overeating when finished.

If you are still not certain or need more assistance with your individual dietary needs, book an appointment with your nearest dietitian.

MEET THE EXPERT

Estée van Lingen is a registered dietitian and has been in private practice since 2014. She is registered with the HPCSA as well as ADSA and served on the ADSA Gauteng South Committee for 2020 – 2022.

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road trips

T1 tips for road trips, hikes and fun stuff

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Going on road trips can be fun, you can turn the music up loud and sing along to your favourite songs, chat to loved ones and play car games. But if you have diabetes there are other things to consider too. Kate Bristow expands on this.

First of all, you should have a checklist. Yes, it’s a good idea to have a checklist to make sure nothing is left out or forgotten.  Planning is essential. If you are a parent of a young Type 1, you will more than likely have this covered already.

Checklist for road trips

  • Insulin and needles (have a small cool bag to carry this in).
  • Blood glucose test meter and strips (make sure you have enough stock and a bit extra for the time you will be away).
  • If you are wearing a continual glucose monitor (CGM), always have enough sensors for the holiday and one or two extra as well. The same goes for pump stock.
  • A phone, in case of emergency and for CGM to do your scanning if you wear a pump or CGM.
  • If you are sitting in a car for long periods your energy needs will drop, so your blood glucose levels may run higher, especially if you are normally active. Be mindful of your numbers and adjust your insulin doses accordingly. This will mean testing or scanning more often.
  • Super C sweets or Jelly Babies/Wine gums, Farbars, a small can of Coke/Energade or Powerade.
  • Future Life Granola Crunch Bars or protein bars as the long-acting carbohydrate in case of emergency. But you could also use your padkos snacks here.
  • Glucagon Hypokit, keep this with your insulin and tell others with you where it is and how to use it.

Snacks and padkos

  • Pack snacks that fill you up without hitting those blood glucose levels; things like raw vegetables: carrots, sugar snap peas, raw broccoli, cucumber and tomatoes. Biltong and popcorn (two cups) are good choices too. Try to limit portion sizes at meals where possible too.
  • If you tend to get bored in a car, it’s easy to want to munch. Don’t have too many carbohydrate-rich choices available. Keep your snacks in a cooler in the boot and make conscious decisions to stop regularly, eat and have a good 15-minute walk around and leg stretch.
  • It’s a good idea to make your padkos at home before the trip. Sandwiches on health bread or wraps, nuts, pretzels, hard boiled eggs, biltong and fruit are good options.
  • Portion out your snacks so you know what your carb content is for anything you eat. The FatSecret calorie counter app is useful to help with knowing the calorie content and portion size for different foods. It’s always useful to carb count with Type 1 diabetes as this gives you much better control of your insulin to food ratios.
  • Be mindful if you intend buying food to go; there are now more choices available on our roads. Pick your stops and restaurants carefully and choose your meal wisely. Wraps or sandwiches on health bread are going to have less effect on those blood glucose than burgers or pizza.
  • Carry lots of water in the car and sugar-free cold drinks. Sugar-free chewing gum and sweets are also nice to have available inside the car.

Hiking and school camps

If you are going on an adventure outing with your school or going on an extended hiking trip, consider the following:

  • On travelling days, it may not be necessary to change insulin doses. Avoid excess snacking as discussed above and choose snacks wisely. Drink plenty of water.
  • On hiking days, it may be necessary to reduce your long-acting insulin doses by 2-4u (use your sensor or blood glucose meter to assess your individual needs).
  • Eat regularly and have something to eat before starting your hike.
  • If having porridge, such as oats, or cereal for breakfast, have some protein as well: egg, sausage, cheese or biltong.
  • Start the hike with a blood glucose level of 7-10 mmol/L.
  • Test and scan often; this is intrusive but knowing your numbers will make your hike easier and more enjoyable because you’ll feel in control.
  • On longer more strenuous hikes, it may be necessary to have about 100ml of an energy drink every hour or two. Some people may prefer a couple of sweets to give the blood glucose levels a bit of a boost.
  • Do not skip lunch on a hike and test your blood glucose levels before eating. Consider a reduction of insulin by 1-2u depending on your numbers.
  • Always carry your blood glucose meter with you and have your insulin and Hypokit available. Scan/test every time you have a break.
  • Have a hiking buddy who knows how to help you and to find your kit and help test if your blood glucose levels drop.
  • Remember that sustained exercise can influence your blood glucose levels for 24 hours so be mindful not to overcorrect slightly higher levels with too much insulin.
  • Frio cold packs are useful to carry and insulate insulin in backpacks for the day hikes.

And remember whatever you are doing and however you are getting there, go out there and have fun and live your best life.

Sister Kate Bristow is a qualified nursing sister and certified diabetes educator.

MEET THE EXPERT

Kate Bristow is a qualified nursing sister and certified diabetes educator. She currently runs a Centre for Diabetes from rooms in Pietermaritzburg, providing the network support required for the patients who are members on the diabetes management programme. She also helps patients who are not affiliated to a diabetes management programme on a private individual consultation basis, providing on-going assistance and education to assist them with their self-management of their diabetes.

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diabetic eye screening

What to expect during diabetic eye screening

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Dr Enslin Uys, an ophthalmologist, describes the process of diabetic eye screening step-by-step and goes on explaining why it is vital.

What is diabetic eye screening?

Diabetes can cause health problems in several ways and your eyes are one part of your body that can be affected. Diabetic eye screening is a test to check for eye problems caused by diabetes.

Diabetic retinopathy is caused by diabetes. This can lead to loss of vision (ultimately blindness) if it’s not found early.

The eye screening test can find problems before they affect your sight. Pictures are taken of the back of your eyes to check for any changes.

If you have diabetes and you are 12 years or over, you should have your eyes checked at least once a year.

Diabetic retinopathy

This condition occurs when uncontrolled blood glucose levels affects small blood vessels, damaging the part of the eye called the retina. It can cause the blood vessels in the retina to leak or become blocked. This can affect your sight.

Diabetic retinopathy

Importance of screening

Diabetic eye screening using direct ophthalmoscopy
Diabetic eye screening using slit lamp examination.
Diabetic eye screening using indirect ophthalmoscopy
Diabetic eye screening using indirect ophthalmoscopy.
Diabetic eye screening using digital photography
Diabetic eye screening using digital photography.

Eye screening is an important part of your diabetes care. Untreated diabetic retinopathy is one of the most common causes of sight loss. When the condition is caught early, treatment is effective at reducing or preventing damage to your sight.

Diabetic eye screening is not covered as part of your normal eye examination with your GP or even some opticians. Screening doesn’t look for other eye conditions and you should continue to visit your optician regularly for an eye examination as well.

How can I reduce the risks?

You can reduce your risk of developing retinopathy, or help to stop it from getting worse by:

  • Controlling your blood glucose level.
  • Tightly controlling your blood pressure.
  • Controlling your cholesterol levels.
  • Keeping fit and maintaining a healthy weight.
  • Give up smoking. Nerve damage, kidney and cardiovascular disease are more likely in smokers with diabetes. Plus, smoking increases your blood pressure and raises your blood glucose level, which makes it harder to control your diabetes.
  • Get regular retinal screening. The most effective thing you can do to prevent sight loss due to diabetic retinopathy is to go to your retinal screening appointments by an eye specialist, also called an ophthalmologist. Early detection and treatment can stop you from losing sight. If you’re pregnant and have gestational diabetes, you will require retinal screenings more often during your pregnancy and after your baby is born.

The process of the screening test

Eye drops being administered prior to screening test

  1. Drops will be administered in your eyes to temporarily make your pupils larger. You may find the drops sting a bit and the eye drops may affect your vision for a few hours, so you shouldn’t drive after your appointment.
  1. Photographs will be taken of the back of your eyes. The camera doesn’t come into contact with your eyes. If the screening test isn’t performed by an ophthalmologist, the photographs will be sent to one.
  2. The appointment will last around 30 minutes.

  3. A feedback letter will be sent to you and your GP within six weeks letting you know your screening results.

 

Possible results

An ophthalmologist will study the photographs of your eyes after you have been screened. If there are any problems or more questions, we may call you back for another assessment.

Screening can detect:

  • Early signs of retinopathy.
  • If you need a follow-up appointment to see whether you need treatment.
  • If you need to have more frequent checks.

Practical tips for the screening day

  • Bring your glasses and contact lenses you wear along with lens solution for contacts.
  • Bring sunglasses as your eyes can feel sensitive after the eye drops.
  • You may want to bring someone with you to the appointment.
  • Eye drops may affect your vision for a few hours, so you shouldn’t drive after your appointment.

Remember, eye screening is part of managing your diabetes and diabetic retinopathy is treatable, especially if it’s caught early.

MEET THE EXPERT

Dr Enslin Uys (MBChB; DA (SA); Dip Ophth (SA); FCOphth (SA)) is a general ophthalmologist with a strong interest in disease affecting the retina. He is the co-founder of the Pietermaritzburg Eye Hospital, where he is currently in full time private practice, and is the current president of the South African Vitreoretinal Society (SAVRS) that represents ophthalmologists in SA involved in treating and managing retinal diseases.
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resistance exercises

The benefits of resistance exercises

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Lisa Grenfell, a biokineticist, expands on the benefits of resistance exercises for people living with diabetes.

You may be asking which type of exercise works better to control your blood glucose levels? We all know that aerobic or cardiovascular exercise like walking, swimming, cycling, or doing vigorous household chores raises your heart rate, improves your general conditioning, and increases weight loss. These exercises accomplish this by burning calories which is always encouraged for people living with Type 2 diabetes as they may have higher fat levels.

When doing physical exercise, energy is used from various sources depending on its intensity and duration. Therefore, your effort will determine the type of energy used.

Resistance training

Resistance training uses muscle strength to move weights or body weight, or it entails moving against elastic bands, free or machine weights.

When muscles contract it changes how the cell membranes respond to insulin, making it more usable. Resistance training increases muscle mass which uses the excess blood glucose as an energy source and therefore controls blood glucose levels better. Blood glucose levels are more stable than if you were doing aerobic exercise alone.

Resistance type exercises are less likely to drop glucose sugar levels with the risk of hypoglycaemia (low blood glucose) than it does during aerobic types of exercise. This type of exercise has been proven to increase insulin sensitivity, muscle strength, quality of life, bone density and reduce blood pressure and lipid (cholesterol) levels and finally it reduces haemoglobin HbA1c (blood test that measures your glucose levels over a three-month period).

In addition, the muscles release a protein which has anti-inflammatory properties and is more effective in reducing blood sugar when used in a combination of aerobic and resistance exercises.

The benefits of resistance exercises

How hard, often and long should I do resistance exercise to gain benefit?

HOW OFTEN: Train three times a week.

HOW LONG: 45 min at a time.

HOW HARD: How much resistance depends on your initial strength and conditioning. A general rule of thumb is the two for two progression rule. For example: if you can do 12 repetitions of the exercise for two consecutive work outs then add two more reps for your third work out and for each subsequent session.

Precautions

If you have joint issues be careful of how you manage this load. A biokineticist can monitor and guide your programme with regards to technique and supervision of the exercises.

8 – 15 reps (moderate intensity)

5 – 8 reps/set (vigorous – this intensity showed the greatest reduction in HbA1c)

1 – 5 reps/set (intensive)

Remember that if your weight goes up, so does the resistance your body is working against. Carrying extra fat mass (adipose tissue) is non contractile or non-working weight and doesn’t contribute to moving you. The muscles have to work harder against this load to achieve the movements it needs. This is why walking upstairs is so much harder than down. Your joints are also more vulnerable as exercise has greater impact on them therefore you need to have a balance between increasing resistance and increasing load on the joints.

Balance issues

If you are older, diabetes alone reduces your muscle strength, especially in the legs and increases the risk of disability by as much as two to three times (commonly due to falls). It would be highly recommended to add balance and proprioception (awareness of your body parts in space) exercises to your regime. Examples of this may be single leg standing or tandem leg standing, or using an uneven surface, such as a high-density foam pad, to stand on to challenge your balance. The smaller stabiliser muscles have to work really hard to maintain your positioning and not lose balance; this increases your spatial awareness, balance, and muscles responsible for posture correcting reflexes. A biokineticist can prescribe a full programme to address these specific areas and ensure you progress at the correct pace while still stimulating positive change. 

Strength issues

From as early as 25 years of age your muscle strength declines and this speeds up from 50 years. So, by age 80 you may have lost as much as 40% of your muscle strength. With loss of strength also comes loss of power, mobility, and the ability to perform activities of daily living, such as walking, climbing stairs, and carrying capacity.

Losing muscle mass reduces where glucose can be used in the body, leaving more available in the bloodstream. This then raises the blood glucose levels.

Combination

A combination of different types of exercise (aerobic, resistance and flexibility) as well as dietary and medication control is more beneficial for people living with diabetes to control blood glucose levels than any one thing alone.

Consult a biokineticist

Now that you know the benefits of resistance exercises, you many ask who can guide me and ensure I do this safely and effectively?

A biokineticist can assist in advising which form of exercise might be most appropriate for your specific condition. Firstly, they will collect a full medical history and evaluation of all your health components (body fat, heart and lungs, muscle strength, endurance, and flexibility as well as screening of cholesterol, glucose, and blood pressure).

They are trained to make sure that if you have any existing conditions, such as high blood pressure (hypertension) or heart problems (angina – chest pain with or without exercise) associated with your diabetes that these are well-controlled and that it’s safe to exercise.

A biokineticist can adapt your training programme (either at home or in a controlled environment like their practice or a gym) to make sure you are training at the correct intensity and that the exercises are appropriate for your level of fitness, or any symptoms you might be experiencing. They also monitor your blood pressure, heart rate and general responses to exercise to track how your body is coping with the stress of exercise.

Contact your a biokineticist to advise you on an appropriate assessment and intervention programme. Find a biokineticist on www.biokineticssa.org.za

References

  1. Wróbel M, Rokicka D, Czuba M, Gołaś A, Pyka Ł, Greif M, et al. Aerobic as well as resistance exercises are good for patients with type 1 diabetes. Diabetes Res Clin Pract. 2018;144:93–101.
  2. McGinley SK, Armstrong MJ, Boulé NG, Sigal RJ. Effects of exercise training using resistance bands on glycaemic control and strength in type 2 diabetes mellitus: a meta-analysis of randomised controlled trials. Acta Diabetol. 2014;52(2):221–30.
  3. Lima V de A de, Menezes FJ de, Celli L da R, França SN, Cordeiro GR, Mascarenhas LPG, et al. Effects of resistance training on the glycemic control of people with type 1 diabetes: a systematic review and meta-analysis. Arch Endocrinol Metab. 2022;(7):1–8.
  4. Röhling M, Herder C, Roden M, Stemper T, Müssig K. Effects of Long-Term Exercise Interventions on Glycaemic Control in Type 1 and Type 2 Diabetes: a Systematic Review. Exp Clin Endocrinol Diabetes. 2016;124(8):487–94.
  5. Consitt LA, Dudley C, Saxena G. Impact of endurance and resistance training on skeletal muscle glucose metabolism in older adults. Nutrients. 2019;11(11):1–17.

Article written by Lisa Grenfell on behalf of the Biokinetics Association of South Africa.
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high-protein diet

The cons of a high-protein diet

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Liesbet Delport and Marinda Venter unpack the cons of a high-protein diet for people living with diabetes and offers the Smart Health Diet as the alternative.

A healthy gut

There is a myth that a high-protein diet is the best way people living with diabetes need to eat to get their blood glucose under control and to improve their health.

High-protein diets are low in fibre and most people with diabetes don’t have a healthy gut, due to limited fibre intake. A type of fibre, called prebiotics, is found in wholegrains, fruit, vegetables and legumes (collectively called functional foods). There is ample evidence of good blood glucose control and improved insulin sensitivity on high-fibre diets based on wholegrains.

For a gut that is soft-stool friendly, you also need the right, good bacteria to be active and flourishing in your gut, creating a healthy microbiome for nutrient absorption and regular soft stools. This good bacteria, called probiotics, is common in fermented dairy like yoghurt, as well as other fermented foods and they live on fibre. Without fibre they wane and so your gut health will wane with it.

On average, the recommended fibre intake per day is 30-35g, chosen from a variety of fibres as they don’t have the same properties. Constipation is often a symptom of a fibre poor diet.

Colorectal cancer

Sixty percent of the body’s immunity is situated in the gut, but apart from protection against colds and flu, a healthy gut is of utmost importance for protection against various cancers, especially colorectal cancer.3 There is convincing evidence that a diet high in red meat and alcohol predisposes to colorectal cancer, whereas a diet high in fibre and rich in calcium protects from colorectal cancer.4

So, although your diet needs to include plenty of vegetables and fruit, the bare minimum is at least three servings of wholegrains per day. Calcium’s best source is low-fat dairy products and again you need at least three servings per day.4

The myth

A high-protein diet for good glycaemic control is a myth, because the benefits of going high on protein and low on carbs will only last for a couple of hours. Protein and fat take longer than carbs to digest and your blood glucose will start to show the effect after two to three hours when the carbs have come and gone.1 This will happen after every high-protein (and/or high-fat) meal.

Many people who have diabetes develop kidney problems (±30%) as high blood glucose levels cause damage to the kidney’s cells, just like it can cause damage to the cells of the retina in the eyes (causing blindness) and/or the cells of your nervous system, referred to collectively as microvascular damage. High-protein meals put more strain on your kidneys, as more protein in the bloodstream forces them to work much harder to get rid of waste products.

Many people with diabetes are sent to a dietitian by their doctor to place them on a low-protein diet, as their kidneys can’t cope anymore. The high-protein approach could fast forward you to chronic kidney disease. Serious circulation problems, due to damage to nerve cells are also common amongst the diabetic community and often end badly with amputations.

Pancreatic function

Taking care of your pancreatic function is at the essence of diabetic self-care. Insulin, which controls blood glucose levels, is excreted by the pancreas. Too much glucose in your blood causes your pancreas to work overtime and after weeks, month or years it gets tired and can’t cope. But it’s not only sugar and high-GI or refined carbohydrates that taxes the pancreas, protein and fat does too.5 So, changing from too much refined carbs to too much protein and/or fatty foods and shakes is like exchanging one bad habit for another.

Type 1 diabetic patients have been found to need extra insulin when they eat high-protein and/or high-fat meals, instead of balanced meals.1 Balanced meals would typically be what you would find in the Mediterranean diet4 or what is promoted in the South African equivalent, the Smart Health diet.

High-protein diets have also been shown to increase LDL cholesterol (bad cholesterol).6 With all the risks of microvascular damage that people with diabetes have to avoid, a high cholesterol level is an unwanted problem. High LDL cholesterol can lead to atherogenesis, which is the main cause of macrovascular damage, leading to heart attacks and stroke. In contrast, wholegrains, legumes, with the addition of fruit and vegetables, are providing soluble fibre which aids in lowering cholesterol.

The diet solution

The diet solution is to have a balanced meal plan (like the Smart Health Diet) that includes healthy functional foods and eliminates all unhealthy foods. As a person with diabetes, it’s best to consult a registered dietitian to explain the detail to you. In the meantime, have a look at www.smarthealthdiet.co.za and use the figure below as a guide to have a healthy meal.

References

  1. Smart, C.E.M., Evans, M, O’Connell, S.M., Mcelduff, P. Lopez, P.E., Jones, T.W., Davis, E.A. and King, B.R. Both dietary protein and fat increase postprandial glucose excursions in children with type 1 diabetes and the effect Is additive. Diabetes Care 2017;36:3897–3902.
  2. Küster-Boluda I., Vidal-Capilla I. Consumer attitudes in the election of functional foods. Spanish J. Mark. ESIC. 2017;21:65–79. doi: 10.1016/j.sjme.2017.05.002.
  3. 3. Tayyem, R.F., Bawadi, H.A., Shehadah, I.N., Suhad, S.A., Agraib, L.M., Bani-Hani, K.E., Tareq, A., Al-Nusairr, M., and Heath, D.D. Macro- and micronutrient consumption and the risk for colorectal cancer among Jordanians. Nutrients2015;7(3):1769-1786.
  4. 4. Sajesh K.V., Wong, T.Y., Loo Y.S., et al. Role of Diet in Colorectal Cancer Incidence. Umbrella Review of Meta-analyses of Prospective Observational Studies. JAMA Network Open. 2021;4(2):e2037341.
  5. Bell, K.J., Gray, R., Munns, D., Petocz, P., Howard, G., Colagiuri, S., and Brand-Miller, J.C. Estimating insulin demand for protein-containing foods using the food insulin index. Eur Jnl Clin Nutr 2014;68:1055-1059.
  6. McMillan-Price, J., Petocz, P., Atkinson, F., O’Neill, K., Samman, S., Steinbeck, K., Caterson, I. and Brand-Miller, JC. Comparison of 4 Diets of Varying Glycemic Load on Weight Loss and Cardiovascular Risk Reduction in Overweight and Obese Young Adults. Arch Intern Med. 2006;166:1466-1475.
Liesbet Delport

MEET THE EXPERT

Liesbet Delport is a registered dietitian with a private practice in Mpumalanga. She is one of the founder members and research and development manager of the Glycemic Index Foundation of South Africa (GIFSA), founded in 1999, and has been involved in determining the GI of South African foods for more than two decades.

Marinda Venter

MEET THE EXPERT

Marinda Venter is a registered dietitian who works part-time at a private practice in Nelspruit. She also works with the Glycemic Index Foundation of South Africa, writing product reports and newsletters.

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Overcoming treatment fears

Overcoming treatment fears

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Dr Paula Diab describes several treatment fears that stand in the way of well-managed diabetes.

“Nothing in life is to be feared. It is to be understood.” – Marie Curie

Marie Curie is often spoken about in recognition of her pioneering work in radioactivity that allows us to walk into an X-ray department, casually and fearlessly, and view if a bone is broken or if we have pneumonia. She was the first woman to win the coveted Nobel Prize and the first person to ever win it twice in two different scientific fields! She and her husband were also the first married couple to win a Nobel Prize and she became the first woman to become a professor at the University of Paris. And all of this she achieved almost four decades before she was even allowed to vote. She clearly didn’t fear progress or change at all.

How fear plays a role

People with diabetes tend to live in a constant state of fear: What happens if I eat this? Will my blood glucose drop? Is it safe to go for a run? What will my doctor say if s/he sees my results? The list is endless. However, fear is counteractive to any type of progress and if we’re going to conquer diabetes and manage it correctly, we need to be one step ahead and not afraid of progressing.

A few years ago, I saw a young lady who was taking maximum oral therapy. She had been a patient of mine for a few years and we had developed a rapport between us. Her HbA1c had increased over time and at every visit, I had gradually started introducing the topic of insulin. My persuasions were met with absolute fear and obstinate rejection. So much so that I was surprised that she continued to return every six months as I thought that she would seek care elsewhere. Her fears to commencing insulin were rooted in her contextual story that included relatives passing away from complications of diabetes and the perception that she had failed in her diabetes management if I was suggesting that she needed insulin.

Fast forward to a few months ago when a happy, content and well-managed patient walked briskly into my office laughing, saying she can’t believe how silly she must have look a few years ago when she was crying and refusing insulin. This patient now injects twice a day with no problems, knows how to adjust doses depending on her activity and meals, and feels so much healthier. Her HbA1c has improved, the mild retinopathy she had has resolved, she has lost weight and now manages her diabetes instead of her diabetes managing her.

Changing treatment fears

What changed? She no longer fears insulin but understands it; that insulin comes in the form of an injection just like oral medications come in the form of tablets. That is how insulins are manufactured. She understands that insulin isn’t the end of the road in diabetes and that many new research papers are starting to advocate the benefit of early onset, very low dose insulin in some cases. She also understands that timely intervention can resolve some complications and prevent others. Now, she understands that there is no such thing as failure in diabetes but rather a different treatment path that needs to be followed.

Diabetes isn’t a disease that can be treated with a bi-annual, 15-minute check-up and six-monthly script. There are so many daily influences on how glucose levels react, and we need to understand how these factors relate to manage diabetes correctly. When you fear insulin initiation or any other aspect of diabetes management, you’re placing unnecessary obstacles in your way that will hinder progress. Hopefully, in understanding these obstacles, they can be overcome.

Fear of insulin

This is probably the most common fear that people with diabetes have. It’s a misconception that only children with Type 1 diabetes will need insulin. If you live long enough with diabetes, you’ll eventually need insulin.

Insulin isn’t dangerous if used correctly and shouldn’t be painful to inject. Using insulin doesn’t have to place restrictions on your lifestyle. Make sure that your healthcare provider shows you how to inject correctly and change the needles. Very often, preventing a painful injection can be as simple as using the correct technique and changing needles regularly.

If given in the correct dose and monitored correctly, insulin isn’t dangerous. It reduces your blood glucose levels but that is what it’s meant to do.

You need to monitor your glucose levels and understand what will cause a precipitous drop and how to avoid those situations. This requires a good doctor-patient relationship, specialised diabetes education and regular glucose testing. Knowing how to manage a lower glucose level and what to do in the case of an emergency are just as important as knowing how to inject the insulin.

Many people also have the idea that to inject, you have to leave the room and do so in private without anyone knowing. Again, this doesn’t have to be the case.

In addition, many newer regimens involve insulin given only at night or an injection given in the morning to control glucose levels throughout the entire day. It may not be necessary to take insulin before each meal when you first start insulin. It can be as simple as when you brush your teeth at night, you take your injection. These are just a few examples of the fears surrounding insulin usage, all of which can be managed through understanding more about the medication and seeking professional advice.

Fear of disease progression

Diabetes is a chronic, progressive disease which means that from the day that you’re diagnosed with diabetes, it will naturally become more of a threat to your general health. In fact, recent evidence shows that by the time you’re diagnosed with Type 2 diabetes, you’ll already have lost 50% of your beta cell functioning in the pancreas and that this loss of function will decline throughout the course of the disease.

This is a good reason to always be one step ahead of your diabetes. Don’t wait until your vision deteriorates before you seek help, get your eyes checked regularly even if you think you can see fine. Don’t wait until wounds start healing poorly or you have cardiac symptoms before you seek specialised care. From the very outset, your healthcare team should be looking for these complications and advising on how they can be prevented.

The disease will progress. The medication that you took two years ago may no longer be effective. Complications will occur. But the trick is to manage these complications, mitigate the risk factors and regularly seek specialised care to help you understand where the risks are and how they can be managed.

Fear of hypos

In a previous article, I spoke about the fears of hypoglycaemia and how to manage them. Hypoglycaemia is a very real threat and is the cause of significant morbidity and mortality every year. However, if you know how to predict and treat hypos and have the correct support in place, this risk can be managed.

Newer insulins and medications have a far lower hypo risk than previous preparations did and are generally safer to use. However, being educated and aware of hypoglycaemia is still the best solution.

Fear of seeing the doctor

Often, I joke with my patients that I don’t have a police hat nor a big stick. As healthcare providers, our role isn’t to chastise patients who don’t behave or to point out all the negative aspects of their management. Our role is rather to guide and educate. Obviously, we do have to identify the short-comings to know where to make changes but thereafter, the solution to fixing the problem is to understand it and give guidance on how to change.

Don’t delay in seeking healthcare and seeking the best type of care you can access because you’re afraid of what the doctor will think or say. The patients who cause us distress are those who are unstable, and we don’t understand, not the ones who need and ask for our help.

Get rid of treatment fears by understanding

The only time diabetes needs to be feared is when left unmanaged as it has complications that can be life-threatening. It requires careful lifestyle management and daily attention to manage it correctly. But it shouldn’t be feared, rather understood.

If you have never seen a diabetes educator, ask your doctor or pharmacist who you can contact in your area to help you understand this curious disease. Seek to understand and embrace your diabetes. In the end, a diabetes lifestyle is a healthy lifestyle that everyone should be following.

Being afraid of diabetes is going to be an obstacle to managing it well. Seek to understand more about the disease, its complications and how it can be managed, and you’ll find yourself walking briskly into your doctor’s office laughing at how unfounded your initial fears really were.  

Dr Paula Diab

MEET THE EXPERT

Dr Paula Diab is a diabetologist at Atrium Lifestyle Centre and is an extra-ordinary lecturer, Dept of Family Medicine, University of Pretoria.

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