Category: 2024

The merits of good diabetic nutrition

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We learn about the six must-have foods for good diabetic nutrition and when to add a nutritional supplement to fill any nutrient gaps.

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Defining good diabetic nutrition

As a person living with diabetes, you may feel overwhelmed with all the things you need to do to manage your health. Good nutrition can assist to manage symptoms of diabetes that you may experience, such as weight loss, feeling very hungry and tired, sores that heal slowly, and having more infections than usual.1

Nutrition is also an important part of a healthy lifestyle to help keep your blood glucose level in your target range. Nutrient requirements for people living with diabetes are likely to be higher than those set for people who don’t have diabetes. This is due to the following:

  • People with diabetes are prone to deficiencies in magnesium and zinc.2,3.
  • Some medications used to treat diabetes can result in increased nutrient requirements.2,3.
  • Nutrition therapy is critical in the management of diabetes to ensure the maintenance of correct blood glucose levels.2,3.

Eating healthy foods in the right amounts at the right times so your blood glucose stays in your target range as much as possible is key. It’s also important to eat foods that helps prevent diabetes complications like heart disease.

Figuring out the best foods to eat when you have diabetes doesn’t have to be tough and you can also include a nutritional supplement to make sure you’re filling any nutrient gaps.

Some of the best foods for people with diabetes are high in protein and low in sugar like avocados (consume in moderation) and grilled fatty fish.

The must-have super six

The following foods can help manage your blood glucose levels:

  1. Fatty fish like salmon and sardines are great sources of omega-3 fatty acids, which have major benefits for heart health.
  2. Leafy greens are low in digestible carbs.
  3. Avocados have less than a gram of sugar, few carbohydrates, a high fibre content and healthy fats.
  4. Chai seeds are extremely high in fibre which reduces hunger. They are also low in digestible carbs.
  5. Beans are rich in B vitamins, beneficial minerals (calcium, magnesium, potassium) and fibre.
  6. Broccoli contains only 3g of digestible carbs.4

Adding a nutritional supplement

If you’re considering using any supplements if you have diabetes, it’s important to get nutritional advice from your healthcare professional prior to using anything.

More than likely, once you have gotten the go-ahead from your healthcare professional, you may choose a nutritional supplement on the merit of the scientific facts of the product as well as what others have to say about it.

For this reason, here are all the beneficial facts of adding LIFEGAINÂź Advanced Nutritional Supplement to your diet as well as patient testimonials.

LIFEGAINÂź Advanced Nutritional Supplement is scientifically formulated to offer beyond everyday nutrition that can support chronic illness. The Triple Protein Formula in LIFEGAINÂź can help you to feel fuller for longer and assist with recovery of muscle tissue and a healthy weight.

The LifegainÂź formula:

  • High in energy, protein, and omega-3 fatty acids.
  • 24 minerals and vitamins, several being key for immune support.
  • High in iron and zinc.
  • Contains fibre.
  • Trans fat-, gluten-, lactose-, and cholesterol-free.
  • Low in carbs (no refined carbs).
  • No added sugar.

Patient testimonials

Monique Mentoor

(On behalf of her dad)

My dad’s health was deteriorating fast in October 2019. He is a diabetic and hypertension sufferer and has had two transient ischaemic attacks due to not managing these illnesses. He was constantly tired, and his quality of life was so poor as he was sleeping all the time. I insisted he come live with me and offered only nutritious meals and added LIFEGAIN¼ Advanced Nutrition Supplement to his diet – and I believe this was the perfect compliment.

Within weeks there was a noticeable difference in his health and the lethargy was improving too. Throughout the lockdown my dad continued taking his LIFEGAIN¼ Advanced Nutrition Supplement and he has not looked or felt better in years. ​

Tebogo Maesela

(Caregiver of his father who has diabetes)

I love LifegainÂź Advanced Nutrition Supplement vanilla flavour. I currently use LifegainÂź to boost my body and support my immune system.

My father is a diabetic patient, and he uses Lifegain¼ to boost his immune system. My journey with Lifegain¼ started two years back when my father was very sick, he was losing weight and he couldn’t eat anything. At that moment we thought that we were losing him. His body was small and frail. Then a family friend suggested that we buy Lifegain¼ supplement for my father. We did, and he started to eat again, and regained energy. Since that day Lifegain¼ has been our supplement.

References

  1. Diabetes Symptoms.2022 Dec 30. Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/diabetes/basics/symptoms.html
  2. Walker, A.F., 2007. Potential micronutrient deficiency lacks recognition in diabetes.
  3. https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-physical-activity. Accessed: 05/08/2020.
  4. Kelly E. Diet for People Living with Diabetes: The Best Foods to Choose and More. 2023 Feb 23. Healthline.com Available from: https://www.healthline.com/nutrition/16-best-foods-for-diabetics      
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salad

Is your salad even healthy?

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Estée van Lingen explores the hidden truths behind your greens and what can make a healthy salad become a dietary disaster.

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Salads are often considered the epitome of healthy eating. Whether you’re trying to lose weight, boost your nutrient intake, or adopt a more plant-based diet, salads seem like the perfect choice.

However, not all salads are as healthy as they seem. Despite being packed with leafy greens, they can quickly become energy dense or nutrient-deficient due to common add-ons and poor ingredient choices. So, is your salad really as healthy as you think?

  1. The base: Choose your greens wisely

The foundation of any salad is the greens. Leafy greens are rich in vitamins, minerals, and fibre. However, the type of green you choose makes a difference in your salad’s nutritional value.

Dark leafy greens like spinach, baby spinach or kale are packed with nutrients like vitamin C, vitamin K, and iron. On the other hand, iceberg lettuce, while low in kilojoules, offers little nutritional value compared to these nutrient-dense options.

Many pre-made salad kits may use iceberg lettuce as a base, which can lead to a false sense of nutritional security. For a truly healthy salad, opt for a variety of dark, leafy greens.

Mixing different types of greens, such as romaine, Swiss chard, and baby spinach, can enhance both flavour and nutritional diversity.

  1. Protein add-ons

Adding protein to your salad is a great way to make it more filling and balanced, but the type and preparation of protein matters. Grilled chicken, hard-boiled eggs, beans, and tofu are healthy protein options that provide necessary nutrients without excessive kilojoules or unhealthy fats.

However, many people opt for processed meats like bacon bits, fried chicken strips, or deli meats, which can increase sodium, fat, and preservatives in your salad. Additionally, adding high-fat cheeses like cheddar or blue cheese may add unnecessary saturated fats and kilojoules.

If you’re looking for a plant-based protein, chickpeas, lentils, and quinoa are excellent choices that bring both protein and fibre to the table.

When choosing proteins for your salad, focus on whole, minimally processed options, and avoid those that are breaded, fried, or heavily processed.

  1. Watch out for dressings

One of the biggest culprits in turning a healthy salad into an energy bomb is the dressing. Creamy dressings, such as Ranch, Caesar, and Blue cheese are typically high in fat, kilojoules, and added sugars. A seemingly small portion can add hundreds of kilojoules to your salad.

Even vinaigrettes, which are often perceived as healthier, can contain added sugars and preservatives.

The best approach is to make your own dressing using simple ingredients like olive oil, vinegar, lemon juice, and herbs. Olive oil provides healthy fats, while vinegar and lemon juice add flavour without the extra kilojoules.

If you prefer store-bought options, look for dressings with simple ingredients, minimal sugar, and healthy fats. Be mindful of portion sizes (especially when using oils e.g. olive oil); a little dressing can go a long way.

  1. Be cautious with toppings

Toppings can take your salad from healthy to indulgent quickly. Croutons, fried onions, candied nuts, and tortilla strips may add crunch and flavour, but they also come with unhealthy fats, refined carbs, and sugar. These additions can significantly increase your salad’s kilojoule count without providing much nutritional value.

Instead, opt for nutrient-dense toppings that still provide texture and flavour. Seeds like sunflower or pumpkin seeds add healthy fats, protein, and a satisfying crunch. Nuts like almonds and walnuts are also great but stick to raw or dry-roasted varieties to avoid added oils or sugars. Fresh fruits, such as berries or apple slices, can also add natural sweetness without the sugar spike of dried fruits or sweetened toppings.

While avocado can also be a healthy topping, it still remains a fat and the portion needs to be controlled.

  1. Portion control: Bigger isn’t always better

Salads are often viewed as free foods because of their low-kilojoule content. However, this perception can lead to overeating. If you’re adding energy-dense ingredients like cheese, nuts, and dressing, even a salad can surpass your daily kilojoule needs.

Healthy options can also include adding butternut, corn, baby potatoes, or grains into the salad and in these cases, portions need to be monitored even more so.

Being mindful of portion sizes is crucial. Stick to moderate amounts of high-kilojoule ingredients and make your salad filling by focusing on vegetables, lean proteins, and fibre-rich grains. A well-proportioned salad should leave you satisfied but not stuffed.

  1. Nutrient balance: More than just greens

A healthy salad is more than just a bowl of greens. To create a balanced meal, make sure your salad includes a good mix of macronutrients (protein, fats, and carbohydrates) and micronutrients (vitamins and minerals).

Vegetables like bell peppers, carrots, cucumbers, beetroot and tomatoes add colour, crunch, and vitamins, while whole grains like quinoa or barley provide fibre and energy-sustaining carbohydrates.

Pasta and potato salads are not real salads but just another form of a starch-based dish. So, don’t eat a whole plate of potato salad and say you had your salad for the day.

Healthy fats from sources like avocado, nuts, or olive oil help with nutrient absorption and provide satiety. By including a variety of colours and food groups, you can ensure your salad is both nutritious and satisfying.

Not all salads are created equal

While the idea of eating a salad may sound inherently healthy, it’s essential to be mindful of the ingredients and portions you choose. Rather make your own salads compared to buying ready-made salads. Start with a base of nutrient-dense greens, opt for lean proteins and healthy fats, and be cautious with dressings and toppings.

With thoughtful ingredient choices, your salad can be the nutrient-packed, wholesome meal it’s meant to be—without hidden kilojoules and unhealthy surprises. Remember, a healthy salad is all about balance and moderation. By making smart choices, you can ensure that your salad truly supports your health goals.

EstĂ©e van Lingen is a registered dietitian practicing in Randburg and Fourways, Gauteng. She has been in private practice since 2014 and is registered with the HPCSA as well as ADSA and served on the ADSA Gauteng South Committee for 2020 – 2022.

MEET THE EXPERT

EstĂ©e van Lingen is a registered dietitian practicing in Randburg and Fourways, Gauteng. She has been in private practice since 2014 and is registered with the HPCSA as well as ADSA and served on the ADSA Gauteng South Committee for 2020 – 2022.

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Desre Williams - My prediabetes diagnosis

Desre Williams – Newly diagnosed with Type 2 diabetes

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Desre Williams was diagnosed with Type 2 diabetes six months ago. She shares how she is adopting a new lifestyle and processing the diagnosis.  

Listen to this article below or wherever you get your podcasts or visit our playlist.

Desre Williams (57) lives in Randburg, Gauteng. She has two adult children.

Desre wasn’t feeling at her optimal health for a while so she went to see her doctor. “I was always feeling dizzy and otherwise, it’s hard to explain but you know you just don’t feel yourself, brain fog, swollen ankles,” she explains.

“My blood pressure was extremely high. My doctor did a full blood count and then checked my blood glucose. When I did my fasting glucose test, my first reading was high but not out of the park, but once I did the test after the two-hour glucose test, my readings were sky high and thus the diagnosis began.”

After trying a few different oral medications, Desre and her doctor were happy with the impact of gliclazide. “Thankfully, I’ve had very few side effects on this medication, but my body does protest when I eat badly,” explains Des.

Overcoming the shock

Even though Desre says she hasn’t been healthy in a while, the diagnosis of Type 2 diabetes still came as a suprise. “I think I knew something was bound to happen, maybe not diabetes but my body was starting to feel like it was shutting down,” she says.

Before her diagnosis, Desre says she had a fair bit of knowledge on diabetes as a close friend was diagnosed a few years back with Type 2 diabetes. “He went through a very difficult time and nearly lost his life twice, and has had his leg amputated below the knee, all caused from the complications of diabetes.”

Adopting a new lifestyle

Desre consulted with a dietitian and was put on a special diet. “I also have a thyroid problem, so I was taken off dairy and now consume lactose-free foods. I still have a way to go with eating, and exercise which is so difficult to get into. Every day you learn something new and how to handle the situation. I’ve had to learn about eating regular meals and how to react when my blood glucose drops very low. It wasn’t a nice experience at all. But I will persevere; I don’t want it to progress or have to use insulin,” Desre says confidently.

For now, Desre has three-monthly check-ups with her doctor. “Once she is happy that I have stabilised then I will only see her every six months.”

Des is happy with how she is managing her blood glucose levels. “I check it before every meal and then two hours after. If I see it’s higher than it should be, then I make a note of what I’ve eaten and change it,” she says.

Support

Thankfully, Desre’s family have been really good in supporting her in this journey and help her where they can. “I read material on the subject but haven’t as yet joined any support groups, but I’m sure as time goes on and things change, I will,” she says.

The fact that the diabetes nurse educator is always at the doctor’s room and just a phone call away gives Desre peace of mind.

Desre adds, “I’ve told my colleagues and bosses and they have been super supportive. My very close friends (colleagues) watch me like a hawk and give me a mouth full if I stray.”

Festive season strategy

When asked if she has a festive season strategy in place with all the family feasting, Desre responds, “My family understands, and I have to be disciplined with all the yummy foods. Luckily, we don’t usually have a very big Christmas and this year the kids and their partners will be away, so a very small Christmas this year.”

Walking for a cause

Desre hopes to start taking part in walks for good causes once she gets into the flow of her exercise regime. Even though she is not a fan of summer (the heat and her aren’t the best of friends) she does love the early sunrises and enjoys taking in the early mornings.

Her advice is, “It’s important to be aware of your health. When something doesn’t feel right, check it out. Whatever it is, if it’s caught earlier enough, there is a good chance of preventing it from getting to the next stage. Like any disease, don’t ignore the warning signs, and most of all, don’t take life for granted.”

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

MEET THE 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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well-being

Embracing well-being in diabetes management

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Bianca Tromp, a dietitian who is part of the FUTURELIFEŸ dietetics team, highlights what diabetes and well-being is all about.

World Diabetes Day was observed on 14 November. The theme Diabetes and well-being celebrates the strides that have been made in the management of diabetes.

Diabetes, once viewed as a life-threatening disease, is now seen as a manageable condition and people living with diabetes can continue to live fulfilling, healthy lives thanks to science and technology offering appropriate care and support.

In the past, diabetes management revolved around medication and controlling blood glucose levels. Now, it’s clear that a holistic approach is vital to ensure optimal health and well-being for those with diabetes.

Nutrition and lifestyle factors play a major role in managing diabetes, but the importance of mental health in this journey can’t be forgotten. Mental health has become crucial to the management of diabetes.

Managing diet

Dietary intervention plays a major role in managing diabetes effectively. Eating habits in diabetes are not just about avoiding sugar; they’re about creating nutritious, well-rounded meals that stabilise blood glucose levels while providing the body with all the nourishment it needs.

Plainly said, a diabetic-friendly diet is a diet all individuals, with or without diabetes, should strive to follow as the nutritional principles of are beneficial for all.

However, managing your diet can be tricky and when it comes to diabetes, one size does not fit all. A registered dietitian can offer invaluable support. To find a dietitian in your area, visit the Association for Dietetics in South Africa (ADSA).

Dietary principles for those living with diabetes

  1. Choose low-glycaemic index (GI) foods and meals

Low-GI foods are carbohydrate-containing foods that are digested and absorbed slowly, causing a gradual rise in blood glucose levels resulting in a lower peak and providing sustained energy for a longer period of time. Examples are low-GI bread, whole grains, most vegetables, some fruit, legumes, and beans.

  1. Count carbohydrates

Meal planning and education about carbohydrate counting can further empower you to make informed choices. Carb counting is all about portion size and spreading carbohydrates throughout all meals. This will ensure that each meal does not contain excessive amounts of carbohydrates that can cause a spike in blood glucose levels. Generally, the rule of nines apply: dividing the daily carbohydrate allowance by 9 and then including 2/9 for breakfast, lunch, and dinner while including 1/9 for snacks three times a day.

  1. Include protein and/or a healthy fat in each meal and snack

Protein and fat take longer to digest than carbohydrates, therefore the GI of a meal can be reduced by adding a lean protein or healthy fat. Adding peanut butter (protein and fat) to a sandwich would lower the GI of the bread for example. Another example would be having an egg (protein) on toast to lower the GI of the meal.

  1. Reduce saturated fats while increasing unsaturated fat

Saturated fats, mostly from animal origin, can reduce insulin sensitivity. Include healthy fats like avocados, nuts, and seeds.

Managing lifestyle

In addition to diet, a healthy lifestyle can greatly improve the health and quality of life of people living with diabetes. Lifestyle choices play an essential role in diabetes management. Regular physical activity helps maintain a healthy weight, improves insulin sensitivity, and can lower blood glucose levels. The American Diabetes Association recommends at least 150 minutes of moderate aerobic activity each week, alongside strength training exercises.

Limiting tobacco use and alcohol consumption can also greatly improve blood glucose levels.

Furthermore, establishing a routine that includes regular exercise, sleep hygiene, and stress management techniques not only improve diabetes management but also contributes to overall well-being.

A supportive community, whether through family, friends, or local support groups, can also significantly impact motivation and encouragement. 

Managing mental health

Mental health is often overlooked in diabetes care, yet it’s a critical component of overall well-being. Research shows that 36% of people with diabetes experience diabetes distress (feelings of frustration, fear, and burnout associated with managing the condition).

Sixty-three percent report that this fear negatively affects their quality of life. Additionally, 28% find it challenging to maintain a positive outlook. Yet, by adopting an active and informed approach to managing their condition, people living with diabetes can regain a sense of control and empowerment, significantly reducing these fears.

Breaking the stigma surrounding mental health is essential. Everyone should feel empowered to reach out for help from mental health professionals, who can provide coping strategies and support. Techniques, such as mindfulness, cognitive-behavioural therapy, and peer support, can help navigate the emotional landscape of living with diabetes. It’s important to remember that seeking help is a sign of strength, not weakness. By addressing mental health, you can foster resilience and a more positive relationship with your diabetes, enhancing their overall quality of life.

Diabetes South Africa has a list of available support groups in South Africa. To view the list and find a support group close to you, click on the following link: DSA Support Group Directory

Seek expertise

Following the advice of medical professionals is fundamental in managing diabetes. Ensure you attend regular follow-ups with your healthcare team while following advice and taking medication as prescribed. To find a healthcare professional within the field of dietetics, you can visit the Centre of Diabetes and Endocrinology (CDE) website.

WHERE DOES FUTURELIFEÂź FIT IN?

Although many of the FUTURELIFEÂź products have a low-GI and are therefore suitable for people living with diabetes, two products are specifically endorsed by Diabetes South Africa and by The GI Foundation of South Africa as an often food for people living with diabetes.

These products are FUTURELIFE¼ Smart foodℱ ZERO and FUTURELIFE¼ Smart foodℱ ZERO with Oats. Both these products are high in protein, energy, fibre, vitamins, and minerals while containing no added cane sugar. They are sweetened with erythritol and sucralose to ensure you get the tasty goodness you have come to know from FUTURELIFE¼.

Our hope

Let’s shift the narrative around diabetes from one of fear to one of empowerment. With a holistic approach including diet, lifestyle, and mental health, diabetes can be managed effectively and those living with diabetes can live healthy, fulfilling lives.

By prioritising well-being and breaking the stigma around mental health, we can create a supportive environment where those with diabetes feel empowered to live their best lives. Together, let’s celebrate progress, promote awareness, and advocate for comprehensive care for those living with diabetes.

References

  1. Diabetes UK. diabetes.org.uk
  2. Diabetes Asia. diabetesasia.org
  3. International diabetes federation. worlddiabetesday.org
  4. The American Diabetes Association. diabetes.org

For more information on the product used in this recipe visit: futurelife.co.za

Label lingo

Learning label lingo

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Christine Manga, a diabetes nurse educator, upskills your label lingo so you know what to look out for when buying food items.

Listen to this article below or wherever you get your podcasts or visit our playlist.

Look familiar? Sugar-free, low-fat, healthy, lite, natural, low kilojoule, free range, and the list goes on. This is just on the front of food packages then there is a mound of information on the back as well.

Companies use these slogans and phrases to make you believe that their food is healthy, better than other brands, good for you, and will give you everlasting energy. It’s called marketing. A number of these claims have some truth in them but can be very misleading, confusing, and have even been known to be unsubstantiated. Do not rely on the front of the package only. The back nutritional label and ingredient list are far more informative.

Why is it important to be able to read and understand food labels?

Well, labels give information allowing you to make informed, healthier food choices that will impact not only on glucose management but weight, cholesterol, and overall health. It empowers you, the consumer.

Nutritional label and ingredients

One of the main nutrients people living with diabetes need to be aware of is carbohydrates. These are the nutrients that cause elevation of blood glucose levels. This is not a bad thing. A carbohydrate (carb) is a sugar molecule made-up of starch, sugar, and fibre. These will be converted into glucose as energy for the body.

Fibre is a non-digestible carbohydrate and therefore has no effect on blood glucose levels. As a matter of fact, if the fibre content is >5grams this can be subtracted from the total carbohydrate amount. The more fibre, the better. It’s the total amount of glycaemic carbohydrates/carbohydrates to be considered when making food choices, not the sugar content.

Key pointers

Whilst perusing the nutrition label and ingredients there are key pointers to keep an eye on.

Serving size

On a nutrition label, there are usually two columns showing nutritional information, one for 100g and one for an individual serving of the product. The product package size is not necessarily the serving size. If a package says low kilojoule, it may be because the serving size listed is very small and unlikely that someone would only have a single serving.

As a South African, you surely know Romany Cream biscuits. The serving size is two biscuits. There are very few people I know who only have two biscuits. The small jelly sweets or gums sold in 75g bags are in fact three servings of 25g each. So, in future, please remember the packet should be spread over three days.

A certain South African brand of flavoured water contains 4g of carbohydrates per 100ml and 62,76kJ. That means 20g of carbohydrates and 313.8kJ per bottle of water.

The label may list that you will be eating a certain percentage of a daily recommended amount of nutrients or kilojoules based on an 8368kJ diet. Remember to multiply by number of servings. Not everyone should be consuming 8368kJ a day.

Ingredients

Ingredients are listed in descending order by weight, meaning the first ingredient is the largest amount of the product. Some foods have a boundless list of ingredients.

It’s safe to say, the fewer ingredients, the more natural and less modified a food is. If a product claims to be whole wheat, then whole wheat must be the first ingredient listed. Anything on the ingredient list means it has been added in the production of the food item.

“Sweets for my sweet, sugar for my honey” come in many disguises. Sucrose, corn syrup, fructose, maple syrup, molasses, and nectar are all forms of sugar. The list of sugars is endless. The names of many sugars end in -ose.

Caffeine can also be masked in the ingredient list. Guarana commonly used in energy drinks is high in caffeine, but it’s not always added to the total caffeine amount.

Ingredients necessary to give colour, thickness, anti-caking agents, gelling, and preservatives are some food additives categorised by E numbers. E249 – E250 indicate the use of nitrites. The less of these consumed, the better.

Substitutes

Manufacturers want their food to taste good and appear healthy. This can be done by using substitutes so that the labels low-fat or sugar-free can be used. These claims may be true, but to replace the sugar and fat, other ingredients are added to maintain flavour, very often salt or sugar (to low-fat).

Checking salt (Na) is important as this should be avoided in people with hypertension. Sugar substitutes and artificial sweeteners have been linked to an increase in appetite in some studies. This defeats the object.

Laws

International laws are changing to make labels more user friendly and less misleading. Traffic light colour coding is currently used in the UK. Red means high, amber means medium, and green means low. These are for fat, saturated fat, sugar, and salt. This system allows you to see at a glance which is a healthier option. Helpful for people with low numeracy and literacy

In 2023, the South African Department of Health drafted new restrictions on food marketing, food labelling, and health claims on packaged food and drink. Hopefully, it will be law soon. In our multi-cultural country with eleven official languages, it’s sad that our food labels are written in English only.

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

MEET THE EXPERT

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

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fibre

The power of fibre in diabetic management

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Retha Harmse explores how fibre influences blood glucose, its benefits for people with diabetes, and practical tips for integrating fibre-rich foods into everyday meals.

Listen to this article below or wherever you get your podcasts or visit our playlist.

Understanding fibre

Fibre, found in plant-based foods, comes in two main types: soluble and insoluble.

Soluble fibre

  • Soluble fibre dissolves in water to form a gel-like substance in the digestive tract.
  • This type of fibre is known for its ability to absorb water, slow down digestion, and help regulate blood glucose levels.
  • Common sources include oats, barley, legumes (beans and lentils), fruits (apples, oranges, and berries), and some vegetables (Brussels sprouts and carrots).

Insoluble fibre

  • Insoluble fibre doesn’t dissolve in water and remains relatively unchanged as it passes through the digestive system.
  • It adds bulk to stools and promotes regular bowel movements, aiding in the prevention of constipation and supporting overall gut health.
  • Foods rich in insoluble fibre include whole grains (wheat, brown rice, and quinoa), nuts, seeds, vegetables (broccoli, cauliflower, and dark leafy greens), and the skins of fruits.

Both types of fibre are essential for optimal health and should be included in a balanced diet. While soluble fibre primarily influences blood glucose regulation, insoluble fibre contributes to digestive health and bowel regularity.

Fibre’s impact on blood glucose

Understanding the intricate relationship between fibre intake and blood glucose levels is essential for effective diabetes management. Fibre influences blood glucose levels through various mechanisms, primarily attributed to its impact on digestion, carbohydrate absorption, and satiety.

  1. Mechanism of action

  • Fibre-rich foods, particularly those containing soluble fibre, alter the digestion and absorption of carbohydrates in the gastrointestinal tract.
  • Unlike simple carbohydrates that are rapidly broken down into glucose and absorbed into the bloodstream, fibre slows down this process, resulting in a gradual and steady release of glucose into the bloodstream.

  1. Soluble fibre’s role in blood glucose regulation

  • Soluble fibre forms a gel-like substance when combined with water in the digestive tract.
  • This gel slows down the digestion of carbohydrates, leading to a slower release of glucose into the bloodstream.
  • Consequently, soluble fibre helps prevent rapid spikes in blood glucose levels after meals, promoting more stable and controlled glycaemic responses.
  • Foods high in soluble fibre (oats, legumes, and certain fruits) are particularly beneficial for people with diabetes in managing postprandial glucose levels.

  1. Impact of insoluble fibre on satiety and carbohydrate intake

  • Insoluble fibre adds bulk to the diet and promotes feelings of fullness and satiety, which can help regulate appetite and reduce overall food intake.
  • By increasing satiety, insoluble fibre may indirectly influence blood glucose levels by moderating carbohydrate consumption.
  • Additionally, insoluble fibre contributes to digestive health and regular bowel movements, which are crucial for overall well-being.

Benefits for people with diabetes

Fibre-rich foods offer numerous advantages for people with diabetes, playing a critical role in managing blood glucose levels, enhancing insulin sensitivity, and supporting weight management.

Understanding these benefits can empower you to make informed dietary choices and optimise your diabetes management strategies.

  1. Regulation of blood sugar levels

  • One of the primary benefits of fibre is its ability to regulate blood glucose levels, particularly after meals.
  • By slowing down the digestion and absorption of carbohydrates, soluble fibre helps prevent rapid spikes in blood glucose levels following meals.
  • This controlled release of glucose into the bloodstream supports more stable and consistent glycaemic responses, reducing the risk of hyperglycaemia and its associated complications.

  1. Improved insulin sensitivity

  • Research has shown that fibre intake may enhance insulin sensitivity, a key factor in diabetes management.
  • Insulin sensitivity refers to the body’s ability to respond effectively to insulin, the hormone responsible for regulating blood glucose levels.
  • Fibre-rich diets have been associated with improved insulin sensitivity, potentially reducing the body’s reliance on exogenous insulin or other diabetes medications.
  • By promoting better insulin sensitivity, fibre can help you achieve better glycaemic control and reduce your risk of insulin resistance-related complications.

  1. Management of weight

  • Weight management is a crucial aspect of diabetes control, as excess body weight can exacerbate insulin resistance and increase the risk of complications.
  • Fibre-rich foods, particularly those high in insoluble fibre, contribute to feelings of fullness and satiety, which can help control appetite and reduce overall calorie intake.
  • Additionally, fibre-rich diets are often lower in energy density and higher in nutrient density, making them conducive to weight management and overall health.
  • By promoting satiety and reducing kilojoule intake, fibre-rich foods can support weight loss or weight maintenance goals, which is essential for optimal diabetes control and prevention of related complications.

Recommended intake and practical tips

The American Diabetes Association recommends daily fibre intake of 25 grams for women and 38 grams for men. Achieving this goal involves incorporating fibre-rich foods like whole grains, fruits, vegetables, legumes, nuts, and seeds into meals and snacks.

Practical tips for increasing fibre intake

  • Incorporate fibre-rich foods into meals and snacks. Choose whole grains, fruits, vegetables, legumes, nuts, and seeds as primary sources of dietary fibre. Aim to include a variety of these foods in your daily meals to ensure adequate fibre intake.
  • Start the day with a fibre-rich breakfast. Opt for whole grain cereals, oatmeal, or smoothies with added fruits and vegetables to kickstart your day with a fibre boost.
  • Choose whole grains over refined grains. Replace refined grains with whole grains (brown rice, quinoa, barley, and whole wheat bread) to increase your fibre intake while also benefiting from additional nutrients.
  • Snack on fibre-rich options. Keep snacks like fresh fruits, raw vegetables, nuts, and seeds on hand for convenient and nutritious fibre-rich snacking options.
  • Experiment with plant-based meals. Incorporate meatless meals centred around beans, lentils, tofu, or other plant-based proteins to increase your fibre intake while also reducing saturated fat and cholesterol intake.
  • Read food labels. Pay attention to food labels and choose products that are high in fibre. Look for whole grain products with at least 6 grams of fibre per 100g.

Best fibre-rich foods for people with diabetes

Whole grains, fruits, vegetables, legumes, nuts, and seeds are excellent sources of fibre. Incorporating these foods into daily meals and snacks can help meet fibre intake goals and support blood glucose management.

Incorporation tips

  • Substitute refined grains with whole grain options in meals such as sandwiches, wraps, salads, and side dishes.
  • Enjoy fruits as snacks, add them to breakfast cereals, yoghurt, or smoothies, or incorporate them into salads and desserts.
  • Include vegetables in meals and snacks by adding them to soups, stir-fries, salads, omelettes, or enjoying them as raw veggie sticks with hummus or yoghurt dip.
  • Use legumes as the main ingredient in soups, stews, chilli, salads, or veggie burgers, or enjoy them as a side dish or snack.
  • Add nuts and seeds to oatmeal, yoghurt, salads, or smoothies, or enjoy them as a standalone snack.

Meal planning tips

Meal planning is crucial for optimising fibre intake and managing diabetes effectively. Sample meal plans featuring fibre-rich foods are outlined, along with strategies for making healthier food choices. Tips include choosing whole grains, loading up on vegetables, including legumes, snacking wisely, reading labels, and staying hydrated.

  1. Choose whole grains: Opt for whole grain varieties of bread, pasta, rice, and cereal to increase fibre intake and promote satiety.
  2. Load up on vegetables: Incorporate a variety of colourful vegetables into meals and snacks to boost fibre content and add essential nutrients.
  3. Include legumes: Add beans, lentils, and chickpeas to soups, salads, and main dishes for a hearty dose of fibre, protein, and minerals.
  4. Snack wisely: Choose fibre-rich snacks such as fresh fruit, raw vegetables with hummus, Greek yoghurt with nuts and seeds, or whole grain crackers with cheese.
  5. Read labels: Check food labels for fibre content and choose products with higher fibre content per serving.
  6. Hydrate: Drink plenty of water throughout the day to support digestive health and aid in the movement of fibre through the digestive tract.

Precautions and considerations

While increasing fibre intake offers numerous health benefits, precautions should be taken, especially if you have diabetes. Gradually increasing fibre intake, monitoring for gastrointestinal side effects, discussing fibre supplements with healthcare providers, monitoring blood glucose levels, and adopting an individualized approach are essential considerations.

Fibre for the win

Fibre plays a crucial role in managing blood glucose levels in people with diabetes. By understanding the impact of fibre on blood glucose, incorporating fibre-rich foods into the diet, and following practical tips for meal planning, you can take control of your diabetes and improve your overall health and well-being.

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 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.

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Semaglutide

Semaglutide: everything you need to know

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Dr Marius Wasserfall looks at semaglutide, the so-called wonder drug for weight loss and, more importantly, the safety for those without diabetes.

Listen to this article below or wherever you get your podcasts or visit our playlist.

As more South Africans turn to medical interventions for weight loss, semaglutide (originally developed as a treatment for Type 2 diabetes) has gained rapid recognition.

Semaglutide can be a valuable adjunct to lifestyle changes like diet and exercise. Though it’s not a silver bullet but can help patients battling obesity make real progress when combined with healthy habits.

Obesity is a growing concern worldwide, with predictions indicating that by 2030, half of the world’s population will be overweight or obese. In South Africa, this figure has already been reached, with more than 50% of adults classified as overweight or obese.

The challenge with obesity is complex. It involves not just will power, but changes in the brain’s appetite regulation and metabolic processes that make long-term weight loss difficult.

Semaglutide works by addressing this challenge at the root. It affects hunger and satiety hormones in the brain, helping people feel fuller for longer and reducing their appetite.

Glucagon-like peptide-1 receptor agonists

Semaglutide, which belongs to a class of drugs called Glucagon-like peptide-1 (GLP-1) receptor agonists, was only officially approved for treating Type 2 diabetes in 2017.

During clinical trials, however, a secondary effect became apparent during clinical trials: patients were experiencing significant weight loss. This discovery has led to semaglutide being prescribed off-label for weight management, although it’s not approved by the South African Health Products Regulatory Authority (SAHPRA) for this purpose. It remains a scheduled product and can only be sold by a pharmacy with a valid prescription from a doctor.

In 2021, the US Food and Drug Administration (FDA) approved a higher dose of semaglutide, specifically for chronic weight management in individuals with obesity or related health conditions. Since then, demand for semaglutide has skyrocketed, driven by glowing endorsements from celebrities and widespread attention on social media platforms.

Risks associated with non-approved purposes

While studies show that semaglutide users may experience up to 15% weight loss, experts warn of potential risks when it is used without medical supervision or non-approved purposes.

Side effects can include nausea, vomiting, and diarrhoea, and long-term safety for non-diabetic users remains unclear. While serious adverse effects are very seldom seen, they include acute pancreas inflammation and gallbladder problems. Some studies involving rodents found that this medication resulted in medullary cancer of the thyroid.

Counterfeit products

Additionally, there are growing concerns about counterfeit semaglutide entering the market. The high demand for the drug, especially for its off-label use, has exceeded forecasts and created opportunities for illegal manufacturers to supply counterfeit products.

When you purchase from an unlicensed manufacturer, there’s no quality assurance. The product may not contain the active ingredient or, worse, it may include harmful substances. Both the FDA and SAHPRA have issued warnings about the dangers of counterfeit versions of these medications.

Despite its effectiveness, there are also concerns about the long-term sustainability of weight loss achieved through semaglutide. Stopping the medication will likely result in the majority of the weight being regained. Studies back this up, showing that patients tend to regain most of the weight after discontinuing semaglutide or similar GLP-1 receptor agonists.

The reason for this lies in how these medications work. Semaglutide improves the brain’s regulation of appetite and alter the body’s biology. However, once you stop using it, your brain biology reverts to its previous state, and you will likely regain the weight.

Cost implications

Affordability is therefore a major factor. These medications are expensive, and many medical schemes will not cover them for weight management, only for diabetes.

This makes it essential for people considering semaglutide or similar drugs to weigh the costs carefully and recognise the commitment required to maintain results.

Availability is another concern. As demand grows among those seeking weight loss, shortage of the drug is making it difficult for people with diabetes, who rely on semaglutide to manage their condition, to access the medication. This has led to calls for caution and more stringent regulations to ensure the drug remains accessible for those who need it most.

Broader societal issue

Semaglutide’s popularity as a quick-fix weight loss solution highlights a broader societal issue: the pressure to conform to ideal body standards. Healthcare professionals stress that any weight-loss treatment should be approached with caution and always in consultation with a medical professional.

Medications like semaglutide are just one piece of the puzzle and weight management remains a multi-faceted issue that requires long-term lifestyle changes to achieve and maintain results.

While GLP-1 receptor agonists show promising results for weight loss, the focus should shift to prevention. We need to prioritise preventing obesity, especially in our youth, to reduce our reliance on costly, lifelong medications like semaglutide. Encouraging healthy habits is crucial. Ultimately, it comes down to this: you’ll face either the pain of self-discipline or the pain of regret; the choice is yours.

Dr Marius Wasserfall is a physician practicing at Mediclinic Panorama. He specialises in internal medicine, with a particular focus in cardiology and diabetes management.

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Dr Marius Wasserfall is a physician practicing at Mediclinic Panorama. He specialises in internal medicine, with a particular focus in cardiology and diabetes management.
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Whipple procedure

How does a Whipple procedure cause diabetes?

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Meagan Achteson, a dietitian, explains how diabetes develops after a Whipple procedure and offers guidelines to healthy eating thereafter.

Listen to this article below or wherever you get your podcasts or visit our playlist.

During a Whipple procedure (pancreaticoduodenectomy), the following are removed: part of the stomach, the small bowel (duodenum), the head of the pancreas, the lower end of the bile duct, and the gallbladder.

After these organs are removed, the surgeon attaches the remaining pancreas, bile duct, and stomach to the intestine. This allows pancreatic juice, bile, and food to flow back into the gut, so that digestion can happen normally.

This surgery normally lasts between four to eight hours. The procedure is used to completely remove pancreatic cancer and give you the best outcome. This lowers the chance of the cancer coming back. However, the chance of the cancer coming back also depends on the type of tumour that you have and stage of the cancer.

Type 3c diabetes

If you’ve had a Whipple procedure to remove pancreatic cancer, you’ll most likely develop Type 3c diabetes (a type of diabetes caused by damage to the pancreas that isn’t autoimmune which affects its ability to produce insulin).

You may also need to take pancreatic enzymes to digest food and insulin or oral medication to control your blood glucose levels.

After surgery, you’ll have to be on a fat-free diet for some time, but you’ll be able to gradually increase healthy fats. Talk to your surgeon and dietitian.

After you’ve recovered from surgery, you may find that your appetite improves and you start to put on weight and get stronger.

It’s recommended to adopt a healthy balanced diet that keeps your blood glucose level in your target range and helps keep you well.

Eating well with Type 3c diabetes 

The aim is to follow a diet that you enjoy that keeps your blood glucose levels stable. Please note: this advice is only for people who are a healthy weight.

  • Aim to have three meals a day with two snacks in between.
  • Don’t skip meals.
  • Cut out added sugars and avoid chocolates, biscuits, sweets, fruit juice, etc.
  • Aim to have at least two fruits and three portions of colourful vegetables a day.
  • When you use fat, use olive-, avocado oil, sugar-free nut butters rather than animal fats, such as butter, lard, or ghee.
  • Eat regular portions of oily fish. Aim for one to two portions each week.
  • Use small amounts of unsalted nuts and seeds as snacks or as part of a meal.
  • Have protein in each of your main meals. Food containing protein include beans, pulses, nuts, seeds, tofu, soya, meat, fish, dairy, and eggs. Eat fruits with a protein (like plain yoghurt) as a snack.
  • Read the nutritional information on packaged foods. Aim for foods that have low or medium levels of sugar, fat, and salt.
  • If you take pancreatic enzymes, make sure you take these when you eat.
  • If you take oral tablets or insulin to manage Type 3c diabetes, make sure you take these as recommended.
  • If you’re struggling with your weight, appetite or blood glucose levels, please see a registered dietitian as soon as possible to help with a meal plan that is individualised to you and your needs.

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Meagan Atcheson is a registered dietitian who focuses specifically in oncology. She is a plant-centric foodie who promotes a nourishing approach to health and wellness using evidence-based research and guidelines only.

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Type 2 diabetes remission

Want to know about Type 2 diabetes remission?

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Dr Angela Murphy looks at how Type 2 diabetes remission can be achieved and how anyone living with Type 2 diabetes can aim for this.

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Receiving a diagnosis of Type 2 diabetes can be distressing. It is a chronic condition that truly invades into daily life. The aim is to keep it controlled to prevent and avoid any future complications. Could you do even better than control? Could you, in fact, reverse Type 2 diabetes?

To achieve diabetes remission, or reversal, certain criteria need to be 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.

Classification of Type 2 diabetes

New research has suggested that there may be four subtypes of Type 2 diabetes. This is important to be aware of as it will influence attempts to reverse diabetes.

  1. Severe insulin-deficient diabetes (SIDD) – Diagnosed at a younger age, lower body mass index (BMI), and early need for insulin therapy.
  2. Severe insulin-resistant diabetes (SIRD) – Higher BMI and features of insulin resistance.
  3. Mild obesity-related diabetes (MOD) – Younger age at diagnosis with high BMI and moderate insulin resistance
  4. Mild age-related diabetes (MARD) – Older age with ‘mild’ diabetes in that very little medication is used to control glucose levels.

Interventions

Currently, interventions to achieve diabetes reversal are aimed at weight loss and kilojoule restriction. These interventions are not appropriate for the MARD person who may develop significant muscle loss and worsen overall health. The intervention may not be adequate for the SIDD who even with weight loss doesn’t have enough endogenous insulin production. However, most people with Type 2 diabetes are overweight or obese and will benefit. The accepted interventions are:

  1. Dietary

In 2011, the Counterpoint Study showed that extreme kilojoule restriction could normalise blood glucose levels in a group of people with Type 2 diabetes. The 11 study volunteers were given a liquid shake (Optifast – available in South Africa) and non-starchy vegetables totalling 2510,4kJ 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. All diabetes medications were stopped. 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 kilojoule-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’s the low carbohydrate intake per se or the associated overall drop in total kilojoules that produces the benefit. In my experience, I like patients to follow diets they prefer as reducing kilojoules is always hard work.

  1. Surgery

Bariatric surgery has been used to treat obesity for many years. The sleeve gastrectomy, Roux-en-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’s not entirely dependent on actual weight loss. The significant drop in kilojoules decreases the fat in the liver and pancreas, restoring normal function in these organs.

In addition, the levels of the gut hormone glucagon like peptide 1 (GLP-1) increase. 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.

Factors that predict diabetes remission include:

  • Age: Younger is more likely to experience remission.
  • Duration of diabetes: A shorter history of diabetes is more likely to experience remission.
  • Weight loss: Losing 10% or more of body weight in the year after diagnosis is a strong predictor of remission.
  • Baseline glucose control: A lower HbA1c at time when weight loss is started is a predictor of remission.
  • Baseline BMI: Higher baseline BMI is a predictor of remission.
  • Baseline medications: Less medications, particularly insulin, at baseline is a predictor of remission.
  • Triglyceride and gamma-glutamyl transferase levels (liver function tests): Lower baseline levels of these are predictors of remission.
  • Quality of life: Reporting better quality of life with less anxiety or depression is a predictor of remission.

Takeaway message

Not all people given a diagnosis of Type 2 diabetes will be able to achieve diabetes remission. This may be due to the subtype of diabetes or the difficulty succeeding with extreme dietary changes, significant weight loss, or access to bariatric surgery.

For some people with Type 2 diabetes aiming for remission is a realistic goal and they should be given the information and access to care they need to achieve this.

Bariatric surgery offers an excellent chance of diabetes reversal, but it’s expensive, and it requires specialised units not necessarily available in every area. Lifestyle intervention should be a simpler option, but the kilojoule restriction is significant and for many people difficult to sustain. This is where newer medications, such as the GLP-1 receptor agonists (liraglutide, dulaglutide, and semaglutide) and the soon to be available, dual action tirzepatide, may help in the long-term use of very low-kilojoule diets.

However, if weight is successfully lost and normal glucose levels achieved while using these medications, we can’t call this diabetes remission. For the exact diagnosis of remission, no medications can be used.

It’s realistic for some people with diabetes to aim for remission. However, it’s extremely beneficial also to aim for good diabetes control which then decreases the risk of diabetes complications.

It’s much more beneficial to achieve a low HbA1c 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.

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 is a specialist physician at Sunward Park Medical Centre. 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 19 years has shown her that knowledge is power.

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deep vein thrombosis

Preventing deep vein thrombosis

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Dr Louise Johnson explains the dangers of deep vein thrombosis (DVT) and advocates prevention is better than cure.

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DVT is a blood clot in a vein, usually in the leg and is a type of peripheral venous disease (PVD).

The earliest known reference to PVD (the broad term referring to disorders affecting the blood vessels carrying blood to and from the arms and legs) is found on the Eber Papyrus, which dates from 1550 BC.

In more detail, DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that returns blood to the heart. DVT is defined as the development of a thrombus within the deep veins of the pelvis or lower limbs.

The prevalence of DVT is reported to be 100 per 100 000 people per year.1 The incidence increase with age and the incidence is higher in men than in women.

Anatomy

The peripheral venous system functions both as a reservoir to hold extra blood and as a conduit to return blood from the periphery to the heart and lungs. Unlike arteries which possess three well-defined layers (a thin intima, a well-developed muscular media, and a fibrous adventitia), most veins are composed of a single tissue layer called endothelium. The lower limb deep venous system is typically thought of as two separate systems, one below the knee and one above.

Pathophysiology

In the 19th century, Rudolf Virchow described three factors that are critically important in the development of DVT.

  1. Venous stasis or sluggish blood flow
  2. Activation of blood coagulation
  3. Venous endothelial damage (vessel wall damage)

These factors have come to be known as the Virchow triad.

Risk factors

  • Age – The incidence of DVT increases with age and is very rare in childhood.
  • Orthopaedic surgery – DVT is more common in patients with lower limb fractures or after hip or knee replacement surgery.2
  • Trauma – Incidence of DVT is significantly higher in patients with lower extremity fractures than those with trauma at other sites. The homeostasis of coagulation shifts to a pro-thrombotic state early after trauma injury. Thus, it is necessary to give anti coagulation medicine early on in treatment. Patients with trauma have a six-fold increase in DVT.
  • Cancer
  • Other factors, such as:
    • Immobility (flights or trips sitting longer than six hours)
    • Pregnancy and postpartum
    • Varicose veins
    • Heart attacks
    • Renal impairment
    • Long hospitalisation
    • Obesity
    • Hormonal therapy

Clinical manifestations

History

Patients will complain about local pain and swelling in a limb. Usually, it’s only on one side. Tenderness occurs in 75% of patients. Associated risk factors may be present.

Clinical picture

  • Limb swelling
  • Homans sign (Calf pain when the foot is flexed upwards. It is only seen in 50% of all DVT patients).
  • The lower limb may have a red purple colour due to venous obstruction.
  • A palpable, indurated, cordlike, tender subcutaneous venous segment.

Diagnosis

The American Academy of Family Physicians (AAFP) recommend a workup of patients with a probable DVT using the Wells scoring system. A Wells score of more than two has a high probability of a DVT.

Wells scoring system

Active cancer within six months +1

Immobilisation of lower limb in cast +1

Localised tenderness of venous system +1

Unilateral swelling of leg +1

Calf swelling more than 3cm circumferential increase+1

Previous DVT +1

Recent bedridden >3 days or major surgery +1

Alternative diagnosis at least as likely as DVT -2

Tests

D-dimer is a test that is easily performed by a blood sample. D- dimer is a small protein present in blood after a clot is degraded. Serum levels of D-dimer may increase in clinical conditions where clots form, for instance surgery, trauma, cancer, sepsis and haemorrhage, particularly in hospitalised patients. Interestingly, these conditions are also correlated with greater risk of DVT.3

The level of D-dimer remains increased in patients with DVT for approximately seven days. Patients that present late in the disease course may have a low level. Solitary DVT in the calf with a low clot burden may have a low D-dimer. Although D-dimer can’t verify DVT diagnosis, it may be highly useful to rule out DVT.

Venous ultrasound is the primary imaging modality to diagnose DVT. It’s safe, non-invasive, and cheap. The sensitivity of compression ultrasound in diagnosing DVT is 94% and its specificity is 98%.

Differential diagnosis

Other conditions that can cause similar symptoms as a DVT that should be considered are:

  • Lymph node enlargement
  • Superficial hematomas
  • Femoral artery aneurism
  • Baker’s cyst
  • Superficial thrombophlebitis

Treatment

Left untreated, DVT can be complicated with pulmonary embolism (PE), which is a blockage in an artery of the lungs caused by a blood clot that has travelled from elsewhere in the body, at an early stage, and is associated with a high risk of recurrence.

Medical treatment

Low molecular weight heparin (LMWH) is recommended as an injection early in the diagnosis to stabilise the clot and prevent propagation of the clot and complications, such as pulmonary clots

Once intense anticoagulation is in place, the patient can be switched to either warfarin or to the newer drugs called non-vitamin K oral anticoagulants (NOACs). These drugs have less bleeding and is as effective as warfarin and need not be tested for dosing. Unfortunately, they are currently still expensive. There are three currently available in South Africa.

Other options

In patients with life-threatening clots, an inferior vena cava (IVC) filter can be inserted by a vascular surgeon.

In patients with massive iliofemoral thrombosis or limb-threatening thrombosis, thrombolysis (a procedure that breaks up blood clots using medication or a minimally invasive procedure) can be used. It has a risk of intracranial haemorrhage.

Prevention

The most important treatment of DVT is to always remember to take precautions to prevent it in the circumstances in which it may occur.

All patients admitted to hospital must be evaluated as a possible risk for a DVT.

Circumstances to consider

  1. Choose anaesthesia well. Spinal or epidural anaesthesia can enhance blood flow and reduce DVT by approximately 50%.
  2. Surgical technique. Meticulous operative skill with as little torsion of veins as possible to prevent endothelial vein damage. Choose surgeon wisely.
  3. This should be adopted as soon as possible after operation. Walking improves the blood flow of the veins. Remember bedrest is exercise for the coffin.
  4. Compression stockings. The below knee and above knee stockings have a similar effect if the stockings are well-fitted.
  5. Intermittent pneumatic compression. This device also referred to as calf pumps can facilitate post-operative blood flow when patients are bedbound.
  6. Chemical methods. Use either LMWH injections or a NOAC tablet as part of prevention.

Accurate and prompt diagnosis of DVT is necessary because thrombosis left untreated can cause life-threatening complications like PE. Remember, prevention is always better than cure in this instance.

References

  1. Al-Hameed F, Al-Dorzi HM et. al. “The Saudi clinical practice guideline for diagnosis of the first DVT of the lower extremity” Ann Thorac Med 2015;10 3-15
  2. Whiting PS, White-Dzuro GA et. al. “Risk factors for DVT following orthopedic trauma surgery: an anlysis of 56000 patients.” Arch Trauma Res 2016;5 e32915
  3. Adam SS, Key NS et. al.) “D-dimer antigen: current concepts and future prospects.” Blood 2009;113:2878-2887
  4. Osman AA, Weina J et. al. “Deep venous thrombosis: a literature review” Int J Clin Med,2018;11(3):1551
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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