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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Prediabetes

Prediabetes is when blood glucose levels are higher than normal, but not high enough yet to be diagnosed as Type 2 diabetes. 

Prediabetes includes the conditions: impaired fasting glucose and impaired glucose tolerance. These describe levels of blood glucose that are higher than normal but not yet in the diabetic range. These higher glucose levels are associated with a significantly higher risk of developing cardiovascular disease as well as progression to diabetes.

Prediabetes doesn’t usually have any signs or symptoms and it’s concerning that in many instances prediabetes is detected when tests are done to investigate another complaint.

Increased body weight is the greatest risk for developing prediabetes. It’s also more frequent in older populations and those with a family history of diabetes. 

Certain ethnicities have a higher incidence and in South Africa, our Indian community has a particular increased risk. Women with a history of gestational diabetes and polycystic ovary syndrome may develop prediabetes or diabetes as well.

Lifestyle interventions, like weight loss and exercise, are best to manage prediabetes. It’s recommended that medications be considered in people who haven’t reversed their prediabetes diagnosis with lifestyle alone or in individuals who are considered very high-risk of progressing to diabetes.

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Type 2 diabetes

Type 2 diabetes is the most common, accounting for around 90% of all diabetes cases.

Type 2 diabetes is caused by insulin resistance, where the body doesn’t fully respond to insulin. Because insulin can’t work properly, blood glucose levels keep rising, releasing more insulin. For some, this can eventually tire the pancreas, resulting in the body producing less and less insulin, causing even higher blood glucose levels.

It’s most commonly diagnosed in older adults, but is increasingly seen in children, adolescents and younger adults due to rising levels of obesity, physical inactivity and poor diet.

There are more risk factors that are linked to Type 2 diabetes: 

  • Family history of diabetes 
  •  Overweight
  • Unhealthy diet
  • Physical inactivity
  • Increasing age
  • High blood pressure
  • Ethnicity
  • Impaired glucose tolerance 
  • History of gestational diabetes
  • Poor nutrition during pregnancy

A healthy lifestyle which includes a balanced diet, regular physical activity, not smoking, and maintaining a healthy body weight are all elements to manage Type 2 diabetes. At diagnosis, all people with Type 2 diabetes are prescribed metformin, a tablet that helps control glucose production in the liver. If lifestyle and metformin don’t achieve good glucose control, more medications will be added. 

It’s important to be aware that diabetes is a progressive disease and eventually the pancreas will not produce enough insulin. At this point, insulin injections will be required. The rate of progression of diabetes is influenced by genetics as well as lifestyle and oral medications used. It’s often possible to keep the pancreas working for many years. 

Symptoms

  • Excessive thirst and dry mouth
  • Frequent urination
  • Lack of energy, tiredness
  • Slow-healing wounds
  • Recurrent infections of the skin
  • Blurred vision
  • Tingling or numbness in hands and feet
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FAST FACT

Changes in diet and physical activity related to rapid development and urbanisation have led to sharp increases in the numbers of people living with Type 2 diabetes.

Type 1 diabetes

Around 10% of all people with diabetes have Type 1.

Type 1 diabetes is an autoimmune disease where the body’s defence system attacks the cells that produce insulin. As a result, the body produces very little or no insulin. The exact causes are not yet known but are linked to a combination of genetic predisposition (with or without a family history) and environmental factors. Some viral infections, this seems to include COVID-19, as well as environmental toxins have been implicated. These factors seem to trigger the immune system that is already programmed to incorrectly attack the insulin producing cells of the pancreas.

Type 1 diabetes can affect people at any age, but usually develops in children or young adults. Treatment includes daily injections of insulin to control blood glucose levels. 

Symptoms

  • Abnormal thirst and dry mouth
  • Sudden weight loss
  • Frequent urination
  • Lack of energy, tiredness
  • Constant hunger
  • Blurred vision
  • Bed-wetting
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Testing

One or more of the following blood tests will be done to diagnose if you have diabetes:

Fasting blood glucose test

After an overnight fast (nothing to eat or drink) of eight hours, blood is taken from a vein in your arm, by a trained nurse in a laboratory, for a glucose level. The results will be made available to your doctor to discuss. 


Glucose tolerance test

This is also known as the oral glucose tolerance test (OGTT); it measures your body’s response to glucose. It can be used to screen for Type 2 diabetes and gestational diabetes.

This test must be booked in advance with the laboratory. Again, after an overnight (eight hours) fast, a sample of blood will be drawn from a vein in your arm to measure your fasting blood glucose level.

You will then be given a glucose solution to drink and two hours later your blood glucose will be measured again. If you’re testing for gestational diabetes, you will test after an hour, two hours and three hours and your doctor will consider the results of each blood glucose test

The OGTT can differentiate between pre-diabetes and diabetes according to the blood glucose levels (see table below).

Prediabetes due to a raised fasting blood glucose is called impaired fasting glucose. Prediabetes due to a raised two-hour blood glucose is called impaired glucose tolerance. It’s possible to have either or both.

DEFINITIONS OF PREDIABETES AND DIABETES AFTER A TWO-HOUR ORAL GLUCOSE TOLERANCE TEST*

Fasting blood glucose mmol/L Two-hour blood glucose mmol/L
NORMAL < 6,1 < 7,8
PREDIABETES 6,1 – 6,9 7,8 – 11,0
DIABETES ≥ 7,0 ≥ 11,1

*After an overnight fast, blood is taken for the fasting glucose sample; then the person is given a 75g glucose drink; a second sample is taken two hours later.


HbA1c

The haemoglobin A1c (HbA1c) test gives a percent average level of blood glucose over the past three months. No preparation is needed before the test. A sample of blood will be drawn from your arm and will be sent off to a laboratory where the results may take two to three days. In many doctors’ rooms this can be done on a point-of-care machine with a finger prick sample. An HbA1c ≥ 6,5% is accepted as a diagnosis of diabetes.

People with diabetes need a HbA1c test done regularly. Staying within an ideal range has been proven to prevent complications. This result, along with self-blood glucose measurements, will guide the need to adjust medication. The targets for HbA1c, fasting blood glucose and two-hour post meal glucose vary according to age.

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

Urine test

Even though this isn’t used to diagnose diabetes, a urine test will show excess glucose in the urine. It’s also used to look for ketones (substances that are produced when there is a shortage of insulin). Ketones can lead to a serious condition called ketoacidosis so must always be reported to your doctor or DE. 


Self-blood glucose test

Your finger is pricked to draw a small drop of blood. This blood is then wiped onto a test strip that will give a glucose reading within seconds. There are many reliable glucometer machines on the market.


Continuous blood glucose monitoring

There are several devices available that can be inserted into the skin of the abdomen or arm which read glucose levels 24/7; most will send these readings to a smartphone.


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Who will treat you

To manage diabetes adequately, continuous support from a multi-disciplinary team of healthcare providers (HPs) will help you in your choices around medication, food, and exercise. There are national treatment guidelines for diabetes which HPs use to determine this best treatment plan.


The doctor

The doctor who treats you can either be a general practitioner (GP), specialist physician, or an endocrinologist (specialist physician with sub-speciality training in the field of endocrinology). Some GPs and specialist physicians have extra training and qualifications in the field of diabetes and can offer more expertise and experience. 

The doctor will assess you by asking various questions about the symptoms you’re experiencing, your lifestyle and if you have a family history of diabetes or other chronic conditions. Your height, weight, blood pressure, and waist circumference will be measured, and a full examination will be done, including your feet and eyes (although this latter check-up can be done by your optometrist).

Basic bloods tests will always be done: HbA1c to assess diabetes control, a fasting lipogram (full cholesterol test), kidney and liver function, a full blood count and a urine analysis to test for microscopic protein (this gives an early indication of the risk of kidney disease). 

A follow-up consultation will be scheduled. This should be a minimum of every six months. A follow-up every three months is ideal and some medical aids’ diabetes managed care programmes do cover this. Usually, these visits alternate between the doctor and diabetes educator.


The diabetes educator (DE)

This is a healthcare worker that has completed with competence a SEMSDA-approved diabetes educators’ course. It’s important to see a DE when you’re diagnosed so they can educate you about your condition. This will include self-management, lifestyle adjustment and setting realistic goals to reach optimal health, based on your needs while respecting your values, culture, ethnicity, and socio-economic situation.

This process should be engaging, and you should feel free to share your concerns, so the goals can be truly individualised.

Initially you may need to see a DE regularly as you may need more time to understand how different factors are affecting you. Managed care programmes allow for two visits to the DE annually.

DEs are there to walk the diabetes journey with you, giving both expert advice and empathic support. 


The biokineticist

If you’re not already regularly exercising, a visit to a biokineticist can help with a structured and safe programme. Exercise is key to good diabetes management. 


The dietitian

Medical nutritional therapy is a vital aspect of both diabetes prevention and management. The objectives are to promote the enjoyment of a variety of nutritious foods in appropriate portion sizes, so you can achieve individual glucose, blood pressure and lipid goals. Assistance to help maintain a healthy body weight is also valuable.

Nutrition therapy should be individualised so working with your registered dietitian (preferably with experience in diabetes management) is vital. You should expect to have about three to four sessions lasting from 45-90 minutes. This should start at diagnosis and should be completed within three to six months. Once this foundation is laid, it’s a good idea to see your dietitian annually for assessment. They can also keep you up-to-date with dietary trends and products that may be useful.


The psychologist

The relationship between diabetes and depression isn’t fully understood but we know that the rigors of managing diabetes can be stressful and lead to depression. Fifty percent of people living with diabetes will experience depression. Your doctor will always acknowledge that it’s essential to treat a mood disorder, such as depression or anxiety, as part of your holistic care. This may require prescription medication, psychotherapy, or both. The psychologist is an integral member of the diabetes team who helps with the burden of chronic disease management.


The podiatrist

In people with diabetes, foot examinations must be an integral component of diabetes management to identify risk for ulceration and lower-extremity amputation. You should have a barefoot examine annually.  

The podiatrist will assess blood flow and nerve function, skin, bones, and joints. They will give advice on footwear and general good footcare. A podiatrist will best educate you on good footcare practices and ulcer prevention. 

Not looking after your feet can be catastrophic so this is one yearly visit that shouldn’t be missed. If you’ve any concerns about your feet always visit your podiatrist first.


The ophthalmologist or optician

Diabetic eye disease is a leading cause of visual impairment due to damage of the small blood vessels in the retina at the back of the eye. Cataracts are also a complication of diabetes which are screened for. An eye test should be done every one to two years. This can be done by your local optometrist who will take a retinal photograph and keep it on file. If there is any sign of retinal disease, you’ll be referred immediately to a specialist ophthalmologist. 

Please remember that long-term diabetes retinopathy will only present with visual changes at the point where vision is about to be lost. The early stages of damage to the retina will be completely asymptomatic so unless the eye check-up is being done you’ll not know the risk. A diabetic eye check is offered by most optometry practices for a little as R150. 

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