Management of diabetic ketoacidosis

Dr Louise Johnson informs on what diabetic ketoacidosis is, the signs and how to manage it.

What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is an acute life-threatening complication of diabetes. DKA happens when your blood glucose is very high and acidic substances, called ketones, build up to dangerous levels in your body. It’s characterised by high glucose and ketonuria (ketones on dipstick in urine) and ketoacidosis.

The cause is due to decreased amount of insulin and too much glucose. The metabolism shifts from the carbohydrate metabolism to a starvation state where the fat metabolism is used.

 Signs and symptoms

  • General weakness, tiredness
  • Polyuria (passing a large amount of urine) and polydipsia (excessive thirst)
  • Nausea and vomiting
  • Abdominal pain
  • Decreased appetite
  • Rapid weight loss in a new Type 1 diabetes patient
  • Altered consciousness, disorientation and confusion
  • Decreased sweating with dry skin
  • Dehydration
  • Laboured breathing, called Kussmaul breathing
  • Apple smell on the breath
  • Dizziness due to low blood pressure and palpitations
  • Glucose more than 20 mmol/L and ketones on some glucose machines (if possible) and in urine as detected by a urine dipstick

Causes of DKA

  • Infection, especially bladder infections, lung infection, feet, tooth or other
  • Inflammation i.e. arthritis
  • Heart attack characterised by chest pain
  • Not taking insulin or enough insulin
  • Insulin not delivered due to pump obstruction or insulin pump failure
  • Trauma that can be either physical or emotional. The death of a pet is enough emotional stress to cause this.

The incidence of DKA is mainly in Type 1 diabetes but can also be seen in Type 2 diabetes that are on insulin and develop a bad infection.

In Type 1 diabetes it’s more common in young children and adolescents due to growth hormone and sex hormones that increases. It’s also seen in adolescents with psychological stress where insulin is not taken correctly or omitted on purpose.

Management of DKA

The most important factor is to test blood glucose when any of the signs are present. Nausea and abdominal pain are early signs that can be used to prevent hospitalisation.

If you are showing any signs, you should check your blood glucose and give a short-acting insulin as a correction to bring the glucose down below 10 mmol/L.

Drink clear water in an amount of 100ml/kg. In a person weighing 60kg that would be six litres. Drink the water slowly and check glucose every hour. About 1 litre fluid per hour.

Should there be excessive nausea, an anti-emiticum can be used for nausea, such as Valoid suppository.

If there are no signs of infection and the glucose is responding to the treatment, you can stay at home. In the case where the glucose is not responding and vomiting or confusion appears, you will need to be admitted to a hospital for intravenous insulin.

Prognosis

The overall mortality rate for DKA is 0,2 to 2% with persons with coma having the worse prognosis.

In properly treated patients, the prognosis is excellent. Before the discovery of insulin, in 1922, the mortality was 100%. Over the last three decades, the mortality rates from DKA have markedly decreased from 7,96% to 0,67%1.

Dr Louise Loot

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.



References:

  1. Lin SF, LIN JD et. al. “ Diabetic ketoacidosis: comparison of patient characteristics, clinical presentations and outcomes today and 20 years ago.” Chaung Gung Med J 2005, Jan 28(1):24-30

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Oral health related to diabetes

Oral hygienist, Sarie Liebenberg, educates us on oral health related to diabetes and whether you should go to a dentist during COVID-19.


There is a direct link between oral health and systemic conditions, like diabetes, respiratory disease and cardiovascular disease. Therefore, it’s of utmost importance to exercise good oral health in the presence of one or more of these underlying systemic diseases.

Should I go to the dentist during COVID-19?

Currently, with the COVID-19 pandemic, you might wonder if it’s important and necessary to go to the dentist/hygienist. The answer is a definite ‘yes’.

HIV-AIDS, tuberculosis and hepatitis, to only mention a few, have been around for a very long time. COVID-19 is just another addition to the list.

Dental professionals are trained to prevent the transfer of bacteria and viruses. Not only does the dental professional have adequate protective measures to prevent the transfer of bacteria and/or viruses from one person to another, but also have the knowledge and understanding not to cross contaminate their working environment. Ultimately, the environment that you will be treated in. With relation to contracting the COVID-19 virus, it’s probably safer to go to the dentist than to the supermarket.

Gingivitis

Epidemiological data unequivocally confirms diabetes as a major risk factor for periodontitis. (This is also true for children and young adults). Uncontrolled diabetes being an even higher risk factor for periodontitis.

Periodontitis is a chronic inflammatory disease of the gums (gingiva), characterised by the destruction of the supporting bone structure around the teeth (periodontium). In most cases, periodontitis starts off as a mild, inflammatory disease, called gingivitis.

Gingivitis is characterised by the gums presenting signs of redness (erythema), swelling (oedema) and bleeding (haemorrhage), especially with brushing or flossing.

At this stage of the disease, the inflammation is limited to the gums and probably asymptomatic, or only with slight discomfort and possibility of bad breath (halitosis).

If treated, the gums can heal with no permanent damage to the bone structure around the teeth. With a good daily oral hygiene routine and regular visits to your dentist/hygienist, the gums can heal and you can prevent the reoccurrence of gingivitis.

If left untreated, gingivitis might develop into a more advanced gum disease, called periodontitis.

Periodontitis

Periodontitis is one of the leading causes of bad breath and is responsible for tooth mobility, with the ultimate result of tooth loss.

Unfortunately, lots of patients do not seek treatment while their gum disease is still in the early stages (gingivitis). By the time gingivitis has developed into periodontitis, it’s not possible to reverse the damage of the supporting bone structure around the teeth.

If you manage to get periodontal treatment in time, and if you are lucky enough to save some of your teeth, it will take great effort, discomfort and financial strain, to slow down periodontal disease.

In rare cases, you can arrest periodontal disease permanently. But even after periodontal disease is arrested, the damage to the supporting bone structure around the teeth is irreversible and will always be compromised.

Patients who had periodontal disease will always have a propensity to relapse. Reduced blood supply to the gums in a person living with diabetes, will always compromise present and future healing.

Link between hyperglycaemia and periodontal disease

There is a clear relationship between the degree of hyperglycaemia (high levels of glucose in the blood) and the severity of periodontal disease and even dental decay.

The mechanism that underpins the link between these two conditions are not completely understood. But, involve aspects of immune functioning, neutrophil activity (white blood cells responsible for healing damaged tissue and resolve infection) and cytokine biology (messaging network that regulates the immune system).

There is emerging evidence to support the existence of a two-way relationship between diabetes and periodontal disease. With diabetes increasing the risk of periodontal disease and periodontal disease negatively affecting glycaemic control.

Compared to diabetic individuals without severe periodontal disease, incidences of macroalbuminuria (protein albumin in urine – a risk factor for kidney and cardiovascular disease in diabetic individuals) increases two-fold in diabetic individuals with severe periodontal disease. End-stage renal disease increases three-fold in diabetic individuals with severe periodontal disease.

Furthermore, risk of cardio-renal mortality (ischaemic heart disease and diabetic nephropathy combined) is three times higher in diabetic individuals with severe periodontal disease than in diabetic individuals without severe periodontal disease.

Dry mouth

Dry mouth (xerostomia) is a common side effect of some chronic medication and often associated with diabetes. There is also a significant correlation between blood glucose levels and salivary glucose levels. Together, they pose a risk for fungal infections and higher incidence of tooth decay.

Oral hygiene treatment plan

If you don’t have an existing professional dental hygiene routine with a dentist/hygienist, book an assessment to discuss a treatment plan for your individual oral health needs.

It’s recommended that everybody has a professional cleaning at least twice a year and a dental examination at least once a year. Unless, it’s recommended otherwise by your dentist/hygienist.

A patient with underlying systemic health conditions will more likely require a professional dental cleaning every three to four months and daily oral hygiene instructions will be explained and monitored.

Your typical home routine will include brushing twice a day and interdental (between the teeth) cleaning by means of flossing, use of a waterpik and/or interdental brushes at least once a day. Oral hygiene instructions will vary, depending on your existing oral health and personal dental needs.

If you have existing inflammation which is characterised by bleeding of the gums when you brush and floss, you will need to have it seen to by a professional.

Chances are good that you have calcified plaque (calculus/tartar) build-up that is responsible for the inflammation and can’t be removed with your toothbrush and needs professionally intervention.

Remember, there is hardly any point in only brushing the teeth and not the gums  and not performing interdental care of some kind.

In addition, the application of fluoride and the use of a therapeutic mouth rinse might be advised by your dentist/hygienist. This needs to happen with caution and not without consultation with your dentist/hygienist as some of these products should only be used for a recommended period of time. Long-term use of some products might have consequences.

Take care of your health

It’s always advisable to take good care of your health. Especially when an underlying systemic condition, like diabetes, is present. Right now, with a much higher risk of contracting COVID-19, keep the following in mind:

  • A healthy and nutritious diet and active lifestyle will help better manage your blood glucose levels, achieve target blood lipid levels and maintain healthy blood pressure and body weight.
  • A multivitamin supplement provides nutrients that your body needs for regular function. Vitamin D is believed to help improve the body’s sensitivity to insulin (the hormone responsible for regulating blood glucose levels). Thus reducing the risk of insulin resistance, which is often a precursor to Type 2 diabetes. Vitamin D also plays a key role in immune function.
  • Bright sunlight exposure is associated with a reduced risk of Type 2 diabetes and heart disease by lowering blood insulin and lipid levels.
  • Sleep plays an important role in healing and repair of your heart and blood vessels.
  • Drinking enough water helps maintain the balance of body fluids. The function of these bodily fluids includes digestion, absorption, circulation, creation of saliva, transportation of nutrients and maintenance of body temperature.
  • Fresh air has been shown to help digest food more effectively, improve blood pressure and heart rate, strengthen the immune system and reduce the risk of obesity.
  • Ongoing sleep deficiency is linked to an increased risk of heart-,  kidney disease, high blood pressure, diabetes and stroke.
  • Stress aggravates diabetes, raises blood glucose levels, activates fat cells, impairs glucose tolerance, increases insulin resistance and impacts blood pressure.
  • Nicotine increases cortisol levels, reducing B cell antibody formation and T cells’ response to antigens. Therefore having a harmful effect on the immune system. It also hardens and narrows the blood vessels, curbing blood flow around the body. Together, making you more susceptible to infection, damage of the lungs and puts you at higher risk for heart disease.

Stay positive and nurture the spirit

Similarly, the mind has great power to influence the body. Knowledge of how to manage your diabetes and prevent complications is an important first step. But, understanding how to stay positive and nurture the spirit can also help in a holistic approach to diabetes care.

Managing diabetes is a lifelong commitment and that includes proper dental care. Your efforts will be rewarded with a lifetime of healthy teeth and gums.

MEET THE EXPERT


Sarie Liebenberg is an oral hygienist in private practice in Sandton, Gauteng with almost 30 years’ experience in dentistry. She is involved in various aspects of the dental industry, including lecturing, speaking and presenting on oral health. 


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Post-transplant diabetes mellitus

Dr Riaan Flooks, a nephrologist, helps us understand what post-transplant diabetes mellitus (PTDM) is and how it develops.


Chronic kidney disease

Chronic kidney disease (CKD) is quite common. This is when kidneys are damaged and can’t filter blood the way they should. Renal (kidney) transplantation is one of the treatment modalities thereof. The leading cause of CKD, worldwide, is said to be diabetes mellitus.

Kidney transplants

In 1964, it was recognised that hyperglycaemia (high-blood glucose) developed in some of the renal transplanted patients.

In South Africa, the first kidney transplants took place on 25 August 1966. But because of the lack of well-designed immunosuppressants, these transplants succumbed due to organ rejection.

Post-transplant diabetes mellitus (PTDM) is associated with increase in hospitalisations and deaths and is also known to cause cardiovascular disease and infections. The latter two conditions are also the leading causes of death in the transplant population.

History

After a meeting in 2003, guidelines were published that changed Transplant-Related Hyperglyceamia to New-Onset Diabetes After Transplantation (NODAT).

In 2014, new and updated guidelines were published, which renamed the disease: post-transplant diabetes mellitus.

Post-transplant diabetes mellitus 

This disease entity describes the presence of diabetes after transplantation, irrespective of the timing of diagnosis, or having had undetected elevated blood glucose levels prior to transplantation.

Some patients may develop elevated blood glucose levels immediately after the transplant, or soon thereafter. This group of patients would be referred to as having Transient Hyperglycaemia and is excluded from PTDM.

PTDM occurs in 4-25% of kidney recipients, and the variation is due to definition, duration of follow-up and the presence of risk factors for developing hyperglycaemia.

Risk factors for developing PTDM

The risk factors that predisposes to the development of PTDM has been grouped into two groups.

Traditional risk factors

Not forgetting that patients who are subjected to renal transplants may have the traditional risk factors that predisposes the general population to develop DM. These risk factors would include advanced age (>40yrs), obesity (BMI>30), Black race, a history of diabetes during pregnancy and a positive family history of DM.

Transplant-related risk factors

The second group of risk factors are referred to as transplant-related risk factors. They include immunosuppressive therapy, infections, impaired glucose tolerance and peri-operative hyperglycaemia and human leukocyte mismatching.

  • Immunosuppressive drugs

Not all immunosuppressive drugs are known to contribute to the development of PTDM. Only the diabetogenic drugs are discussed below:

  1. Glucocorticoids/Steroids

These drugs have an effect on the production of glucose in the liver and it also reduces glucose uptake in fat cells. Higher doses of glucocorticoids in these patients has been associated with the development of PTDM.

  1. Calcineurin Inhibitors (tacrolimus and cyclopsorine)

Patients on tacrolimus have a higher chance of developing PTDM. Patients with higher tacrolimus drug levels (>15ng/mL) have a higher chance to develop PTDM.

Both these drugs are toxic to the pancreatic cells (reduces insulin secretion and makes cells resistant to the effects of insulin), and thus causes PTDM to develop.

  1. Sirolimus

This drug is also known to cause diabetes.

  • Infections

There are certain infections that predisposes the recipients to develop PTDM. These infections would be hepatitis C and Cytomegalovirus (CMV).

  1. Hepatitis C is primarily a liver disease, which causes liver dysfunction and also causes pancreatic cell dysfunction. For these two latter reasons, this infection results in hyperglycaemia.
  2. CMV infection is also known to cause PTDM.

Patients who have impaired glucose tolerance (glucose level is elevated, but not high enough to make a diagnosis of DM) before transplantation are also more prone to develop PTDM. Patients who develop hyperglycaemia around the time of the transplantation are also at risk of developing PTDM.

Clinical relevance

PTDM is associated with the development of cardiovascular disease, and thus an increase in mortality. Studies have also shown that patients who had diabetes before the transplant compared to those who develop PTDM have an even higher cardiovascular mortality rate.

Although newer immunosuppressive therapies have improved allograft survival, the development of PTDM decreases the long-term allograft survival.

It is postulated that the recipients who develop PTDM, may be due to diabetic nephropathy (diabetic kidney disease) or the early efforts to reduce the diabetogenic immunosuppressants, which then lead to rejection.

PTDM is also associated with more frequent infections; the infections that seem to occur more commonly is CMV, urinary tract infections and lower respiratory tract infections.

Diagnosing PTDM

Elevated blood glucose levels are commonly seen in the peri-operative time period, and is related to surgical stress and the use of high-doses of steroid therapy that forms part of the induction therapy.

This is referred to as transient post-transplant hyperglycaemia, and can last up to six weeks. Thus, a diagnosis of PTDM should not be made within the first six weeks, post-transplantation. This group of patient is also at an increased risk of developing PTDM at a later stage.

The blood glucose level should be monitored weekly for the first four-six weeks post-transplantation and then at three months and six months.

To diagnose a patient with PTDM, you would prefer to have a non-acutely ill patient, who is stable on immunosuppressants and whose transplanted kidney is having stable renal function.

Diagnosis requires the same symptoms that is seen in non-transplanted diabetic, in combination with a biochemically proven hyperglycaemia.

The symptoms usually include: excessive thirst, excessive hunger, unintentional weight loss and excessive urination. These symptoms usually occur in combination with a random blood glucose level of ≥11,1mmol/L. The diagnosis can also be made by having a fasting blood glucose of ≥7mmol/L.

The HbA1c can also be used as a marker of glucose control after the first three months post-transplantation.

Management

The current treatments available include oral hypoglycaemic agents and insulin therapy. Adjustment of the immunosuppressive therapy should also be considered, but it should be weighed against the possibility of the recipient suffering an acute rejection episode.

Conclusion

Post-transplant recipients have similar complications as the non-transplanted diabetics. Immunosuppressive therapy has become more sophisticated and has improved long-term graft survival, but some of them still has diabetogenic effect. Also, with the change in the field of diabetes management, the treatment of PTDM has become slightly easier.

Read Jordan Barber’s story of developing post-transplant diabetes mellitus after a kidney transplant. 

MEET THE EXPERT


Dr Riaan Flooks is a practising nephrologist at Bloemfontein Mediclinic. His interests include ICU Nephrology, Diabetic Kidney Disease, Hypertension and Transplant Medicine. He forms part of the Transplant Team in the Free State Province, and is an active member of the Bloemfontein Mediclinic Medical Board.


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The science behind caring for dry skin

Dr Alexander Filbry, Head of Product Development for Body Care at Eucerin, looks at the causes of dry skin and the science behind Eucerin’s UreaRepair PLUS range.


What causes dry skin?

Dry skin is a very common condition and often results in visits to dermatologists. Symptoms vary according to the severity of dryness, but skin can be tight and rough and/or prone to itching, scaling, flakiness and redness. In extreme cases, skin is pathologically dry.

The main reason for skin dryness is an impaired skin barrier function which results from:

  • A lack of lipids that help to protect skin from moisture loss.
  • A deficit of urea and natural moisturising factors (NMFs) which bind moisture into the skin.

The story behind Eucerin UreaRepair PLUS

In the 1990s, Eucerin skin scientists were the first to discover how to include a natural moisturising factor in a dermo-cosmetic product. The NMF they used was urea and it has gone on to become one of the most respected and widely used ingredients in the treatment of dry skin symptoms.

People who suffer from dry skin need more than just immediate relief. They need a long-term solution which will prevent symptoms, such as roughness, itchiness and flakiness from returning.

The Eucerin team set out to create an effective range of products that would deliver both immediate and long-lasting relief for dry, very dry and extremely dry skin.

What are the active ingredients in the formula?

Urea is the key ingredient in Eucerin UreaRepair PLUS and, as part of our formulas, it improves natural skin exfoliation and soothes and smooths the surface of dry skin.

As an NMF, urea helps skin to regulate its moisture content and, being a natural skin compound, it is well-tolerated even by dry and sensitive skin.

Urea more effective when combined with other moisturisers

Our formulas are enriched with additional NMFs too. These include amino acids, inorganic salts and lactate, and they work alongside the urea to improve skin’s water-binding capacity and increase its moisture content.

Another key active in the range is ceramide. Ceramides prevent moisture loss from evaporation, and help to keep out the irritants that cause itching and inflammation. It has also been proven to help repair and regenerate skin’s natural barrier, lock in moisture and prevent and treat dryness.

These ingredients work together in the Eucerin UreaRepair PLUS formulas to repair the skin barrier, reduce moisture loss and bind water into the skin and many of the products deliver immediate + 48h dry skin relief.

 

dry skinChoosing the right product for dry skin conditions

Eucerin UreaRepair PLUS offers a comprehensive range of products which includes a cleanser, body lotions and creams.

These products are available with different concentrations of the water-binding active urea: 5%, and 10%. The concentration of urea needed, depends on the dryness of the skin. Those with dry skin may want to use a body product with 5% urea whereas very dry skin will benefit from a 10% urea product.

Clinically and dermatologically proven products

All the 5% and 10% urea Eucerin UreaRepair PLUS moisturisers are clinically and dermatologically proven to replenish both lipids and moisture, delivering immediate + 48h dry skin relief. They leave skin looking and feeling smooth, soft and supple.

Research on Eucerin UreaRepair PLUS 5% Urea Body Cream indicates:

  • A significant improvement in moisturisation, both immediately and 48 hours after a single application.1
  • 95,9% of patients scored the cream as “very good” and “good” in terms of tolerability.2

Research on Eucerin UreaRepair PLUS 5% Urea Body Lotion and Eucerin UreaRepair PLUS 10% Urea Body Lotion indicates a significant reduction of dry symptoms with daily use.3

Eucerin’s UreaRepair PLUS 5% Urea Hand Cream scored equally well in research with the sample reporting:

  • An immediate and significant decrease in skin dryness and roughness after a single product application.1
  • 97,2% of patients scored the hand cream as “very good” and “good” in terms of tolerability.2

Research proves the effectiveness of Eucerin UreaRepair PLUS products. Clinical and dermatological studies have also shown that UreaRepair PLUS products are suitable for mature skin and for those with psoriasis, keratosis pilaris and diabetes.4


References:

  1. Clinical grading and Corneometer measurements – Data on file BDF
  2. In vivo efficacy and tolerability study ¬– Data on file BDF
  3. Treatment of Xerosis with a topical formulation containing Gluco Glycerol, Natural Moisturising Factors and Ceramide; Weber et al., JCAD 2012
  4. Not all products are suitable for all conditions. Please refer to the information on pack.

MEET THE EXPERT


Dr Alexander Filbry is the Head of Product Development for Body Care at Eucerin and leads an outstanding team of skin scientists. He has a PhD from the University of Hamburg and over two decades of experience in derma cosmetic research.



For more information please visit www.eucerin.co.za


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Diabetic erectile dysfunction

Dr Larisse Badenhorst helps us understand why men who have diabetes may also suffer with diabetic erectile dysfunction.


Understanding erectile dysfunction

Erectile dysfunction (ED) is defined as the inability to get or maintain an erection firm enough for sex.

A lot must work together to get an erection. Men need healthy blood vessels, good blood supply, intact nerves, balanced and adequate hormones (these include oestrogen, testosterone and thyroid hormones), and a desire to be sexually stimulated.

This is a complex interaction of vascular, neurological, hormonal and psychological systems. It is therefore imperative to seek expert help when you are experiencing ED.

Screening, monitoring and appropriately treating diseases that are comorbid with erectile dysfunction is essential. This will enhance life quality and improved motivation in men with existing erectile dysfunction comorbidities or risk factors. 

Diabetic erectile dysfunction

Erectile dysfunction is a common and distressing complication of diabetes. Both Type 1 and type 2 are risk factors for the development of erection problems.

Many unique characteristics distinguish these two, including insulin and cholesterol levels, obesity status and inflammatory agent profiles. The causes in diabetic erectile dysfunction are multifactorial and it is found that it is more severe and more resistant to treatment when compared with non-diabetics. Erectile dysfunction in diabetics develops 10 to 15 years before men without diabetes.

There are many associated factors, namely advancing age, duration of diabetes, poor glycaemic control, high blood pressure, high cholesterol, sedentary lifestyle (which pertains to lack of exercise and increased weight), smoking, presence of other diabetic complications, depression and other psychological diseases, prostate problems and low testosterone levels.

As important as these are in leading to erectile dysfunction, the medication used in treating these conditions are as important. There are a lot of medicines used to treat other conditions that can make erectile dysfunction worse.

It’s vital to screen for these other conditions in erectile dysfunction sufferers. Premature ejaculation and low libido is commonly associated with diabetic erectile dysfunction. It is important to see to these as well if present.

Diminished erection spontaneity, rigidity (firmness) and/or sustaining capability also negatively affect mood, self-esteem, and confidence. These can compromise motivation to be compliant with medications that treat diseases comorbid with erectile dysfunction.

Managing erectile dysfunction

Seeking medical expertise is imperative to treat the cause and comorbid conditions that can lead to ED. The following treatment is important in diabetic erectile dysfunction, but also important to be addressed in non-diabetics.

Optimising glucose levels is vital, especially in young men with diabetes. Lifestyle modifications are important; these include dietary changes, cessation of smoking and weight loss. Managing other comorbidities adequately is also of utmost importance.

As said before, optimising treatment of diabetes and other comorbidities, and reviewing all medication used much be done, as these can play a vital role in worsening erectile dysfunction.

Tablets

Specific treatment for erectile dysfunction is phosphodiesterase type 5 inhibitors (PDE5I). These include tablets like Viagra, Cialis and Ciavor. These tablets work extremely well, but it is important to be prescribed by a medical professional who will make sure there are no contraindications in the use of these, as well as educating you on the side effects and risks.

Injections

Intracavernosal injections (these are injections administered directly into the penis) also work very well and are commonly used if PDE5I don’t work or contraindications to their use exist.

The dosage needed must be monitored by a medical expert because prolonged erections (known as priapism) can result from the use of the injectables and can have long-term effects.

Pumps

Vacuum devices or pumps are also available. They draw blood into the penis to then obtain an erection and a ring is used to then keep the blood within the penis to maintain the erection.

A common problem is that the device is not used correctly and therefore a lot of men think that it doesn’t work.

Platelet rich plasma

A newer treatment available is platelet rich plasma (PRP). This involves using the person’s own blood products to promote healing and rejuvenation in certain areas of the body. It has gained a lot of popularity in sexual medicine but is still seen as experimental in treating things like erectile dysfunction.

Treating possible underlying psychological problems are very important and seen as key in patients with performance problems.

With the pharmaceutical advances and expanded knowledge of the effects of lifestyle on sexual health, there is seldom a reason for a man to suffer bad erections in this day and age. The earlier you treat, the better the outcome for your general health as well as long-term effects.

MEET THE EXPERT


Dr Larisse Badenhorst is a medical doctor. She joined the My Sexual Health team, in Bryanston, Gauteng, during May 2019 as general practitioner with a special interest in sexual health and HIV. For more info visit, www.drlarissebadenhorst.co.za


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10 foods to build immunity

The Heart and Stroke Foundation South Africa advises what foods should be eaten to build immunity during this viral era.


While many people are stocking up on immune boosters, vitamin C tablets and green juices, we’ve put together a few ideas on the type of nourishment our bodies need as we fall into winter. More importantly, as we find ourselves caught up in this viral era, here are 10 top foods to build immunity, without compromising your diabetes.

  1. Citrus fruits

All citrus fruits, such as oranges, grapefruits and lemons are high in vitamin C, which acts as an antioxidant. Antioxidants help fight free radicals; a type of unstable molecule known to damage the immune system. Vitamin C also increases the production of white blood cells which are key to fighting infections.

Keep seedless oranges in a fruit bowl (up to four days with peels intact) for easy grab-and-go snacks.

When it comes to fruits, try to limit your intake to two fruits per day and where possible a fruit should be consumed with the skin on for that extra fibre.

  1. Spinach

Spinach is rich in vitamin C. It’s also packed with numerous antioxidants and beta carotene, which increases the infection-fighting ability of your immune system. Spinach is healthiest when it’s cooked as little as possible so that it retains its nutrients.

  1. Yoghurt

Yoghurt is a fermented food that naturally contains lots of probiotic cultures. These cultures help to increase the good bacteria in your gut – the place where more than 70% of your immune cells live.

  1. Oily fish

Salmon, tuna, sardines and other oily fish are a rich source of omega-3 fatty acids. Omega-3 fatty acids suppress inflammation and keep immunity in check.

Fatty fish also contain vitamin D which helps regulate the immune system and is thought to boost the body’s natural defences against diseases.

Vitamin B6 found in fatty fish is vital to supporting biochemical reactions in the immune system.

Make sardines in tomato sauce on toasted low-GI bread with a few slices of avo – creamy and delicious, or if you prefer add anchovies for a salty kick.

  1. Mushrooms

Mushrooms contain antioxidants that provide anti-inflammatory and immunity protection. Cooking mushrooms lowers their anti-inflammatory compounds so it is best to eat them raw or lightly cooked.

  1. Almonds

Almonds are packed with vitamin E, which is a powerful antioxidant. Maintaining ample levels of vitamin E is crucial for maintaining a healthy immune system.

Almonds are also a source of zinc; zinc is an essential mineral involved in the production of certain immune cells.

For a dose of protein and healthy fats, add a spoonful of almond butter to oatmeal.

  1. Green tea

Green tea has high levels of epigallocatechin gallate (EGCG) which is a powerful antioxidant that enhances your immune function.

  1. Ginger

Ginger is another ingredient many turn to after getting sick. It helps to decrease inflammation, which can reduce a sore throat and other inflammatory illnesses.

  1. Garlic

Early civilisations recognised garlic’s value in fighting infections. It’s immune-boosting properties come from a heavy concentration of sulphur-containing compounds, such as allicin.

  1. Turmeric

Research shows that high concentrations of curcumin, which gives turmeric its distinctive colour, help to prevent inflammation.

Use a pinch of turmeric in scrambled egg. If you or your family are new to turmeric, this is a great place to start because the colour is familiar and the flavour subtle.

Make tea by simmering turmeric with coconut milk to make an earthy and comforting beverage aka the popular Golden Milk.

This winter, plan your meals and snacks to include these top 10 powerful immune boosters.

For more information go to www.heartfoundation.co.za or find us on Facebook @HeartStrokeSA or on Twitter @SAHeartStroke

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Winter foot care advice

Podiatrist, Dennis Rehbock, shares winter foot care advice for people living with diabetes.


While winter in South Africa may not be extremely cold and snowy like other places in the world, it can be unpleasant and pose some dangers to the feet of a person living with diabetes.

Foot care is of great importance to a diabetic patient and should be practiced every day. But, in winter it’s even more important if the patient is high risk, such as poor circulation, Raynaud’s disease (a condition in which some areas of the body feel numb and cool in certain circumstances), peripheral neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), or any foot ulceration.

Winter foot care tips

  • Check your feet every day. Do this yourself if you can or get a family member or helper to do it. This will enable you to see any problems before they happen.
  • Inspect for any lesions, discolouration, swelling, dryness, corns, cracked heels, peeling skin (especially in between toes), pain and numbness. Anything new or unusual should be seen to as soon as possible.

Even in this COVID-19 lockdown period you may and should go to your podiatrist or diabetic doctor for any problem or foot problem that you are having.

Keep your feet dry and warm

  • Wash your feet daily. Dry them very well, especially in between the toes. Be gentle.
  • If necessary, use foot powder on them before you put your socks and shoes on.
  • If you have very dry feet then moisturise them daily after your bath or shower.
  • Use an urea-based cream that is especially for dry feet. There are many on the market these days.
  • Do not cream in between your toes. Rather keep that area dry. 

Socks

  • Any socks that are worn should be soft, warm, comfortable and should not have seams in them that could damage your skin. You do get special socks for diabetic feet to protect them.
  • The sock material should be a moisture-wicking material to keep the feet dry. Cotton, wool and merino wool is good for this purpose.
  • Modern sports and running socks are also made from materials like Drynamix and merino wool (see Falke and Balega socks).
  • Some sock materials are infused with silver and copper to help with bacteria.
  • Change your socks daily.

CAUTION: If you have cracked wet itchy skin in between your toes, go and see your podiatrist. It may be a fungus (Athlete’s foot) that needs treatment.

Shoes

  • In winter, it is best to wear closed shoes that will keep your feet warm and protected. They must keep your feet comfortably warm to help prevent chilblains, ulceration and Reynaud’s.
  • The shoes should fit well and not cause any pressure or friction. They must also have good traction to help prevent slipping and falling.
  • When you are around at home it is okay to wear thick soft warm sheepskin slippers.

CAUTION: Please do not heat your feet up in front of a fire, or a heater, or in any hot bath or footbath. Electric blankets must be used with extreme care.

Dry skin and hard skin

  • If you have dry skin on your feet, moisturise them as mentioned.
  • If you have hard skin, like corn, blisters and callouses, refrain from any self-treatment. Do not cut them yourself or use any acid-based creams on them. This is dangerous if you have poor peripheral circulation or peripheral neuropathy.
  • Go and see your podiatrist for professional treatment of these lesions.

CAUTION: Do not cut these lesions yourself.

Nail care

  • If you can reach your nails and see them well then you may carefully cut your own nails. Cut straight across and file them to make them smooth.
  • If you cannot reach or see them well then please do not cut them yourself. Go and see your podiatrist for regular foot care and they will cut your nails.
  • Other nail pathologies also need treatment. Damaged nails, ingrown nails, fungal nails can also be treated.

Peripheral nerve changes

  • Nerve changes in the feet can occur in patients living with diabetes. If your feet go numb (peripheral neuropathy), it can be a bad thing.
  • Nerve changes can affect your ability to balance, to feel pain and foot damage. Your ability to feel heat could also be affected and this may cause foot damage without you knowing.
  • Check the temperature of your bath before you get into it.
  • Do not sit in front of a heater or fire to warm your feet. You could burn them.
  • Keep your blood glucose levels well-controlled. Monitor your diet, exercise regularly, and avoid smoking.
  • Have your feet screened once or twice a year for neural and vascular changes.

Circulation

  • The peripheral circulation is often affected in people living with diabetes. This can lead to minor vascular lesions in the feet, like chilblains, and to more serious lesions, like ulceration.
  • Chilblains are a typical lesion that can occur in very cold weather, especially with sudden changes of temperature. If your circulation is also poor then you are at great risk of getting them.
  • The lesions present as red/blueish patches on the skin of the feet and toes. This can also occur on the hands or other exposed areas. The small blood vessels go into a spasm and are usually painful. They are usually self-limiting, but if necessary, they need treating.
  • Keeping your feet gently warm, and not smoking is important as smoking is a factor in the cause of chilblains. There are rub-on-creams that may help.
  • In more severe cases, oral medication may be necessary to improve the peripheral circulation.
  • Exercise also helps improve the peripheral circulation.
  • It’s been observed that COVID-19 positive patients may have chilblain-like symptoms on the feet. Painful lesions that look very much like chilblains can appear in these patients, so care must be takes in the diagnosis of the chilblains.

Summary

  • Go and see your podiatrist regularly (once or twice a year) or if you have any sudden foot problems in winter.
  • Do not treat your own feet. Look after them, observe them daily, but go for professional treatment when necessary.
  • Be very careful of using any unusual, untested products on your feet. Rather get professional advice.
  • Urea-based foot creams or heel balms are good to use for dry feet.
  • If you see any signs of infection or ulceration on your feet, go immediately to your foot care professional.
  • Smoking is bad for your peripheral circulation.
  • Exercise is good for your peripheral circulation. Get moving and go and walk or run.

MEET THE EXPERT


Dennis Rehbock is a podiatrist in private practice in Johannesburg. He has been a part-time lecturer and clinician at the University of Johannesburg Podiatry Department for 37 years. His special interest includes podiatric sports podiatry and the diabetic foot.


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Diabetes complications – your screening check list

Diabetes nurse educator, Christine Manga, explains why screening for diabetes complications should form part of your diabetes healthcare plan.


Screening for diabetes complications

Diabetes is a disease that affects and damages the vascular system, large and small blood vessels. It is damage to the vascular system that leads to diabetic complications.

Large blood vessel damage is associated with increased risk of heart attack and strokes. Small blood vessel damage is associated with increased risk of kidney failure, retinopathy (blindness) and peripheral neuropathy.

Maintaining good blood glucose control can help with delaying and possibly preventing complications. But this alone is not enough. Blood pressure and cholesterol levels also need to be managed.

Screening for diabetes complications should form part of your diabetes healthcare plan. Regular screenings allow for early detection of complications before you are aware of the problem.

Most of the complications are ‘silent’ with symptoms developing after damage has occurred. All people with diabetes should undergo screening for complications.

Screening for retinopathy

Eyes should be screened annually. An ophthalmologist usually does the screening, though some optometrists have the training and equipment required to perform the test.

Drops are placed into the eyes to dilate (widen) the pupils so that the examiner can see the retina of the eye. The drops may cause your vision to blur and driving would not be possible for a few hours after the procedure.

Any abnormal blood vessels, scar tissue, new blood vessels, swelling, bleeding or fatty deposits in the retina will be detected. In addition, any damage to the optic nerve and cataract development would be observed.

A separate test will be done to measure the pressure of the eye. Increased eye pressure, a condition called glaucoma, can also cause blindness.

The results of the screening will show:

  1. No signs of the complications.
  2. Early signs of complications.
  3. Follow-up and treatment decision required. Treatment may not improve sight, but it can prevent further deterioration.
  4. More frequent check-ups required.

Early detection and treatment of eye complications is usually successful and can prevent vision loss.

Screening of peripheral neuropathy 

Peripheral neuropathy is pain, weakness or numbness in the feet and, occasionally, hands caused by nerve damage. It can also present as a burning sensation or pins and needles.

Due to damage of the small blood vessels, the nerves can’t receive nourishment. The blood vessel damage will cause ischaemia (poor blood circulation) in the lower legs and feet. This can further cause redness or a blueish tinge, swollen and sore feet. It also increases the risk of developing skin infections and skin ulcers.

Seeing a podiatrist (foot specialist) at least once a year is recommended. A podiatrist will examine your feet for blood flow, temperature, sensation and general condition. They may detect a ‘silent’ loss of sensation.

You will also be educated on good foot care. This will include the teaching of self-foot examination, proper nail cutting technique and the importance of foot moisturisation. Footwear choices as well as the appropriate type of shoes for your feet and how to wear in new shoes will be discussed.

Blood pressure and cholesterol screening

Blood pressure should be checked at least every three months. This can be tested at a routine visit to the doctor, your local chemist or at home on a home device.

Blood pressure targets should be personalised and discussed with your doctor. There are general guidelines that he/she will follow. Blood pressure and cholesterol management go hand in hand.

A lipogram, a full cholesterol test, checks all aspects of the cholesterol and should be performed annually. The reference ranges of results are different for people with diabetes who have more risk factors compared to the general population. Medication and dietary modification will be prescribed to manage these conditions if necessary.

Dental screening 

People with poorly-controlled diabetes are at a greater risk of developing dental problems, such as periodontal disease. Other oral manifestations could include a very dry mouth, a burning sensation in gums, delayed healing of mouth sores as well as an increased frequency and severity of infections.

Poor glucose-control exacerbates dental complications. The reverse is also applicable, periodontal disease worsens blood glucose control.

Dental treatment may need to be delayed until blood glucose levels are under control. A dental screening should be performed at least every six months.

Early detection is key

It is vital that screening is done on a regular basis for all possible complications. As stated earlier and cannot be emphasised enough, early detection is key to early management.

eating time budget

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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Why experts recommend urea for the treatment of dry skin

According to medical experts, urea, an organic compound, is the gold standard treatment for dry skin. We learn why this is so.


When it comes to treating patients, and giving advice on special conditions, doctors often turn to trusted medical bodies and their latest research for advice.

Dry skin (or xerosis cutis) is a common skin complaint, caused by internal and external factors disturbing the skin’s moisture balance. This skin condition is highly prevalent among the South African population. Yet, surprisingly, there was no standardised approach on how best to treat the condition until recently.

Medical experts agree on the best way to treat dry skin

In 2018, a group of renowned physicians published a medical paper on the Diagnosis and Treatment of Xerosis cutis. The report summarises the latest research findings in the prevention, diagnosis and treatment of dry skin and gives doctors practical advice on how best to treat the condition.

The medical paper states that dry skin can, in principle, be treated effectively. The decisive factor in the effectiveness of dry skin treatment is choosing the appropriate care product.

Moisturising should involve a combination of hydrating and lipid-replenishing ingredients, formulated to restore the skin’s natural barrier function in the best possible way and prevent skin from drying out further.

Urea – the gold standard treatment    

The paper explains that, “based on the available scientific data, urea is the gold standard for the therapy of xerosis cutis1.”

Urea has the advantage of being effective on two fronts; as a natural moisturising factor, it binds moisture into the outermost layers of skin. Plus, it also supports desquamation which is the natural process by which skin sheds dead skin cells. Healthy desquamation is linked to smooth skin.

The Diagnosis and Treatment of Xerosis cutispaper also explains that when urea is combined with other moisturising ingredients and lipids, the effect is even better: It states, “The combination of urea with ceramides, NMF and glycerol shows a significantly better effect than the effect of urea or the vehicle alone2.”

Eucerin UreaRepair PLUS

Eucerin scientists were the first to effectively include urea in a dermo-cosmetic product, and now have more than 25 years’ experience of maximising the benefits of urea in skincare formulas. Experience that includes more than 30 clinical and dermatological studies, involving 10 000 volunteers.

The lotions and creams in the Eucerin UreaRepair PLUS range offer people with dry skin exactly what the independent expert paper recommends. The formulas include:

  • various concentrations of urea (ranging from 5% to 10%).
  • other natural moisturising factors (NMFs), ceramides and gluco-glycerol.

The range is clinically and dermatologically proven to offer immediate and 48hour dry-skin relief.3

Urea and 17 other natural moisturising factors help the skin to attract and bind in moisture, thereby improving the symptoms of dry skin.

Ceramides repair and strengthen the skin barrier and thus reduce moisture loss.

Urea binds water into the outermost layers of skin and, at the same time, breaks down the connections between dead skin cells. This promotes desquamation and ensures a smoother skin surface.


References:

  1. Augustin M et al., Diagnosis and Treatment of Xerosis Cutis. JDDG, July 2018: Suppl 4, Volume 16.
  2. Weber TM et al., J Clin Aesthet Dermatol 2012, 5:29–39.

3. Beiersdorf. Data on file


For more information please visit www.eucerin.co.za


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Make your medical aid work for you

Sarah Nicholson, Justmoney’s commercial manager, offers ten tips to help ensure you enjoy the medical aid scheme benefits to which you’re entitled.


Extremely high medical costs mean that many South Africans prudently subscribe to a medical aid scheme. But how do you make the most of your selected package, which needs to meet your medical needs for the year ahead?

Read the fine print

You may have stayed with the same plan for many years. Take time to understand the rules and benefits, which may have changed since you first signed up.

Maximise your money

Take up preventative health screenings and tests, free vaccinations, and baby programmes. You may also decide to register for a programme to better handle a chronic condition.

Explore loyalty programmes

Benefits could vary from product discounts to travel and retail promotions, and subsidised gym memberships.

Spread out claims

Rather than blow your allocation early in the year on over-the-counter purchases, speak to your pharmacist and health practitioners about how to best allocate medical, optical, and dental purchases.

Keep your benefits for essential medicines and services to be used as the need arises. This is especially important if you have small children or sickly dependants.

Choose wisely

Build up a good relationship with your pharmacist, who can advise you on general health topics from seasonal allergies to stress management.

Ask your doctor to prescribe generics which cost less. Whether you are looking at over-the-counter medication, or prescription drugs, generics can cut your bill considerably. You can also shop around and compare prices.

On the record

Be meticulous about filing claims and saving correspondence.

Plan for a procedure

If you require an operation or specialist treatment, obtain pre-authorisation. Do your homework, get a quote from the hospital and medical practitioners before you are admitted. Determine if there will be a shortfall and plan how to fund this. Check if you can use designated healthcare providers on your medical aid’s network for cheaper negotiated rates.

Back a buddy

Oncology and other treatments can make one feel under par for a lengthy period. Ask a family member or friend to help you keep track of medical claims and submissions, or offer to do the same for them.

Conflict resolution

If you’re having difficulties resolving a problem with a call centre agent, find out if your medical aid has a walk-in service. Dealing with someone face to face can help resolve a problem quicker.

Saving grace

Should you have problems keeping up with payments,speak to your medical aid about alternative, cheaper plans. Don’t drop your medical aid completely as medical bills can be enormous.

If you don’t yet have a medical aid, do comparisons online or ask for advice from a qualified broker. This will help you to choose the scheme and plan that offers the best possible cover for your age and personal circumstances.

MEET THE EXPERT


Sarah Nicholson is the commercial manager for Justmoney. Justmoney is a personal finance website that provides busy and digitally savvy South Africans with easy access to financial products, services and information, including medical aid.


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