Keep an eye on your diabetes

Dr Paula Diab advocates the need to move away from a curative, rehabilitative model of treating diabetes and invest time and money into preventing the complications, such as eye disease, by early detection, timeous treatment where necessary and appropriate follow-up.


It’s probably fairly common knowledge that diabetes can affect your eyes and, in some cases, even cause people to lose their sight completely. It’s estimated that over 7 million people over the age of 40 have some degree of diabetic retinopathy and that this number will increase to 11 million by 2030. The good news though is that it’s estimated that 95% of severe visual loss from diabetic retinopathy can be prevented.

Who is at risk?

All people with diabetes, be it Type 1 or Type 2 diabetes, are at risk. Complications are more common in those people who have had diabetes for longer or whose diabetes has been uncontrolled, but that doesn’t mean that everyone else is safe.

Anyone who already has another form of vascular disease is already at high-risk of developing eye disease. The blood vessels in the eyes are obviously much smaller than those in the heart, brain and limbs so we can often pick up early vascular disease much earlier by shining a light in the eye than we can on an angiogram. Anyone who already has heart disease, suffered from a stroke or heart attack or poor limb perfusion is most certainly already at high-risk.

Because the eyes also have multiple vessels that supply them, the clinical signs of poor vision don’t always correlate with the pathological decline. In other words, it’s not reliable to wait until you experience visual loss or a deterioration in your vision before getting your eyes examined.

How is it detected?

The only way of detecting diabetic eye disease is by regular screening by an optometrist or ophthalmologist. This is not the same as your annual update of your glasses or contact lenses. This is a comprehensive examination where the optometrist or ophthalmologist is specifically looking for complications related to diabetes.

When we renew our script for glasses or contact lenses, we are concentrating mainly on the lenses, the windows of the eye through which we see. In diabetes, we need to assess the blood supply and the potential damage to the retina of the eye which often requires a more sophisticated examination and photographs to be taken. Current South African guidelines recommend that every person with diabetes has their eyes screened at least annually from the time of diagnosis of diabetes, even in childhood.

As mentioned above, please don’t wait for deterioration in your vision before you seek help; at this stage it’s often too late. Regular monitoring and documentation of declining eye function often encourages a diabetologist to enhance medical therapy and prevent the decline in vision before it becomes noticeable. This is why comprehensive care and good communication amongst the various specialists is vital.

How can eye disease be treated?

Firstly, and most importantly, addressing any additional risk factors is very important.

  • Stop smoking.
  • Ensure that your blood glucose levels, blood pressure and cholesterol levels are well within target and that you’re taking all the correct medication.
  • Maintaining a healthy diet and regular physical exercise will also go a long way to ensuring good cardiovascular health.

Some eye conditions can be treated with eye drops and topical medications whilst others may need surgical intervention. Eye surgery and treatment has progressed at a rapid rate over the last few years and many procedures are extremely safe, quick and have remarkable outcomes. However, the longer that these diseases are left before treatment is commenced, the more difficult it becomes and the more the prognosis deteriorates.

What type of damage can occur?

Diabetic retinopathy is a general term for all disorders that affect the retina caused by diabetes. The retina is the back surface of the eye where all the blood vessels are found and where the images we see are imprinted onto the retinal cells. It stands to reason that if these blood vessels are blocked or leaking in any way, that the images we see may not be correct.

Proliferative retinopathy refers to the new vessels that are formed when older vessels become damaged or obstructed. These new vessels are often fragile or weak and can leak into the vitreous humour (jelly-like substance at the back of the eyeball) causing haemorrhages, scar tissue and even retinal detachment.

Non-proliferative retinopathy refers to the phenomenon where capillaries in the back of the eye balloon and form pouches. As the condition worsens, more blood vessels become blocked depriving areas of the retina from their blood supply. This results in new but weaker vessel formation.

Maculopathy is when fluid leaks into the centre of the macula, causing the macula to swell and blur the vision. The macula is the central area of the retina where colour vision is perceived and where the image is the most focussed.

Cataracts may also be found as a result of diabetes although they may also occur independently of blood glucose levels. These cause cloudy vision and difficulty with night vision.

Glaucoma (damage to the optic nerve) caused by an increased pressure build-up within the eye can also be a consequence of diabetes and may occur quickly or over a longer period of time but can also have a severe impact on vision.

What should you do? 

Talk to your doctor today and ask for a referral to get your eyes tested as soon as possible. South African guidelines recommend that you get your eyes checked annually regardless of what visual symptoms you may have.

Trials have shown that good glycaemic control, managing other risk factors and regular eye screening can prevent or delay many complications related to diabetic eye disease. Test your glucose levels regularly and understand the fluctuations that occur on a daily basis. Ask your doctor to explain how you can manage your diabetes more effectively and look for complications. Don’t wait for the symptoms before you act.

Finally, please don’t put off these tests because you can see okay or just got new glasses last month. Diabetic eye disease is preventable and treatable if detected early. It’s also an excellent sign of other vascular damage in the body and a skilled clinician will be able to adjust your chronic medication to address these changes and prevent any further damage taking place. There is no need to lose your vision due to diabetes.

Dr Paula Diab

MEET THE EXPERT


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


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The benefits of Cupping therapy for people living with diabetes

Farhana Cassim, a Cupping therapist, explains the benefits of Cupping therapy, highlighting the good it does for people living with diabetes.


What is Cupping therapy?

Cupping is a safe, non-invasive and inexpensive technique that has been practiced since ancient times. It’s used to alleviate the pain and discomfort arising from disorders of internal organs, and muscle spasms, joint pains, diabetic neuropathy and numerous other conditions. There are three types of Cupping: Dry-, Wet- and Massage Cupping.

After a long period of neglect, Cupping was revived in the Islamic age. Strict adherence to rules of application was demanded, with close attention to timing and patient condition. Traditional healers in many parts of the world use Cupping or versions of it in their healing repertoire. The technique has historically been used by practitioners of conventional medicine for many centuries to treat a range of diseases. It’s also an important aspect of traditional Chinese medicine.

How does it work?

Cupping causes the tissues beneath the cup to be drawn up and swell. This increases blood flow to the affected area. This enhanced blood flow under the cup draws impurities and toxins away from the nearby tissues and organs to the skin.

The release of the vacuum redirects toxic blood that had pooled at the site and redirects it to other areas of the body, thus allowing fresh blood to replace it. This facilitates the healing process. Localised and deep-tissue healing takes place.

Cupping diverts toxins and impurities from important organs, such as the liver or kidney, to the upper surface of the body.
In Dry Cupping, the toxins are brought to the underlying skin. In Wet Cupping, the toxins are brought out of the body, onto the surface of the skin. This process strengthens the immune system, so encouraging the optimum functioning of the body.

The benefits

Cupping assists the liver by increasing blood perfusion, so removing the metabolic load imposed by the disease and perhaps any drugs used to treat the disease. It also supports the immune system, by acting on the reticuloendothelial system to help it in opposing the actions of invading microbes. In addition, Cupping supports the nervous system, by helping to reverse ischaemia (reduced blood flow), which can lead to conditions characterised by cerebral metabolic insufficiency, such as memory disturbances, epilepsy and emotional conditions.

It supports the renal system, by helping to reverse the ischaemia which underlies many disorders. Cupping is also involved in the release of cortisol and serotonin, important mediators in pain and stress. Added to that, it also stimulates meridians, and releases biological opioids called endorphins.

Clinical value

The benefits have been extensively researched and documented. Cupping is recommended for people with recurring, refractory headaches, skin disorders, stomach pain, boils; disorders of the heart and circulation, such as varicose veins and hypertension; joint and neck pains, for example, arthritis and rheumatism; diarrhoea and vomiting; menstrual cramps; bronchitis; colds; asthma; infertility; impotence; and haemorrhoids, amongst other ailments.

The clinical benefits of Cupping continue for several days after the procedure. These are for most ailments that effect a large number of diabetic patients.

The use of whichever form of Cupping is at the discretion of the practitioner.

Studies in people with diabetes

Diabetic patients (Type 2) that were treated with Cupping therapy, the results showed that blood glucose levels were lowered consistently in almost all experimental patients subjected to Cupping, when comparing blood glucose levels before (mean 11.98 ± 10.11SD) and after (9.86 ± 8.93 SD).

On quality of life issues, people with diabetes showed substantial improvement in patient health parameters when the final cupping session was compared to the initial one. The majority of patients showed an increase in energy levels and improvement in sleeping habits.

Although Cupping is not a cure for diabetes, it can assist by detoxing the body and blood by reducing the toxic accumulated waste in the body and improving blood circulation. Cupping also assists in cleansing the blood and cells, resolving stagnation and blood stasis in the body.

Diabetes can make it difficult to control your blood pressure and cholesterol, which can lead to heart attacks, stroke and other serious conditions. Cupping increases blood flow in the body and improves circulation; it also reduces blood pressure and cholesterol when performed regularly.

Farhana Cassim is a Hijama Cupping therapist certified via Hijama Association South Africa. She is passionate about bringing benefit to mankind, your health is your wealth. Cupping 4 Cure

MEET THE EXPERT


Farhana Cassim is a Hijama Cupping therapist certified via Hijama Association South Africa. She is passionate about bringing benefit to mankind, your health is your wealth. Cupping 4 Cure


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Foot pain and reflexology treatment

How delightful would it be to dance into spring with pretty painted toes, soft heels and, more importantly, no foot pain? It’s possible.


“The job of feet is walking, but their hobby is dancing.” Amit Kalantri

First, a little bit more about these two important, yet sadly often neglected parts of your body. The feet really do have a rotten deal. They carry us throughout our lives, get shoved into ill-fitting shoes and are seldom given the praise and recognition they deeply deserve.

As a Pilates instructor and therapeutic reflexologist, I’ve seen 100s of pairs of feet in my studio; all of which tell a tale. Hardly ever have I heard anyone say, “I love my feet.” They are always berated and presented to me with embarrassment and copious apologies for how ugly they are.

The magnificent structures of feet

Each foot consists of 26 bones, 33 joints, over 30 ligaments, 19 muscles and tendons. Don’t forget the 250 000 or so sweat glands in both, or the 7 000 nerves in each.

The feet are the most superb shock absorbers. They cushion up to approximately 454kg of pressure during one hour of strenuous exercise. They provide support of up to 1,2 times our body weight while walking and 2 to 3 times that while running.

The feet are our foundation and keep us balanced. Since 25% of the body’s bones are in our feet, when they are misaligned the implications for our posture are enormous.

What your feet say about you

From a reflexology perspective, the feet can tell a tremendous amount about the state of our mental, emotional, and physical health.

A therapeutic reflexologist can look for signs of disease and pain in the different regions of the foot which have reflexes corresponding to the various organs and systems of the body.  Seldom are these wrong. So, while a reflexologist may not diagnose, they can assuredly suggest where you need to pay attention in your health concerns.

Problems which feet present are many and varied. The most common are:

  • Neuropathy – common in diabetes
  • Hammertoes
  • Bunions
  • Cracked, painful heels
  • Morton’s neuroma
  • Dropped arches
  • Plantar fasciitis

These are the tip of the iceberg and all play a significant role in the rest of your body’s health and posture as when your feet are painful, we compensate when we walk, and the quality of life is seriously impacted.

Identifying the culprits

Unfortunately, it’s neglect, lack of awareness, poorly-fitting shoes (the biggest culprit), high heels, cold temperatures and in particular never walking barefoot that contribute to foot pain. Do your feet a favour, take those shoes off and go and walk on the grass. They will love you for it and the health benefits are far-reaching. Watch Earthing Movie for more information on this powerful yet free health supplement right under your toes. (Please note if you have lost sensation in your feet due to neuropathy, it’s advisable to not walk bare feet).

Addressing foot problems

Apart from visiting a podiatrist and taking up Pilates which will teach correct foot placement and how to walk properly, reflexology is a brilliant modality to assist with foot problems.

Remember that reflexology is not simply a foot massage. A properly qualified therapeutic reflexologist has tremendous knowledge of the feet, the reflexes and what they reveal and how to work these reflexes correctly and effectively.

Many health issues can be noted and assisted with reflexology. For example, bunions (those painful bumps that develop on the side of the foot under the big toe) aren’t only due to incorrect foot placement and poorly-fitting shoes but may also indicate blood glucose imbalances or thyroid pathologies.

Constant and painful, deeply cracked heels aren’t only dryness but more often than not a sign of poor gait, as well as lower back problems or issues in the reproductive organs because the heel reflex corresponds to the pelvic and lumbar area of the back. You can go for as many pedis as you like. Until your address the underlying issues, the cracked heels will persist.

Plantar fasciitis which is that horrendous pain in the sole of the foot could relate not only to badly-fitting shoes, but also to tight calf muscles or even a tight lower back. And, from a reflexology perspective, kidney issues.

Neuropathy, the diabetic patient’s nightmare is a numbness of the feet which can be lethal as often pain and injuries can’t be felt and can often lead to more serious symptoms. Reflexology will bring unnoticed injuries to your attention and will also stimulate feeling in the feet.

Awaken the reflexes

Reflexology will awaken these reflexes, bringing energy to the relevant areas encouraging healing to occur. Of course, a session is usually wrapped up with a relaxing foot and calf massage which will loosen tight calves, mobilise immobile ankles, and bring much needed love and relief to sore, tired feet. Reflexology is a many faceted bonus for the body and feet.

Let’s start spring with not only a step but a dance in our feet. Look at your feet with new eyes and thank them for how well they carry you through every moment of your life.

MEET THE EXPERT


Fiona Hardie has recently relocated to the Western Cape and is teaching Pilates online and looking to further her offerings with Rebounding. She is also studying yoga and new modalities that will facilitate the healing that is so necessary today. She is focusing on growing her online presence and when she finds the right space she will open a Pilates and therapy studio.


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Reflexology for menopause

Fiona Hardie explains how reflexology can help with easing the symptoms of menopause.


Menopause is a momentous time in a woman’s life marked by major transitions. From cessation of her periods, physical changes in her body, emotional highs and lows, and her general identity shifting, menopause is the ideal time when a woman needs more than ever to care for herself psychologically, emotionally, spiritually and physically.

The threat of ill-health is also ever greater as blood glucose levels fluctuate due to hormone imbalances that are more prevalent, making it harder to keep diabetes well-controlled.

Generally occurring between the ages of 45 and 55, menopause is when fertility ceases, and oestrogen and progesterone are no longer produced by the ovaries. This really need not be a time of discomfort, hot flushes or depression, particularly if a therapy such as therapeutic reflexology is made use of regularly.

What is therapeutic reflexology?

Therapeutic reflexology is an ancient treatment which involves stimulation of the tops and soles of the feet (hands, face and ears can also be treated) using the thumbs to apply pressure.

Reflexology is not a foot massage but a targeted treatment using a specific technique which aims to bring the body’s systems into a state of homeostasis or balance. The reflexes that are worked on correspond to different parts of the body. For example, in working on the ball of the foot which is the lung reflex, the actual lungs will be stimulated together with their partner meridian the lung meridian.

Benefits related to menopause

This makes for a powerful treatment to aid in alleviating many of the symptoms of menopause, such as bloating, constipation, insomnia, brain fog and not to mention the ever-dreaded hot flushes.

Several clients enduring hot flushes and who after receiving reflexology, noticed a considerable drop in the occurrence and severity of these sweaty episodes. It’s suggested that at onset of any symptoms, in fact even before, a regimen of reflexology sessions be started and continued regularly throughout these years.

What will reflexology will alleviate?

Reflexology will in alleviating other symptoms such as:

Hot flushes

The hypothalamus is a gland in the brain that regulates body temperature by sending signals to the organs, muscles, and endocrine and nervous systems. During menopause the body becomes more sensitive to fluctuations in core body temperature, so enlargement of blood vessels and sweating is increased. By working the big toe which is where the reflex for the hypothalamus is located, this function can be regulated.

Hormone regulation

The reflexes of the endocrine glands, such as the thyroid, and the reproductive system, such as the ovaries and uterus, are stimulated to ensure energy flow and harmony in these areas. And of course, the release of “love” hormones, such as oxytocin, enhance the feeling of well-being and self-care. Feeling good about oneself is of great importance during this massive transitory period.

Insomnia

Recipients of a session report better quality sleep. Reflexology is extremely relaxing and this in itself can help the body to regulate itself for it’s when the body is relaxed, it’s able to heal and function efficiently.

Anxiety

Due to the adrenal glands producing more of the stress hormones, adrenalin and cortisol, anxiety levels can increase exponentially especially as an array of other hormones are also out of balance. Reflexology brings about a wonderful feeling of ease and hence a reduction in anxiety. Coupled with anxiety is very often a dose of constipation. By working on the sole of the foot where the digestive reflexes are situated, regular bowel movements are encouraged.

Peripheral neuropathy

The loss of sensation in the extremities particularly the feet which can be problematic in people with diabetes. Reflexology is very effective in ensuring blood flow to the feet, stimulating the nerves and keeping the heels well-moisturised as a treatment is usually wrapped up with a nurturing oil or cream massage. The reflexologist can also pick up if there are any cuts or sores that perhaps have not been felt by the patient.

Research

Research into reflexology sessions on menopausal women found that two sessions a week for six weeks significantly reduced fatigue, total cholesterol levels and cortisol levels.1

Therapeutic reflexology is a well-respected therapy and modality which can hold its own as an extremely effective ongoing treatment not only for menopause or to ease symptoms thereof, but to maintain a healthy, well-functioning body. When we feel loved and nurture our bodies, our minds respond with health and calm. A therapeutic reflexology session can give that and so much more.


Reference:

  1. (Ref: Evidence based reflexology research for Health Professionals and Researchers by Barbara and Kevin Kunz pg. 89).

MEET THE EXPERT


Fiona Hardie has recently relocated to the Western Cape and is teaching Pilates online and looking to further her offerings with Rebounding. She is also studying yoga and new modalities that will facilitate the healing that is so necessary today. She is focusing on growing her online presence and when she finds the right space she will open a Pilates and therapy studio.


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Changing medication: why it’s necessary to keep up-to-date

Diabetologist, Dr Paula Diab, explains the four scenarios in which changing medication is needed when treating diabetes.


Very often we get stuck in a place where we’re comfortable. We tend to stick with the same toothpaste or washing powder and go to the same restaurant for dinner. It’s good to feel comfortable but sometimes change is also good. This doesn’t mean a new set of wheels every year or trying out every restaurant in town, but it’s good to re-evaluate things from time to time.

So, why should you change your medication?

  1. Firstly, diabetes changes

It’s a little-known fact that the underlying pathogenic metabolism of Type 2 diabetes is present prior to the actual diagnosis of diabetes. What this means is that the cells in your body that produce insulin are significantly damaged even at the very start of your journey with diabetes. It’s important to remain ahead of these changes and ensure that the medication that you’re taking is constantly providing maximum benefit both in terms of managing your day-to-day health and preventing further damage and complications.

Over time, further pathological changes occur in the body which often necessitates a change in medication. Kidneys or vessels may become damaged and may require additional support or protection. These changes may occur not only because of lifestyle or dietary choices but purely due to the development of diabetes through the years. In addition, it also doesn’t make sense to continue targeting your therapy at a damaged organ. For example, as the cells in your pancreas become damaged, stimulating those cells to produce more insulin is like flogging a dead horse. Rather target a different pathway or mechanism of action.

  1. Your lifestyle may change

The most obvious example here is to compare a busy thirty-year-old working mother to a retired old lady living in an old age home where meals are provided at set times and activity is limited, not only by choice but also by physical ability. The same medication isn’t going to work for both of these people.

Some people eat erratic meals; they may eat out often, have business lunches whilst others have little to no control over their choice of food. Activities change on a daily basis and over time. The day you run a half marathon will require a different strategy from the rainy weekend you spend watching movies at home.

Sometimes our financial position and priorities in life also change. Rather than struggling with the same status quo, we may need to consider a different perspective. As we get older, our metabolism changes, our lifestyles change, and our goals change. Medication may also need to change.

  1. New medications are developed all the time

In just over two decades of managing people with diabetes, the scope of medication has almost completely changed. Some of the original medications used, no longer exist and others have been completely replaced. In fact, there is probably not one single tablet or insulin that was popular then, that is still used frequently today.

In the last two years that we have all been staying home and avoiding public events, there have been about eight new drugs developed and launched on the South African market specifically targeted for diabetes. This includes one completely new combination of medication as well as new delivery devices. Continuous glucose monitoring systems and pump therapy has changed, and closed-loop pumps are now also on the market.

These new drugs often provide an easier dosing regime, upgraded technology or an improved side effect profile. Recently, pharmaceutical companies have also been working at combining different classes of drugs so that multiple pathways can be targeted at the same time. Drugs that work synergistically not only benefit your body in that they often have a complementary side effect profile and enhance the action of the other but are also much easier to administer and reduce the burden of a box full of medication every day.

Researchers are also working on looking at additional mechanisms of treating diabetes and managing high glucose levels. Is it possible to prevent complications or even enhance the functioning of certain organs at the same time as managing your daily glucose fluctuations? There are very few other chronic diseases where the medication aims to treat daily symptoms and prevent further damage. This is exactly what we are striving for in diabetes.

  1. Protocols also change

The new South African guidelines are due to be released towards the end of this year. These will cover a range of topics that are associated with diabetes and provide expert guidance in terms of best available evidence. Although these guidelines are updated every five years, financial implications often mean that they don’t make their way into routine care. However, evidence-based, cost-effective medicine is still the ultimate goal of every healthcare provider no matter where they work or who the patient is.

Your responsibility

It’s your responsibility as a person living with diabetes, to identify key lifestyle factors that may influence your diabetes management and discuss these with your doctor.

Your doctor’s responsibility is to keep up to date with latest guidelines, evidence and protocols and to understand how the medications work.

The art of medicine is then beautifully demonstrated in the conversation that follows where doctor and patient work together to negotiate and decide on the best possible plan for that individual. A plan that is cost-effective, simple, evidence-based and will ultimately reduce the burden of diabetes.

Regular follow-up and changes to your medication shouldn’t be seen as a failure or medical authorities trying to benefit financially from the situation, but rather an opportunity to achieve a healthier and more manageable outcome. Ask your healthcare provider to assess your individual risk and situation and discuss the various alternatives with you: how the medications work, why they’re preferable and what benefit they have, and then you can make an informed decision about your health and disease management.


References available on request  

Dr Paula Diab

MEET THE EXPERT


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

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The GlucaGen hypo kit

Kate Bristow, a diabetes nurse educator, explains how to use a GlucaGen hypo kit and what to be aware of.


Hypoglycaemia or low blood glucose can be a diabetes emergency. Let’s talk more about how to manage this and when to use the GlucaGen kit.

Recognise a hypoglycaemic episode

The first thing that is important is to recognise a hypoglycaemic episode.

Early signs include:

  • Sweating
  • A feeling of tiredness
  • Dizziness
  • Hunger
  • Tingling around the lips
  • Shaking
  • A rapid heartbeat – palpitations
  • Irritability, anxious feelings
  • Pallor

Symptoms of an untreated low can result in:

  • Weakness
  • Blurred vision
  • Confusion and difficulty in concentration
  • Slurred speech, unusual behaviour, and clumsiness (like being drunk)
  • Sleepiness
  • Seizures
  • Collapsing or passing out

How to respond to a low

 

RESPONSIVE AND ABLE TO SWALLOW CONFUSED AND AGGRESSIVE BUT AWAKE AND ABLE TO SWALLOW UNRESPONSIVE – SEIZURE OR COMA
Give 15g oral quick-acting CHO

e.g. Super C or Coke

Give 15g oral quick-acting CHO

e.g. Super C or Coke

Get someone to help if necessary

This is when if you have a GlucaGen hypo kit, it is time to use it as per below instructions
Wait 15 mins and check blood glucose levels Check blood glucose in 15 minutes and assess responsiveness Call for medical attention if no improvement in blood glucose or readings
If blood glucose has improved resume normal regime
If still low – give a further 15g CHO
If blood glucose has improved resume normal regime
If still low – give a further 15g CHO

What is GlucaGen?

Your GlucaGen hypo kit contains an injection of GlucaGen, a generic drug called glucagon. Glucagon works by triggering the liver to release some of the sugar that it has stored to help increase blood glucose levels.

It’s injected into the outer thigh but it does have to be mixed before injecting it so teach your friends and family how to use it as you may not be able to do it yourself.

The kit comes in an orange box and there are instructions inside the lid to show you how to use it.

  1. Pull out the syringe, slip off the grey needle protector on the syringe.
  2. Clip off the orange cap on the powder-filled vial and push the liquid contents through the rubber stopper into the powder in the second vial. Do not use anything except the pre-filled syringe to reconstitute the powder in the vial.
  3. Keeping the needle inside the vial, turn it the other way over and draw back all the contents of the second vial into the syringe. Make sure you have mixed the contents well before you do this by gently shaking it. You should end up with a clear solution. Be careful not to pull back air into the syringe.
  4. Take the syringe and needle out of the vial and inject into the outer upper thigh. Gently pinch the skin at the injection site and with the other hand insert the needle into the skin and push the plunger downwards until the syringe is empty.
  5. Your doctor should have told you exactly how much to inject. A child may not need as much as an adult so have clear instructions with your kit. The dose is calculated on weight of a child. Generally, a child under 6 years/below 25kg would be given 0,5mg. Over 6 years to adult would be given 1mg/1ml.
  6. After administering the injection, turn the person on their side as a precaution against vomiting and choking.
  7. ALWAYS CALL EMERGENCY SERVICES IMMEDIATELY AFTER ADMINISTRATION.
  8. Be aware that even after using a GlucaGen injection a second hypoglycaemic is possible.

General rules

  • It’s good idea to have two GlucaGen kits prescribed; one for home and another for the office or school.
  • Teach family and close friends how to use the kit in case of emergency.
  • It doesn’t have to be stored in the fridge by do try to keep it in a cool place, easily accesible.
  • In the case of a severe hypoglycaemic event, GlucaGen should be used quickly and medical help should be summoned as soon as possible.
  • Once concious and able to swallow have something sweet by mouth too.
  • Advise your healthcare team every time you have to use the kit. Your diabetes medication may need to be adjusted to prevent hypos.

When not to use GlucaGen

  • In rare cases where there may be other health conditions or rare tumours, GlucaGen is contraindicated. Please check this with your doctor.
  • Severe allergic reactions include rash, difficulty in breathing or low blood pressure. If this happens do not use GlucaGen.

Common side effects

  • Reactions at the injection site, generally localised and will resolve
  • Nausea and/or vomiting
  • Headache and dizziness
  • A feeling of drowsiness
  • Pallor
  • Diarrhoea
  • Low energy levels
  • Low blood pressure

Side effects generally resolve when blood glucose normalises and the effect of the injection wears off.

Final thought

Prevention is better than cure and although it’s essential to have GlucaGen as part of your diabetes emergency kit, we would prefer that if it gets to expiry date that it shouldn’t be used.

If you are having regular hypoglycaemic events, please talk to your healthcare team about adjusting your insulin doses.

When your blood sugar has normalised, resume your normal diabetes regimen with guidance from your diabetes team.

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

MEET THE EXPERT


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


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The four hormones in glucose control

Bongiwe Nkondo expands on the four hormones needed for glucose control: insulin, amylin, incretins and glucagon.


Glucose, also known as blood sugar, is the preferred source of energy by the body cells. It’s transported from the liver or intestines to the cells of the body through the bloodstream. The body has a system that regulates the glucose level so that it doesn’t rise too high or drop too low, as this has detrimental health complications.

The regulation of glucose is done through an intricate system, involving various hormones insulin, amylin, incretins and glucagon.

Blood glucose regulation 101

When glucose levels are higher than normal (hyperglycaemia), the hormone, insulin, is released from the pancreas and this allows the glucose circulating in the blood to be taken up by the body cells and also to be used to create fat cells. This restores the blood glucose to a normal level (euglycaemia).

When the glucose levels are lower than normal (hypoglycaemia), the hormone, glucagon, is released and then the glycogen in the liver is broken down and converted into glucose, restoring euglycaemia.

The four hormones

Insulin

Insulin is a hormone secreted by the beta cells of the pancreas. It’s carefully regulated in response to circulating blood glucose levels. It allows body cells to access glucose for energy and it’s also involved in the creation and storage of fat.

Insulin isn’t secreted if the blood glucose level is less than or equal 3,3mmol/L, but is released if the amount is higher and increases as blood glucose levels increase.

After eating, insulin is released in two phases: an initial rapid release of preformed insulin, followed by an increased secretion by the pancreas and subsequent release in response to the blood glucose levels. There is a long-term release of insulin if the blood glucose levels remain high.

While glucose is the most potent stimulus of insulin release, there are other factors that also stimulate the creation and release of insulin, like certain amino acids, such as arginine, leucine, lysine, and glucagon-like peptide 1 (GLP-1) after a meal, to name a few.

So, how does it regulate blood glucose? When your glucose levels are increased, insulin is released. The insulin allows glucose entry into the muscles and liver, converting glucose to glycogen for storage and the remainder of the glucose is converted into fat cells. Hence, glucose is removed from the blood, restoring the glucose level to normal.

Amylin

Amylin is also a hormone which regulates blood glucose levels and is secreted by the pancreas alongside insulin. It complements the effects of insulin by reducing the blood glucose level after meals and by suppressing the creation of glucagon (which would work to increase blood glucose levels).

In Type 1 diabetes, the secretion of amylin is also deficient. Amylin also helps to slow down gastric emptying, the process by which the contents of the stomach are moved or emptied into the small intestine, and therefore slowing the rate of absorption of nutrients by the small intestine.

Incretins

These are hormones made by the digestive tract and includes GLP-1. They increase the amount of insulin released by the pancreas after eating, even before blood glucose levels become elevated. They also slow down the rate of absorption of glucose in the blood by reducing the rate of gastric emptying/digestion and may directly reduce food intake. Incretins also inhibit the release of glucagon from the alpha cells of the pancreas.

Glucagon

Glucagon is a hormone released by the alpha cells of the pancreas. It’s released in different circumstances: when the blood glucose level is low (hypoglycaemia), or when there are increases in adrenaline and epinephrine when you feel threatened or your body is under stress (fight or flight mode), and due to other factors.

When glucagon is released, the liver converts glycogen (sugar previously assimilated and stored) into glucose, thus raising the blood glucose level and restoring a balance.

Work with a multi-disciplinary team

The body is so intricate and complex. Each organ, hormone and substance play such a crucial role in maintaining balance. Glucose control is reached through the harmonious work of the different elements. When one element is off balance, it has an effect on the balance of the overall system, as seen in diabetes. Therefore, it’s best to work with a multi-disciplinary team to ensure you have the necessary tools to create balance in your body.


References

  1. Holst JJ et al. (2021). The Role of Incretins on Insulin Function and Glucose Homeostasis. Endocrinology 162(7): 1 – 10.
  2. Dong XL et al. (2018). Influence of blood glucose level on the prognosis of patients with diabetes mellitus complicated with ischemic stroke. Journal of Research in Medical Sciences23:10
  3. Mayan KL, Raymond JL. (2017). Krause’s Food and the Nutrition Care Process.14th Elsevier: Missouri.
  4. Stephen LA et al (2004). Glucose Metabolism and Regulation: Beyond Insulin and Glucagon. Diabetes Spectrum 17(3): 183 – 190.
Bongiwe Nkondo is a registered dietitian and has worked in both public and private practise. She is currently the vice chair and CPD portfolio holder of the ADSA Gauteng South Branch Committee. Her areas of interest are optimum nutrition, nutrition throughout the life cycle and non-communicable diseases. She is passionate about empowering people to make better health choices.

MEET THE EXPERT


Bongiwe Nkondo is a registered dietitian and has worked in both public and private practise. She is currently the vice chair and CPD portfolio holder of the ADSA Gauteng South Branch Committee. Her areas of interest are optimum nutrition, nutrition throughout the life cycle and non-communicable diseases. She is passionate about empowering people to make better health choices.

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The connection between kidney disease and diabetes

Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. It’s important to follow the five point treatment plan to decrease developemnt.


The kidney is a vulnerable organ as well as the most important target of microvascular damage in both Type 1 and Type 2 diabetes.

The first description of the association between diabetes and kidney damage in humans was in 1552 BC.2 As the disease spectrum has changed around the world, diabetic kidney disease (DKD) has become the single most frequent cause of end-stage kidney disease.

Kidney involvement both directly and indirectly increase involvement of other organs especially the heart and eye, and increase morbidity and mortality in diabetic patients.

The overall incidence 20 years after the diagnosis of diabetes is approximately 4 to 17% and after 30 years is about 16%. According to some studies the incidence of kidney disease in Type 1 diabetes is decreasing. The main reason for that is early diagnosis of Type 1 diabetes and good control of hyperglycemia.1

In Type 2 diabetes. the kidney damage may be present at the time of diagnosis. This is why it’s so important to screen people susceptible to Type 2 diabetes regularly for abnormal glucose values.

Genetics

Many patients with long-term high glucose have no diabetic kidney disease while others with a short disease course have clinical diabetic kidney disease (nephropathy). This may be due to predisposing factors including genetics.

The risk of diabetic kidney disease increases in Type 1 and Type 2 diabetes if the patient has a history of diabetic kidney disease in one of their first-degree relatives.

Patients living with diabetes who have a family history of hypertension or heart disease are more likely to develop diabetic kidney disease.

Screening

The easiest screening method is to evaluate a urine sample. This can be done in a doctor’s office with a urine dipstick. If this is normal, the urine sample should be sent to a laboratory for a urine albumin-creatinine ratio test.

Natural course of diabetic kidney disease

First stage

The filtration through the kidney tubes, called glomeruli, increases and the kidney enlarge. The urine albumin-creatinine ratio is still normal and blood pressure is also normal.

Second stage: microalbuminuria

With the progression of kidney involvement, urine albumin-creatinine ratio will also increase. This stage is called hidden or subclinical kidney disease.

In this stage, the conventional urine test strip in the doctor’s rooms will be negative but the risk of heart disease starts to increase. With Type 1 diabetes, the prevalence of other microvascular (small vessel) diseases start to increase, such as the eye and the feet. With Type 2 diabetes, other factors, such as age, high cholesterol, high blood pressure and duration of disease, play a role to increase microalbuminuria (small proteins in urine).

Diagnosis at this stage is a very good opportunity to prevent progression to clinical kidney disease.

Third stage: macroalbuminuria

This stage is also called diabetic kidney disease or clinical nephropathy. It occurs about 10 to 20 years after onset of diabetes; about five to 10 years after the onset of microalbuminuria.

In this stage, heart disease and strokes also increases compared to the previous stage, and about 75% of patients have high blood pressure. Control of blood pressure in Type 2 diabetes with previous hypertension becomes more difficult.

The conventional dipstick test in the doctor’s rooms is positive for proteins. Due to the leaking of proteins in the urine, these patients can develop swelling of the legs. If the leaking of proteins increases more the swelling can also develop around the eyes.

Fourth stage: End stage kidney disease

The end stage of kidney disease is reached about 10 years after the onset of clinical kidney disease (stage 3). The risk of heart disease and stroke increases, and the incidence of foot ulcers are also increased.

The prevalence of Type 2 diabetes to develop end stage kidney disease is nine times higher than Type 1 diabetes.

Diagnosis

To prove the diagnosis of diabetic kidney disease, the following criteria is used:

  • Enough time. At least 10 years past the onset of diabetes but this may be shorter in Type 2 diabetes.
  • Persistent proteins in urine more than 300mg in 24 hours ( normal is less than 30mg per 24 hours).
  • Diabetic retinopathy (eye disease) at the same time.

There are other causes in diabetes that can also lead to kidney disease:

  • Uncontrolled blood pressure
  • Recurrent bladder infections
  • Increased cholesterol with renal artery stenosis (decreasing of blood flow to the kidney)

Five point treatment plan

Treatment is based on the following principles:

  • Tight control of glucose

Keep the HbA1c (3 month average blood glucose) below 7% and in patient with glucose sensors; keep the time in range (time between 4 and 10 mmol\L in 24 hours) more than 70%.

  • Control of blood pressure

Both high glucose and high blood pressure can progress to kidney disease. In the control of blood pressure, it’s important to use the correct drug that address the kidney function as well. The renin-angiotensin-aldosterone system inhibitors can reduce the progression of diabetic kidney disease. There are two groups in this class: ACE inhibitors (perindopril or enalapril) and ARB group. (valsartan or losartan).

  • Restriction of protein intake

High protein intake increases the filtration of blood through the kidney. Protein restriction can decrease the progression of kidney disease

  • Stop smoking

  • Manage cholesterol

The aggressive treatment of abnormal lipids reduce both microvascular (small vessel disease such as eye, kidney and feet) and macrovascular disease (heart attack and stroke). The therapeutic target for LDL cholesterol (bad cholesterol) is below 1,8 mmol/L.

New drugs

The use of the ACE and ARB drugs was up to 2016 the only drugs, except cholesterol lowering medications, that could slow diabetic kidney disease.

There are now two new drugs available in SA that decrease the progression of diabetic kidney disease by 30%. These drugs are from the class sodium glucose transporter 2 inhibitor (SGLT2i) and work in the upper part (proximal tubuli) of the kidney. The reabsorption of glucose and salt are blocked. This leads to glucose in the urine and due to this: weight loss, decrease of blood pressure and improvement of kidney function are seen. The two available drugs in RSA are dapagliflozin and empagliflozin.

Final thought

Diabetic kidney disease remains the most common cause of end-stage kidney disease in the world. It’s important to follow the five-point treatment plan to decrease the chance to develop the disease, and should it already be present to use the correct drugs to decrease the progression of the disease.


Reference:

  1. Bojestig M et.al. “ Declining incidence of nephropathy in insulin dependent diabetes mellitus.” N Engl J Med 1994;330: 15-18
  2. Cameron J.S. 2006 “The discovery of diabetic nephropathy: from small print to centre stage.” Journal of Nephrology 19 ( Suppl 10): S75-S87
Dr Louise Johnson

MEET THE EXPERT


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.


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A closer look at Type 1 diabetes

Dr Angela Murphy shares informative insight on Type 1 diabetes, how it is managed and what the future holds.


What’s in a name?

The word diabetes originates from Greek, meaning increased or excess urination, a symptom common in the initial presentation of diabetes. However, an imbalance of hormones controlling water balance can also cause increased urination, but the quality of the urine is very different. Hence the terms mellitus, meaning sweet, and insipid which means clear. Diabetes mellitus describes the group of conditions where blood glucose is too high. Diabetes insipidus is an abnormality of water balance, either in the kidney or from the hormones in the pituitary.

What’s in a type?

Diabetes seemed to present in two different ways: more slowly and in older patients or very suddenly in younger patients. Some patients required insulin to survive, others could be managed with dietary changes and later, when they became available, oral medications.

Classification of diabetes has changed over the years and continues to be debated as there is likely an overlap of the different types. The current classification is based on the cause of the diabetes, not patient age or whether insulin is used.

Type 1 diabetes – autoimmune diabetes which will be discussed further.

Type 2 diabetes – insulin resistance (usually due to excess body fat) and decreasing insulin secretion from the pancreas cause high blood glucose levels. This is the most common type of diabetes accounting for more than 90% of cases.

Gestational diabetes – is diabetes occurring in the second or third trimester of pregnancy without a prior diagnosis of diabetes

Diabetes due to other causes – this includes monogenic diabetes, such as Mature Onset Diabetes of the Young (MODY); diseases of the pancreas, such as pancreatitis and drug-induced diabetes.

What went wrong?

Type 1 diabetes is a genetic, sometimes hereditary, autoimmune disorder present from birth. Our immune systems should activate to attack external dangers such as infections and allergens which could cause harm.

In autoimmune disease, the immune system is activated by an external trigger but then proceeds to attack the body’s own cells. In Type 1 diabetes, the target is the insulin secreting beta-cells which lies in the islets of the pancreas. There may be more than one attack on the pancreas before evidence of diabetes is seen. Insulin secretion is usually at 50% of normal before blood glucose rises significantly causing symptoms.

How does Type 1 diabetes feel?

Glucose is the primary fuel for the body and required for all cellular function. Almost all food is ultimately digested to glucose which is then transported around the body in the blood vessels. For glucose to enter each cell, insulin needs to unlock the cell door. If insulin is absent, as in Type 1 diabetes, the glucose gets trapped in the blood vessels. This causes:

Hyperglycaemia

Blood glucose is now trapped in the blood vessels causing hyperglycaemia (high blood glucose). When this blood is filtered in the kidneys, excess glucose spills into the urine drawing fluid with it.   This is what causes the excess urination as well as the ‘sweet’ urine. The glucose in the urine can be a breeding ground for bacteria and a urinary infection can further worsen the symptoms. This excess loss of fluid stimulates the thirst centre and so the person will develop another common symptom: incredible thirst and increased consumption of fluids.

Ketone formation

While the high glucose is causing problems by remaining in the blood stream, the lack of glucose entering the cells leaves them starving.  The cells must look for other sources of nutrition for energy production. Protein and fat stores are broken down to provide this source and as these are used up the person with Type 1 diabetes starts to lose weight, another common presenting symptom.

The energy produced may not be as great and so tiredness and fatigue become a complaint as well. As more fat is broken down, it creates a by-product – ketones. Ketones are acids which alter the pH of the body as they accumulate and can cause the dangerous condition of diabetic ketoacidosis (DKA). Sadly, an all-too-common presenting feature of Type 1 diabetes. The only way to rid the body of ketones is to give insulin which will then move glucose into the cells and switch off the use of fat as a source of energy.

Long-term complications

The circulating high blood glucose causes damage to the blood vessels, both small blood vessels (microvascular) and later large blood vessels (macrovascular).

Large clinical trials have conclusively shown that good glucose control reduces the risk of long-term complications. The most important trial, the Diabetes Control and Complications Trial (DCCT) showed intensive glucose control reduced the risk of all complications.

The Epidemiology of Diabetes Interventions and Complications (EDIC) trial followed the DCCT patients for up for a further 12 years and saw that the original intensively controlled group of patients continued to have a significant reduction in complication rates compared to those who had standard control. This proved the concept of ‘metabolic memory’ which means good control from diagnosis is vital for long-term protection.

How is Type 1 diabetes diagnosed?

The diagnosis of diabetes is the same for all types and accepted internationally as follows: if  fasting blood glucose level is ≥ 7,0mmol/L, or a two-hour post glucose challenge is ≥ 11,1mmol/L, or a HbA1c value is >6,5%.

In most instances, people presenting with Type 1 diabetes will have symptoms as described above so one test will confirm the diagnosis.  If there are no symptoms, a second confirmatory test has to be done.

How is Type 1 diabetes treated?

This is truly a one-word answer: insulin. This year we celebrate 100 years since the discovery of insulin and the fact that people diagnosed with Type 1 diabetes can live a long life. I have had several patients in my practice who have had Type 1 diabetes for more than 40 years and one remarkable lady for more than 60 years.

A healthy, balanced diet is important for people living with Type 1 diabetes and will contribute to overall better diabetes control.  However, the most important aspect of treatment is to ensure that there is enough insulin, at the right time, to move glucose from the blood stream into the cells.

Insulin fast facts

  • Basal insulin gives the necessary background insulin and specifically controls glucose released by the liver when a person has not eaten. It is longer-acting and is usually given as a daily dose; in some patients the dose can be split and given twice daily.

  • Bolus (short-acting) insulin is needed to absorb glucose derived from food eaten at mealtimes. The timing of bolus insulin is one of the biggest challenges for people living with Type 1 diabetes. It is essential that glucose and insulin ‘meet’ and do not miss each other. This means that the bolus injection must be given before meals and often up to 30 minutes before the meal. This holds true even for the new analogue insulins. No insulin is fast enough that it can be injected at the time of eating or even after a meal. For people with diabetes wearing sensors, it’s even easier to spot bolus insulin timing issues as we see a typical ‘witch’s hat’ picture in the glucose tracing (Fig.1). The sharp increase in the glucose is pathognomonic of a late bolus dose.

  • Pre-mix insulin has a fixed ratio of short-acting insulin and intermediate or long-acting insulin (ones that are usually used as basal insulins) and must again be given before meals. They are usually given twice daily before breakfast and before supper. In some instances, they may be used for the breakfast dose and other insulins used for the rest of the day. This is particularly the case with children when trying to cover food eaten at school.

How is Type 1 diabetes monitored?

Trying to manage Type 1 diabetes without regular measuring of blood glucose levels is like trying to drive a car with a blindfold on.  There are excellent glucometers available which allows accurate testing with results in seconds.

The advent of continuous glucose monitoring devices has truly improved the burden of glucose testing.  Not only does it mean less, or no finger pricks, but so much more information can be seen on the continuous sensor. Everyone living with Type 1 diabetes knows that no two days are alike. Being able to ‘see’ the glucose and take immediate action gives much better overall control.

It is still valuable to look at averages, patterns and, of course, HbA1c (three-monthly test). Most people with Type 1 diabetes should be aiming for a HbA1c of <6,5%. Guidelines tell us that this means keeping fasting blood glucose between 4 mmol/L and 7 mmol/L and the two-hour mealtime glucose should be less than 8mmol/L.

For those people fortunate enough to use a continuous glucose sensor, we look at a new parameter called Time in Range. This measures all readings from 4mmol/L to 10 mmol/L.  A Time in Range above 70% is considered good control.

Can Type 1 diabetes be cured?

Although many advances have been made to manage Type 1 diabetes, we cannot claim yet to have a cure. Research has focused on a biological cure, but it is technology that is making the greatest strides.

The age of the ‘artificial pancreas’ is here in the form of insulin pumps that respond to glucose readings from continuous glucose monitoring systems. The most sophisticated of these have almost closed the loop in diabetes control with only the calculation of carbohydrate content of a meal and the timing of food boluses still needing to be done by the person with diabetes. There is no doubt that these systems help achieve better and consistent glucose levels.  Unfortunately, they are expensive and not available to most people living with diabetes.

This means that instead of just supplying the body with insulin, a biological cure would need to supply the body with the functioning islet cells needed to make insulin. However, these islets need to be protected from being attacked by the same autoimmune process that caused the diabetes in the first place. The race is on to create the ideal barrier to protect the transplanted islet cells. There is, in addition, a need to produce large volumes of islet cells that does not rely solely on organ donation. And there is debate about the ideal site to introduce the new islets cells to, ranging from the liver to subcutaneous fat.

Much to be grateful for

I’m grateful that insulin was discovered 100 years ago and has allowed people to continue living with Type 1 diabetes. I’m grateful that there is still so much dedication and research in this field. And I’m hopeful that a cure will be found. In the meantime, managing blood glucose levels with a healthy lifestyle and access to insulin and glucose measuring should be something all people with Type 1 diabetes have the chance to do.

MEET THE EXPERT


Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She runs a busy diabetes practice incorporating the CDE Programme, Discovery Diabetes Care Programme and an accredited insulin pump centre.


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The sunshine vitamin and diabetes

We have been hearing a lot more about vitamin D since the COVID pandemic and by now we all know it helps to boost the immune system. Kate Bristow highlights why the sunshine vitamin is needed.


First, let’s understand a bit more about vitamin D

Vitamin D is a fat-soluble vitamin which has a role in maintaining the health of bones, teeth and joints. It also assists in maintaining the functioning of the immune system.

Vitamin D is found in some foods, but it’s also known as the sunshine vitamin.  When our bare skin is exposed to the sun, we convert a cholesterol derivative into vitamin D. However, a lot of people are deficient in vitamin D, and this includes people with diabetes.

Time in the sun and the sunshine vitamin

In the past the best way for humans to get vitamin D was through exposure to sunlight. However nowadays we have less exposure to sunlight. This is due to our work being mostly indoors (except for a lucky few).

There is also increased fear of skin cancers, so we use sunscreen, hats, and other sun barriers. Some people have religious beliefs requiring the skin to be covered, and environmental factors, such as pollution and less daylight hours in the northern hemisphere, decrease our daily exposure to sunlight.

How are we affected by a deficiency of vitamin D?

Signs of lack of vitamin D can range from depression, bone pain and muscle weakness as well as a weakened immune system. Severe muscle weakness with pain and difficulty walking is known as osteomalacia.

Statistics also show that long-term deficiency can result in obesity, high blood pressure, psoriasis, osteoporosis, chronic fatigue syndrome, Alzheimer’s, cancer and Type 2 diabetes.

Symptoms of vitamin D deficiency are often very non-specific and thus often missed.

In children, deficiency can affect growth and tooth formation. Severe deficiency results in children with soft skulls or leg bones (legs become bow-legged, and they complain of pain in legs and muscle pain or weakness). This condition is known as Rickets. Rickets, which is very severe, can cause breathing difficulties and seizures requiring hospital admission. Irritability in children may be because of vitamin D deficiency.

Who is more at risk?

  • Ageing skin and skin darker in colour requires longer exposure to sunlight to enable vitamin D synthesis.
  • Certain medical conditions affect how vitamin D is absorbed: Crohn’s disease and coeliac disease (which can be associated with diabetes) and some types of liver and kidney disease.
  • Deficiency can also occur in people taking certain medications. Discuss this with your healthcare practitioner.
  • Vitamin D deficiency is more likely to occur in people who follow a strict vegetarian or vegan eating plan, or one that excludes fish.

How do we make sure that our vitamin d levels are stable?

It is said that exposing your skin daily to 5-30 mins of sunshine, preferably between 10am and 3pm, at least twice a week, can help your body to produce its own vitamin D and thus decrease risk of diabetes and other serious medical conditions. But that isn’t always practical.

  • Dietary choices that can increase your vitamin D levels include foods such as nuts, oily fish, eggs, powdered milk, and some cereals which have been fortified with vitamin D. But most foods don’t contain a lot of vitamin D.
  • Fatty fish and seafood are foods that have the highest levels of vitamin D. Although the amounts may vary depending on the type and where they came from. Choices include tuna, mackerel, oysters, shrimp, sardines and anchovies
  • Eat more mushrooms. Mushrooms are the only vegetarian source of vitamin D. Mushrooms make vitamin D² through exposure to sunlight or artificial UV light.
  • Eat more egg yolks. Egg yolks are a good source of vitamin D, however the amounts may vary. Free range have higher quantities due to the exposure to natural sunlight (20% RDI), and chickens fed on fortified grain may provide eggs yolks with 100% of the RDI.
  • Take a recommended supplement. Discuss this with your healthcare professional as dosages can vary and the amount you need will depend on what your levels are.
  • Artificial UV radiation is a possibility particularly in countries with shorter day length, or in those who do long hours in an office. However, this needs to be very carefully controlled as too much exposure can burn your skin. Recommended exposure is 15 minutes at a time.

How do we know what our levels of vitamin D are?

It is important to discuss this with your healthcare practitioner and have the levels tested in a laboratory.

Ampath lab use the following levels in their testing of vitamin D (National Osteoporosis Foundation of South Africa).

  • Deficiency = Levels below 12ng/mg (30nmol/l)
  • Insufficiency 12-19 ng/ml
  • Sufficiency 20ng/ml (50nmol/l and above)

Ampath in a recent update also commented that vitamin D levels above 30ng/ml may have additional benefits to health, which include decreasing risk of common cancers, autoimmune conditions, Type 2 diabetes, cardiovascular disease and infectious disease, but these claims have not been proved in clinical trials.

That said, Diabetes UK concludes that it is now known that raising the amount of vitamin D in your body to around 60-80 ng/ml can help keep blood glucose levels under control, which is vital for people with diabetes.

It is important to know that vitamin D levels vary from person to person, and that vitamin D sufficiency or deficiency is monitored by a medical practitioner, and that different levels apply to different people. And if a person is put on vitamin D supplementation by a healthcare professional, they should be told that it takes about three months for levels to rectify, so retesting levels sooner than that is not going to be significant.

Other health benefits of vitamin D include

  • Assistance in weight loss. Good vitamin D levels help to reduce levels of parathyroid hormone (PTH) which long term may promote weight loss and decrease risk of obesity (of major risk in Type 2 diabetes).
  • Regulation of appetite. Vitamin D can increase the body’s level of the hormone leptin. Leptin controls how the body stores fat and helps us to feel full so we don’t feel so hungry.
  • An increase in vitamin D can help to lower our cortisol level which is a stress hormone produced by our adrenal glands. The function of cortisol includes how we respond to stress and how we regulate blood pressure. Higher levels of cortisol in the blood can lead to increased amounts of abdominal fat, which is linked to various health conditions which include Type 2 diabetes.
  • There is some evidence that there may be a beneficial link in vitamin D improving insulin sensitivity, insulin resistance and that it possibly has some role in the health of the beta cells of the pancreas. But further research is needed in this area, so at this stage this is unsubstantiated.

What types of vitamin D are there?

There are two main forms of vitamin D: ergocalciferol (vit D²) and cholecalciferol (vit D³). Vitamin D² is synthesised by plants (mushrooms and yeast) and vitamin D³ is synthesised by the skin when it is exposed to ultraviolet B rays from the sun. Vitamin D³ is also found in a few foods e.g. fatty fish.

It is difficult to get enough vitamin D from food alone, and both D² and D³ can be synthetically manufactured and are used to fortify some types of foods, such as milk products, soy milk, margarine, and it’s also used as a dietary supplement in tablet form. It is metabolised in the liver and kidneys so diabetic patients with liver or kidney problems have a higher risk of deficiency, and the same applies to patients with gastrointestinal conditions, such as coeliac disease, pancreatitis, or low bile levels or sprue (a disease of the small intestine causing malabsorption of food).

Is there any link between vitamin D levels and diabetes?

It is believed that vitamin D may improve the body’s sensitivity to insulin.  Insulin is a hormone which regulates blood glucose levels, which decreases insulin resistance. Insulin resistance is a precursor to Type 2 diabetes. Some scientists also believe that vitamin D may help how insulin is produced in the pancreas.

According to the American Diabetes Association (ADA), vitamin D and diabetes have a common trait: both are pandemic. The International Diabetes Federation estimate of the number of people worldwide with diabetes is close to 285 million (7% of the world population). By 2030, this number is predicted to exceed 425 million. This number does not include those who have pre-diabetes.

Vitamin D deficiency is thought to affect 13% of the world’s population. ADA say that there is increased evidence that a deficiency of vitamin D is possibly a contributing factor in development of Type 1 and Type 2 diabetes. It seems that treatment with vitamin D can improve glucose tolerance and insulin resistance. Deficiency of vitamin D leads to decrease in the secretion of insulin.  In animals, vitamin D supplementation showed improvement in insulin secretion.

Quoted from ADA Diabetes Spectrum, “Although the role of vitamin D in helping to regulate blood glucose remains poorly understood, vitamin D status appears to play a role in the development and treatment of diabetes. It is possible that optimal levels of serum vitamin D may be different for people at risk for developing diabetes, those with diabetes, and those without diabetes.

According another study1, “Both animal and human studies support the notion that adequate vitamin D supplementation may decrease the incidence of Type 1 and possibly also of Type 2 diabetes and may improve the metabolic control in the diabetes state. However, the exact mechanisms are not clear and need further investigation.”

The bottom line

Vitamin D is an essential nutrient that many people around the world do not get enough of. It is possible to boost your vitamin D levels by getting out in the sun more often, and eating vitamin D rich foods, as well as taking supplements.

It’s an important nutrient which needs to be given credit in our daily eating plan. If you are concerned about a possible low vitamin D level or fall into the risk categories mentioned above, please discuss this with your healthcare provider so that you are given appropriate treatment.

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

MEET THE EXPERT


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


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