Regular check-ups

Regular follow-up appointments with your healthcare team is important. It allows for timeous interventions when necessary and forms the basis of managing a chronic condition, such as diabetes. If any change or intensification of treatment is required, early implementation can delay the onset of diabetes complications. 

It’s also important to communicate with your healthcare team between appointments, this can lead to better outcomes. Confirm what forms of communication the practice uses: e-mail, phone calls or WhatsApp. 

Also ask about emergency contact details or hotline numbers.

Honest communication is important. Remember, these diabetes check-ups are confidential. If you feel that you’re unable to be completely honest, it may be worth considering changing practitioners. Keep an open mind and give input on your treatment plan.

What check-ups do you need to do?

Every three / six months

HbA1C (glycated haemoglobin) 

• Blood pressure

These can be done by your doctor or diabetes educator. The frequency of these check-ups will depend on how stable your diabetes is but may also be influenced by your medical aid reimbursement.

Once a year

Feet -This can be done by your doctor, diabetes educator or podiatrist.If you have cuts, bruises, or numbness in your feet the podiatrist is the ideal person to see. Otherwise see your general practitioner as soon as possible.

Eyes -This can be done either every year or every second year by your optometrist. Remember, this check-up is to look for any damage to blood vessels in your eyes which you’ll not know about. If you have any visual changes always seek advice immediately from your optician or doctor.

Cholesterol and kidneys – Blood and urine tests will assess kidney function and a fasting blood test will measure cholesterol levels.

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Wound care

When a person has diabetes, wounds can take longer to heal. High blood glucose affects both the immune system and the circulation. If the latter is not efficient, then nutrients aren’t delivered to the wound to promote repair of tissue. 

Wounds on the feet and legs impact on mobility. There is a risk that a minor cut or abrasion can develop into a larger ulcer and even affect bone. Osteomyelitis (infection of bone) is a serious condition requiring hospitalisation. Chronic (present for more than three months), poorly healing ulcers are painful and stressful to manage. The worst outcome is amputation, but good wound management should always prevent this.

Initial assessment of any wound on the feet should ideally be with your podiatrist, but if there is none available then please see your doctor. It may be necessary to send you to a specialist wound clinic and there is no doubt that over the long-term you’ll see better and quicker healing with less complications, such as the formation of excess scar tissue.

Prevention and treatment

  • Manage your blood glucose.
  • Clean any cut or abrasion thoroughly.
  • Practice good footcare.
  • See your doctor at once for a significant wound, a minor cut that looks infected (red and swollen, maybe with pus) or a wound of any kind that doesn’t heal in a few days.
  • Go for regular check-ups with a podiatrist.
  • Wash your feet daily, drying between the toes and moisturise well.
  • Inspect your feet daily.
  • Trim toenails carefully.
  • Don’t pull dry skin or shave callouses.
  • Wear good shoes.
  • Don’t walk barefoot.
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Monitoring blood glucose

Glucose, the simplest of all sugars, enters the bloodstream from two main sources: food and drink consumed and the liver. Your blood glucose levels will fluctuate throughout the day. There are various ways that you can measure your blood glucose.

Finger-prick measurement using a glucometer. This is how you find out what your blood glucose level is at that moment in time. It’s a snapshot. You’ll need these things to do the measurement:

1. A glucometer (glucose monitor). There are several brands on the market so it might be best to ask your healthcare team for advice on a glucometer that will suit you. Some have a larger display for people with impaired sight and others have sophisticated technology allowing you to upload glucose readings to a smartphone or computer. Remember many medical practices will be able to supply a glucometer free of charge. Always make sure that you get the correct strips to match the glucometer you’re using.

2. A finger-prick or lancing device which comes with the glucometer. These pierce the skin with a needle (lancet) so that a drop of blood can be taken for measurement. The depth of piercing can be adjusted by dialling numbers 1 to 5, with 1 being a very shallow and 5 the deepest. The thickness of your skin will determine what number to set. There is no set time to change the lancets but if pricking your finger becomes particularly painful then a new lancet is indicated. People with diabetes soon work out how often they prefer to change the lancet. To change the lancet, remove the cap from your finger-prick device and put in a new lancet usually by twisting and pushing in. Then put the cap back on. 

3. Glucose strips. These strips usually come in batches of 50 and must work with the type of meter you’ve chosen.

How to measure your blood glucose

  • Wash your hands with soap and warm water. Don’t use wet wipes or sanitiser as products in them can affect the result. Ensure your hands are warm so it’s easier to get blood thus reducing discomfort.

  • Take a strip, keeping the side with the bar code facing up, slot the barcode   end into the glucometer. 

  • The glucometer will now switch on and a display, usually a flashing drop of blood, will indicate it’s ready for the test.

  • Load the plunger of the pricking device by pulling the top of it backwards until a click is heard.

  • Choose which finger to prick but avoid your thumb and index finger. Try not to prick the middle of the finger pad, or too close to a nail. Place the flat end of the device against the side of your finger and press the release button (often white or yellow). Use a different finger or area of the finger for the next measurement.

  • Take your meter with the strip and hold it against the drop of blood. It will tell you if the strip is filled, usually by beeping. 

  • Before you look at your reading, check your finger. Use a tissue to stop bleeding if necessary. If you get the depth of prick correct, then often there will be very little blood to wipe away.

  • Most meters show the result in five seconds. Usually, they have a memory you can access but if you’re keeping a diary then note it down.

  • You can use the same tissue to take  out the strip and throw that away too.    

  • Taking out the strip will usually turn the meter off.

  • If you’re still unsure then google your device, and invariably there will be a website, or video explaining. This is useful for resetting the time and date on the glucometer.

Electronic blood glucose monitor, called a flash glucose monitor or continuous glucose monitor (CGM).These devices don’t require regular skin pricking or needles. Instead, they use a sensor inserted into your skin. They measure the amount of sugar in the fluid surrounding your cells, called interstitial fluid rather than blood glucose. There will always be a lag between interstitial fluid glucose and blood glucose so they may not match exactly. Most CGM devices are so accurate that they don’t need to be calibrated against a finger-prick measurement. The CGM transmits the measurements to a reader or smartphone. 

Know your body and how it works

Measuring your blood glucose should always be done with a purpose. This can be to assess the effect of medication, including insulin, on your blood glucose. It’s also valuable to know what food, exercise, and other life events, such as illness, can do to your blood glucose.

To see how food affects your blood glucose, it’s best to measure before and two hours after a meal. This can be recorded in your machine to be downloaded later, or in a diary. Some meters are linked to apps which allow you to see the readings on your smartphone.  Alternatively, there are also diabetes apps you can manually enter your reading into and then see them in the form of graphs or tables.

The most important reason to check your blood glucose is to have information that will continue to improve your control. Your diabetes team will continue to help in the decision-making process, but it’s also valuable to keep learning how to act on blood glucose readings. 

How often should you test

This depends mainly on your current diabetes control and the type of treatment you’re receiving. As a rule, people on oral medications should measure about three times a week. Patients using insulin should measure as often as they inject. This means a person taking one long-acting insulin injection daily should check their fasting blood glucose daily. A person injecting a mixed insulin twice daily should measure before each injection, so two readings daily. Similarly, a person using a basal bolus regimen of one long-acting insulin daily 

and short-acting insulin before meals should check before each injection and before bed: four readings daily. However, there are people who check many times more than this, especially if using a CGM.

TARGETS FOR GLUCOSE CONTROL

HbA1c Fasting blood glucose mmol/L Two-hour post meal blood glucose mmol/L
YOUNG < 6,5% 4 – 7 4,4 – 7,8
MOST < 7,0% 4 – 7 5 – 10
ELDERLY < 7,5% 4 – 7 < 12

Low blood glucose

If your blood glucose is too low, usually below 4 mmol/L, you may experience  hypoglycaemia. These need to be treated immediately by consuming quick-acting sugar, otherwise your blood glucose will drop further. If this happens, you may experience a severe hypo and need emergency treatment. Your healthcare team will advise on the amounts and types of sugar that can be used.

High blood glucose

The level at which symptoms begins to appear is different for everyone, but the common ones include passing more urine than normal, being very thirsty, having headaches and feeling tired and lethargic.

For people using insulin, a ketone test should be done if there is persistent or unexpected high readings. Ketones are acids produced when the body breaks down fat stores. The presence of ketones indicates a shortage of insulin, and is dangerous causing nausea, vomiting, dehydration and coma. People using insulin should be educated on how to manage ketones. However, if you have ketones always contact your healthcare team or go to the nearest emergency room.

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Monitoring your diet

A healthy, balanced diet is integral to the holistic management of your diabetes. Diabetes doesn’t mean you can’t eat; it simply means to eat right. 

Of all the things that make blood glucose levels rise, food plays the biggest role. Some foods can raise your blood glucose more than others and portion size plays a significant role too. The same foods can have different effects on blood glucose in different people. It’s important to learn what your individual response is and have some control of your diet.

Although it’s helpful to have an individualised eating plan to help with your diabetes, there are basic concepts that are common to everyone. All food can raise blood glucose, but the different macronutrients have different effects. 

1. Carbohydrates, which includes all sugars and starches, raise blood glucose the fastest. For this reason, this is the food group you should have most knowledge about. 

The glycaemic index is a measure of how much a particular carbohydrate is likely to increase the blood glucose by. High-GI foods (white flour, refined cereals, etc.) cause immediate spikes in blood glucose. Low-GI foods slowly increase blood glucose and avoid spikes. Portion plays an important role as higher portions will usually cause higher levels of blood glucose after meals. Hence why you should know the carbohydrate content in various foods to make the right choices. Discuss with your dietitian the right amount of carbohydrates to keep track of the amount eaten and set a limit. 

2. Protein, animal or plant-based, has a minimal effect on blood glucose as long as there is sufficient insulin working in the body. Protein helps a person to feel full which can decrease snacking.

3. Fat has little direct effect onblood glucose, but excess amounts contribute to weight gain and insulin resistance which in turn worsens diabetes control.

A balanced diet must be planned to support a healthy weight and get blood glucose levels to target. These levels can change throughout the day and are affected not only by food but also activity and medication. Measuring your blood glucose levels before and after your meals helps see the immediate effect of your food choices and portions on your blood glucose. This post-meal measurement must be done at two hours after. Glucose levels peak from 1 ½ to two hours after a meal. International and national guidelines have standardised post-meal targets at two hours. 



Self-monitoring of blood glucose chart

A chart to document self-monitoring of blood glucose, also referred to as a diabetes diary, is an important tool in diabetes management. It helps you and your doctor assess the effect of medication as well as to evaluate your meal choices.

For example, if your two-hour post-meal glucose is more than 3mmol/L higher than your before-meal glucose, next time you could eat a smaller portion of carbohydrates.  

You can use apps to measure and monitor dietary intake or speak to your dietitian or diabetes educator for a list of carbohydrates in common foods and use food labels to calculate and record your carbohydrate intake so that you can identify how many carbohydrates are ideal for you.

TARGETS FOR GLUCOSE CONTROL

HbA1c Fasting blood glucose mmol/L Two-hour post meal blood glucose mmol/L
YOUNG < 6,5% 4 – 7 4,4 – 7,8
MOST < 7,0% 4 – 7 5 – 10
ELDERLY < 7,5% 4 – 7 < 12
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De-stressing techniques

Constant stress, whether from a daily commute, unhappy marriage, or heavy workload, can have real physical effects on the body. It has been linked to a wide range of health issues, including mood and sleep disorders, appetite problems and even heart disease.

In diabetes, heart disease is a common complication. Both high blood glucose levels and stress hormones increase inflammation in blood vessels which can result in heart disease.

Stress can also cause negative behaviours, such as unhealthy eating, being sedentary, smoking, and drinking too much alcohol.

Breaking the connection requires both learning to deal with stress and managing unhealthy habits. 

10 tips to help you de-stress

1. Laughter has been found to lower levels of stress hormones, reduce inflammation in the arteries, and increase good HDL cholesterol.

2. Meditation and deep breathing have shown to reduce heart disease risk factors, such as high blood pressure. Yoga and prayer can also relax the mind and body.

3. Exercise releases mood-boosting chemicals called endorphins. Exercising not only helps you de-stress, it protects against heart disease by lowering blood pressure, strengthening your heart muscle, and helps maintain a healthy weight.  

4. Unplug from the world of technology. Avoid e-mails and news. Take time each day, even if it’s for just 10 or 15 minutes.

5. Find ways to de-stress, like a warm bath or a favourite hobby. Research has shown that colouring in, especially complex geometric patterns, is a perfect outlet for stress.

6. Get a hug from a loved one. When you hug someone, oxytocin is released. Oxytocin (cuddle hormone) is associated with higher levels of happiness, lower levels of stress, and lower blood pressure. This is because it reduces norepinephrine, the stress hormone. 

7. Enjoy aromatherapy. Emerging research suggests certain scents can alter brain wave activity and decrease stress hormones in the body. Use candles, diffusers, or body products  to achieve the benefits. 

8. Adopt a balanced diet. Refined carbohydrates, like cookies and potato chips, can cause a spike in blood glucose. When this crashes, you might experience more stress and anxiety. Foods like eggs, avocado, and walnuts support mood regulation and energy balance. 

9. Develop a positive self-talk habit. Harsh self-criticism, self-doubt, and catastrophic predictions worsen states of stress. It’s important to learn to talk to yourself compassionately. 

10. Express gratitude. Grateful people generally enjoy better mental health, lower stress, and a better quality of life.

 

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Bariatric surgery

Bariatric surgery is a treatment option for obesity and diabetes in patients whose body mass index (BMI) is ≥ 35 kg/m2 and glucose levels aren’t controlled despite the best efforts with medications and lifestyle modification.

BMI is calculated as follows: BMI = weight (kg) ÷ height (m²).     

Bariatric surgery has been a major advancement in treatment of people living with obesity and diabetes in recent years. Between 70 and 90% of these people will still be in diabetes remission two years post-surgery. Remission is defined as normal blood glucose on no diabetes medication for at least a year. Even 15 years after bariatric surgery, a third of people will still be in remission. Of those that need diabetes treatment again, simpler regimens achieve glucose control. 

There are a variety of procedures available, and this should be individualised by the bariatric centre which will be staffed by a full multi-disciplinary team: surgeon, specialist physician, dietitian, psychologist, and exercise therapist.

The benefits extend beyond improving glycaemic control, as multiple other comorbidities (hypertension, sleep apnoea, high cholesterol) are also positively affected. 

Bariatric surgery has few complications, but regular structured follow-up is essential. Particular attention must be paid to those complications relating to nutritional deficiencies since the stomach and intestines are responsible for absorbing nutrients from food eaten.

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Insulin pump therapy

Insulin pump therapy, also known as continuous subcutaneous insulin infusion, uses a small, computerised device to deliver insulin continuously in the way a functioning pancreas would. Only short-acting insulin is used for both the background and mealtime requirements.  

Insulin is administered via a plastic tubing connected to the pump on one side and a small cannula inserted through the skin. The subcutaneous site can be on the abdomen, outer thigh, outer arm, or top of buttock. The abdomen is usually the preferred site. The site needs to be changed every three to four days to prevent infection or inflammation.

A background basal rate is set up to give insulin continuously. This rate will vary over the 24 hours of a day depending on the requirements. 

For mealtimes, you will need to give a bolus insulin dose. To do this, the blood glucose value and amount of carbohydrates (in grams) is entered into the pump. The amount of insulin needed to cover the carbohydrates is pre-programmed. In the same way the on-board computer will calculate how much insulin is needed to correct a high blood glucose reading.

Some pumps can communicate with continuous glucose monitoring devices which has brought a new level of accuracy. The most sophisticated of these systems allows the pump to adjust basal insulin according to requirements, switch off insulin delivery if glucose levels drop to low and give small boluses of insulin to correct glucose levels starting to rise. This system has been dubbed the artificial pancreas. 

People with Type 1 diabetes are ideal candidates. However, people with Type 2 diabetes who inject insulin four times a day can also benefit. Unfortunately, pumps are expensive and only worth considering if you have medical aid that will cover the costs.

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Oral medication

All patients with diabetes are initiated on medication at diagnosis. People with Type 1 diabetes will require insulin replacement due to the damage to the pancreas. People with Type 2 diabetes are prescribed oral medication according to international and national guidelines. In addition, lifestyle measures including a balanced diet and exercise are recommended for both types of diabetes.

The first medication prescribed to people diagnosed with Type 2 diabetes is metformin. This can be given as a daily extended-release pill, or twice daily normal formulation. The dose is increased according to average glucose levels. Metformin improves the action of insulin in the liver and thus, decreases the production of glucose from the liver. Similarly, it helps the work of insulin at the level of the muscle to absorb glucose from the bloodstream. 

Metformin benefits and side effects

Metformin also has benefit in protecting the body against the abnormal, complication-inducing complexes that form when glucose levels are high. For this reason, metformin is continued life-long for benefits beyond just lowering of glucose. 

The side effects of concern are gastrointestinal, especially diarrhoea, bloating and nausea. Some patients can’t tolerate metformin at all but for many who develop side effects, a lower dose allows them to continue treatment. (softlay.com) The daily extended-release formulation also seems better tolerated.

Other classes of agents

If diabetes isn’t controlled, as measured by HbA1c, three months after initiating metformin, then a second agent needs to be added. There are four classes of agents: sulphonylureas (increases insulin secretion); dipeptidyl peptidase inhibitors; thiazolidinediones; and sodium-glucose like transporter-2 inhibitors (results in sugar being flushed out of the body via the kidneys). 

A non-insulin injectable can also be used; these are the glucagon-like peptide receptor agonists. These latter agents help with weight loss as well as HbA1c control.

Type 2 diabetes is a progressive condition. This implies that periodically there will be further deterioration in control and at some point, the pancreas may not produce enough insulin. This may require one to four injections of insulin daily to supplement what the body needs. There is no doubt that a healthy diet, weight control and regular physical activity will slow this progression.

Side effects

It’s possible that you may have some side effects when taking oral medications but it’s important that you don’t stop taking your medicine without speaking to your doctor first. Side effects usually settle down once your body gets used to the medicine. Check the patient information leaflet that comes with your medicine for more info. 

The most common side effects include a metallic taste in the mouth, nausea, vomiting, or diarrhoea. Some of the medications may cause hypoglycaemia and you should report this to your doctor immediately. The medications which work through the kidney can increase the risk of urinary and genital infections which need to be speedily treated. Again, you need to alert your healthcare team.

Management of diabetes in the modern age includes maintaining a balanced lifestyle and appropriate medications so that you may be assured to decreased risk of complications.

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Insulin

Insulin lowers blood glucose by stimulating the uptake of glucose into your muscles and fat and stops the liver from producing and releasing more glucose into the bloodstream.

Insulin is the first-line treatment for people diagnosed with Type 1 diabetes as pancreatic destruction means they don’t produce their own insulin. 

People with Type 2 diabetes or gestational diabetes who don’t achieve good glucose control on oral agents will also need to be initiated on insulin. Often people starting insulin feel that they’ve failed in their efforts to manage their diabetes with exercise and diet. Starting insulin isn’t a reflection on discipline or perseverance. Often insulin is the only therapy that can control blood glucose and improve management. It shouldn’t be seen as a last resort or as a punishment.

Types of insulin:

  • Basal or long-acting insulin is usually taken once a day and provides insulin coverage over 18 to 24 hours.
  • Bolus or rapid-acting insulin is taken before meals to prevent a spike in blood glucose from food. An additional amount (correction dose) may be added to lower an already high blood glucose. This usually reduces high blood glucose quickly and will remain in your body for three to five hours.
  • Mixed insulin is a mix of long-acting and rapid-acting insulin. It’s usually taken twice a day before breakfast and dinner and has eight to 12 hours of coverage in your body. The initial amount of insulin will be faster-acting with smaller amounts in your body after five hours. 

Your doctor will discuss which option would be preferable depending on the features of your diabetes. It’s ideal to also see a diabetes educator and dietitian when you start insulin. The diabetes educator will provide education about how to use insulin and help to make any necessary adjustments. The dietitian will discuss the best strategies for eating.

Side effects

The most common side effect is hypoglycaemia (blood glucose level < 4mmol/L). People using insulin should always carry a fast-acting carbohydrate with them, such as sweets or juice, as well as a blood glucose kit. Patients requiring high doses of insulin can also experience weight gain. Adjusting carbohydrate intake can assist with this.

Tips for effective use

  1. The insulin pen in current use can be kept at room temperature while all spare insulin is stored in the fridge. Using a cooler box or gel pack is useful if insulin has to be kept in the car.
  2. Speak to your doctor about using insulin cartridges instead of disposable pens as these are often cheaper and fully reimbursed by medical aids.
  3. Looking after injections sites is vital which involves changing the needle after every third injection and using different sites each time.
  4. When initiating insulin, your dose may need several changes so keep in close touch with your doctor or diabetes nurse. One dosage change every few months isn’t adequate.

Optimal control with insulin is dependent on your individual requirements which is assessed by checking your blood glucose regularly. 

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Gestational diabetes

Gestational diabetes develops during pregnancy in women who don’t have diabetes. It usually develops in the third trimester (between 24 and 28 weeks) and typically disappears after the baby is born.

The risk factors that increase the chances are:

  • Family history of gestational diabetes
  • Overweight or obese
  • Polycystic ovary syndrome
  • Have had a large baby weighing over 4kg
  • Causes of gestational diabetes may also be related to ethnicity. Some ethnic groups have a higher risk of gestational diabetes.

Gestational diabetes typically doesn’t have any symptoms. Your medical history and whether you have any risk factors may suggest to your doctor that you could have gestational diabetes, but you’ll need to be tested to know for sure.

Gestational diabetes is much like prediabetes when it comes to treatment, if healthy eating and being active aren’t enough to manage your blood glucose, your doctor may prescribe oral medication or insulin.

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