Stages of chronic kidney disease

Although chronic kidney disease is a progressive disease the good news is that not everyone will go on to develop kidney failure. Dr Louise Johnson explains the stages and why screening is imperative for people with diabetes.


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World Kidney Day is 14 March 2024. Visit worldkidneyday.org

Chronic kidney disease (CKD) is a term that includes all degrees of decreased kidney function from at risk to mild, moderate and severe kidney failure.

Almost half of patients with CKD are older than 70 years of age. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines established the diagnosis of CKD as:

Either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60ml/min/1.73m2 for at least three months.

The different stages form a continuum and are classified as:

  • Stage 1 – Kidney damage with normal or increased estimated GFR (>90ml/min).
  • Stage 2 – Mild reduction in GFR (60 – 89ml/min).
  • Stage 3a – Moderate reduction in GFR (45 – 59ml/min).
  • Stage 3b – Moderate reduction in GFR (30 – 44ml/min).
  • Stage 4 – Severe reduction in GFR (15 – 29ml/min).
  • Stage 5 – Kidney failure GFR < 15ml/min.

Markers

By itself measurement of estimated GFR may not be sufficient to identify Stage 1 and Stage 2 CKD. In these patients, the estimated GFR may be normal or near normal. In such cases, the presence of one or more of the following markers of kidney damage can establish the diagnosis:

  • Albuminuria (albumin excretion in the kidneys >30mg/24 or Albumin: creatinine ratio > 30mg/g)
  • Urine sediment abnormalities
  • Electrolyte disorders
  • Structural kidney abnormalities as seen by imaging
  • History of kidney transplant

Two important tests

  1. Urine Albumin-to- Creatinine ratio (UACR)

This is a test of the urine to assess the relationship between albumin (which is a protein that shouldn’t be in urine) and creatinine. If protein leaks into the urine, it’s a sign of kidney damage.

UACR levels are staged as:

  • A1 – lower than 3mg/mmol
  • A2 – 3 to 30mg/mmol – moderate increase
  • A3 – higher than 30mg/mmol – severe increase
  1. Estimated Glomerular Filtration Rate (eGFR)

This is a blood test that shows how well your kidneys filter your blood per minute. A GFR of 100 is normal.

Stage 1 kidney disease

In Stage 1, there is mild damage to the kidneys. They are quite adaptable for this, allowing them to keep performing at 90% or better. At this stage, CKD is likely to be discovered by chance during routine blood analysis. Usually in people with diabetes or hypertension (these are the two main causes of CKD).

Symptoms

None

Treatment

Manage all risk factors:

  • Keep blood glucose in normal range or HbA1c below 7%.
  • Keep blood pressure below 130/80 mmHg.
  • Don’t smoke.
  • Sleep seven to eight hours per day.
  • Exercise 30 minutes five times a week
  • Reduce stress and anxiety.
  • Maintain a healthy weight.

Stage 2 kidney disease

In Stage 2, the kidney function is between 60 and 89%.

Symptoms

Usually, asymptomatic

Treatment

Manage risk factors as in Stage 1.

Stage 3 kidney disease

Stage 3a is when your kidney function is 45 to 59%.

Stage 3b is when your kidney function is 30 to 44%

The kidneys aren’t filtering waste, toxins and fluids as well as it should, and toxin and fluid build-up begin to manifest.

This is usually the first time when people with CKD are diagnosed.

Symptoms

Not all people are symptomatic yet, but you can have these symptoms:

  • Back pain
  • Fatigue
  • Loss of appetite
  • Persistent itching
  • Sleep problems
  • Swelling of hand and feet
  • Urinating more or less
  • Weakness

Treatment

Dietitians may help to prescribe a diet that is low in sodium, phosphate, potassium and protein to protect the kidneys.

Medication that reduce symptoms and preserve kidney function:

  1. Angiotensin-converting enzyme (ACE) inhibitor.
  2. Sodium glucose cotransport 2 (SGLT2) inhibitors. In SA, there are two drugs in this class dapagliflozin and empagliflozin. This class showed in specific studies with patients with and without diabetes an improvement in kidney function on this drug.
  3. Diuretic for fluid retention.
  4. Cholesterol lowering drug. This is important since the risk of ischemic heart disease and stroke increases in this stage. Important to stop taking certain pain killers called non-steroidal anti-inflammatory drugs (NSAIDS).

Stage 4 kidney disease

This stage has moderate to severe kidney damage. The kidneys function between 15 and 29%. According to the Centre for Disease Control and Prevention (CDC), 40% of people with severe reduced kidney function aren’t aware they have it.

Symptoms

  • Back pain
  • Decreased mental sharpness.
  • Fatigue
  • Loss of appetite
  • Muscle cramps and twitches
  • Nausea and vomiting
  • Persistent itching
  • Shortness of breath
  • Sleep problems
  • Swelling of hand and feet
  • Weakness
  • Weight loss

This stage is also at high risk for heart disease and stroke.

Treatment

The same as Stage 3. In Stage 4, it’s important to be part of a health team to monitor you closely regarding electrolytes, medication, diet as well as possible complications, such as anaemia, bone loss and hypertension.

In Stage 4, erythropoietin supplement for anaemia is important.

Stage 5 kidney disease

This stage means your kidney function is less than15% or you have kidney failure.

Symptoms

The symptoms are the same as Stage 4, but the intensity is worse. A significant drop in kidney function puts more stress on the heart, increasing the risk of heart disease and stroke.

Once you have Stage 5 kidney failure, life expectancy is a lot shorter without dialysis or a kidney transplant.

Dialysis isn’t a cure for CKD but a process to remove fluid and toxins.

Although CKD is a progressive disease, not everyone will go on to develop kidney failure. Symptoms of early kidney disease are mild or even absent. It’s important to screen for kidney disease if you have risk factors such as diabetes and hypertension. Always join a healthcare team to help you along this journey.

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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10 tips to improve your time in range

Diabetes nurse educator, Christine Manga, shares 10 practical tips to improve your time in range.


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Time in range 101

Let’s start off by discussing time in range (TIR) and the importance of this concept.

  • Time in range is the amount of time spent in a specific target blood glucose range and is measured in %.
  • Target range is set at 3.9mmol/L – 10.0mmol/L for most people with diabetes.
  • Guidelines recommend that at least 70% of a day should be spent in range, which equates to just shy of 17 of 24 hours.
  • Less than 4% should be lower than 3.8mmol/L and less than 1% lower than 3mmol/L.
  • Time above range, higher than 10.1mmol/L should be kept to below 25%.
  • Pregnancy has a much narrower range of 3.5mmol/L – 7.8mmol/L. This is to mitigate the risks of pregnancy and birth complications including premature birth, high birth weight babies, miscarriage, or a stillborn baby.

Important to note: The guideline ranges may be too low for certain people. Factors that need to be considered for setting different target ranges in these certain populations would include age, duration of diabetes, life expectancy, physical or mental disabilities and work environment. These targets should be discussed with your health care provider for best long-term outcomes.

How is TIR calculated?

It’s calculated by taking a certain number of readings over a 24-hour period and dividing the number of readings in range by the total number of readings taken and multiplying by 100. This will give a percentage.

The easiest way to determine TIR is by wearing a continuous or flash glucose monitor. These systems measure glucose every five minutes, 288 times a day. An individual using these sensors can see TIR for a rolling 24hours. To get a true reflection of overall glucose control, a period of at least 14 days should be used.

TIR and Hba1c

Hba1c used to be the gold standard for measuring long-term glucose control. Unfortunately, there are shortfalls to using this method; it’s unable to expose glucose excursions and misses hypoglycaemia.

In the below image, all three patients have an Hba1c of 7%. The glucose readings of these patients are vastly different. Patient 3 has a TIR of 100% whereas patient 1 has huge variability. Glucose variability is considered an independent risk factor for developing long-term diabetes complications. TIR and Hba1c are closely correlated. Depending on baseline Hba1c, for every 10% change in TIR there is a 0.4 -1.0% change in Hba1c.

Ticking the TIR boxes

Maintaining a good TIR is possible and made easier by following some of these 10 simple tips:

  1. Medication

Take your diabetes medication as prescribed. Timing and dosage are imperative. Missing doses, taking too much or too little medication or insulin will reduce TIR. If necessary, set a reminder alarm on your phone to take medication timeously.

  1. Eating

Eating low-carb and low-GI foods prevent huge swings in glucose levels. Adding a protein to a meal assists in stabilising glucose levels. Eating vegetables with meals adds fibre, once again preventing spikes. If you are snacking, aim for less than 15g of carbs per snack. Be aware of portion sizes of meals, as the larger the meal, the greater the glucose fluctuation.

  1. Exercise

Regular exercise improves insulin sensitivity. It allows your body to better use the ingested glucose. Exercise can lower glucose levels for up to 24 hours post exercise. To remain in range, it’s important to make sure your glucose levels are not above 14mmol/L when starting exercise or below 5,5mmol/L. Exercise can assist in weight loss.

  1. Stress management

Stress releases hormones such as glucagon, adrenaline and cortisol. These increase insulin resistance causing an increase in blood glucose levels. Illness is a form of stress. Seek medical attention if you are ill.

To manage daily stress, meditation, breathing exercises and general exercise are excellent. If the stress is too great to manage alone, make an appointment to see a doctor or psychologist. During times of stress, try to increase glucose testing frequency.

  1. Monitor blood glucose levels

If you are fortunate enough to have access to sensor technology, use it. But, most importantly is to react to any alerts, high or low. It doesn’t help to know what your glucose level is if you’re not going to do anything about it.

Finger stick monitoring is most common in SA. The general rule is for every insulin injection given; you should be testing. Testing two hours post meal can assist you to increase your TIR by adjusting future meals or insulin doses. If a reading is out of range, think why that would be and see what changes you can make for next time. Advocacy is being done to enable more people with diabetes in SA have access to continuous glucose monitoring sensors.

  1. Sleep

Insufficient sleep can cause insulin resistance giving rise to elevated blood glucose levels in people with diabetes and increasing the risk of developing diabetes for those without.

Hormones released overnight also cause insulin resistance which result in elevated glucose readings in the hours before rising.

This overnight rise can be managed with diabetes medication. Sleep apnoea is another cause of insulin resistance, worsening TIR. If you snore or stop breathing overnight (often mentioned by your partner), it may be worth testing for sleep apnoea.

  1. Weight

Maintaining a healthy stable weight aids in keeping glucose levels stable. If you are overweight, losing just 5% of your body weight will improve insulin sensitivity and therefore glucose levels. If more weight is lost, medication doses may need to be reduced to prevent hypoglycaemia. Imagine having greater TIR with less medication.

  1. Sensor augmented insulin pump therapy

Having the privilege of wearing an insulin pump with a connected sensor is one of the easiest ways to maintain a high TIR. The insulin pump adjusts the insulin doses according to the sensor blood glucose levels. These systems enable you to reach a high TIR with a very low time below range.

Unfortunately, these systems are very expensive and not available to most people with diabetes. As mentioned earlier, there are wonderful advocacy groups putting pressure on the necessary bodies to get these pump systems to more individuals.

  1. Sick day/back up

When you are sick, glucose levels usually spike. It’s important to have a sick day protocol especially when using insulin. This will aid in keeping you in range. Your healthcare provider will be able to assist you with this.

Having backup stock for hypos is important, be prepared. Carry sugar or honey sachets, Super C’s or Jelly Babies. To remain within range don’t over correct a low blood glucose. Have 1 to 2 Super C sweets and wait twenty minutes, then retest your glucose level. If still below 3.9mmol/L, then have 1 more Super C.

10. Consistency

Try to remain consistent with all the above. Routine makes staying in range easier. There will be days that regardless of what you do your blood glucose will appear to have its own agenda. That happens. Accept it and move on. It’s the bigger picture that counts, long term, a less than good day here and there is not the end of the world.

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

MEET THE EXPERT


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


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A closer look at fat-burning heart rate zone

We learn about the science behind the fat-burning heart rate zone as well as practical tips to help reach your weight loss goals.


The science of fat-burning heart rate

When you exercise, your body uses different energy sources, primarily carbohydrates and fats. The fat-burning zone represents the range of heart rates at which your body burns more fat for fuel.

Typically, this zone falls within 60 to 70% of your maximum heart rate (MHR). Your MHR is a rough estimate of the maximum number of beats your heart can handle in one minute, and it’s often calculated using the formula 220 minus your age. 

For example, if you’re over 30, your estimated MHR would be 190 beats per minute (220 minus 30). So, in this case, your fat-burning heart rate zone would be 114 to 133 beats per minute (60 to 70% of 190).

Myth busting: the fat-burning zone isn’t a magic bullet

It’s important to understand that the fat-burning zone doesn’t magically help you shed unwanted kilograms without you having to work. Here’s why:

  • Calories still matter:While you burn more fat calories in the fat-burning zone, the overall number of calories burned might be lower than in higher-intensity workouts. Weight loss ultimately boils down to burning more calories than you consume.
  • Total fat burn:Working out at a higher intensity may lead to higher complete fat burn, even though the percentage of calories burned from fat is lower. It’s like the difference between a gentle, steady stream eroding a rock over time and a powerful waterfall breaking it down faster.
  • Time and consistency:Staying in the fat-burning zone for extended periods can be time-consuming. It’s vital to consider your lifestyle and how much time you can devote to exercise.
  • Individual variations matter: It’s essential to recognise that individual variations play a significant role in the effectiveness of the fat-burning zone. Genetics, fitness level, andmetabolism can influence how your body responds to exercise. What works for one person might work differently for another.

Finding your fat-burning zone

You might wonder, “Is the fat-burning zone still relevant?” In short, the answer is yes, especially for beginners, those with medical conditions, or if you are looking for a low-impact workout. 

While calculating your fat-burning zone, as mentioned earlier, the easiest way to ensure you’re exercising within your target heart rate range is to wear a heart rate monitor during your workouts. Many fitness trackers and smartwatches have this feature built-in.

Some exercises can burn more calories per hour than others. To burn the maximum calories, you should consider running. Running is the biggest calorie-burning activity per hour. If running isn’t your thing, other calorie-burning activities include HIIT workouts, jumping rope, and swimming. You can perform any combination of these exercises depending on your interests and fitness level.

Practical tips for effective fat burning

Start with a light warm-up to elevate your heart rate gradually. This prepares your body for more intense exercise. While the fat-burning zone can be effective, keep yourself open to workouts outside this range. Incorporate a variety of workout intensities to keep your routine exciting and maximise overall calorie burn.

Remember that muscle burns more calories at rest than fat (about 50 times more), so incorporate strength training into your fitness regimen to boost your metabolism. Give your body adequate time to recover between workouts. Overtraining can lead to burnout and hinder your progress.

Tracking your progress

To gauge the effectiveness of your workouts within the fat-burning zone and assess your weight loss journey, keep an eye on changes in your body measurements, such as waist circumference and body fat percentage. 

Notice how you feel during and after your workouts. Increased energy levels and improved stamina can be indicators of progress. 

Lastly, while not the sole measure of success, tracking your weight on a scale over time can help you see trends and make necessary adjustments to your routine.


*This article is attributed to Affinity Health.

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Addison’s disease and Type 1 diabetes

With Addison’s Disease Day on 29 May, Dr Angela Murphy explains the disease and how to manage it if you have Type 1 diabetes too.


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Visit our channel mypod.zone/diabetessa

In 1855, English physician, Thomas Addison, described bronze skin disease as being caused by the destruction of the adrenal glands. This resulted in a deficiency of the hormones produced by the adrenals.

The adrenal gland

Image by hopkinsmedicine.org

Addison’s work showed that the adrenal gland is essential for life. The gland is divided into two sections (cortex and medulla) and produces three main hormones:

  • Glucocorticoid – cortisol
  • Mineralcorticoid – aldosterone
  • Adrenalin

These hormones are critical for, among other things, the regulation of blood pressure, fluid balance, immune function, and carbohydrate metabolism. Any damage to the glands will result in a decrease in the hormones produced and thus, cause a range of clinical problems.

Decreased function of the adrenal glands may be described as primary or secondary.

Primary – Direct damage to the adrenal glands.

Secondary – Damage is to the pituitary gland and affects the secretion of ACTH, the hormone that control glucocorticoid release. The most common cause of this is the use of cortisone-based medications (e.g. prednisone).

Primary Addison’s disease (adrenocorticoid deficiency)

Causes

  1. Autoimmune – This is the most common cause and can occur in combination with other autoimmune conditions and this is known as polyglandular endocrinopathies:
    1. Type 1 Autoimmune polyglandular syndrome – This has a classic triad of Addison’s disease, hypoparathyroidism and mucocutaneous candidiasis (a skin disorder).
    2. Type 2 Autoimmune polyglandular syndrome – Combines several conditions such as Addison’s disease, Type 1 diabetes, thyroiditis, pernicious anaemia (vitamin B12 deficiency), vitiligo or alopecia.
  2. Infections – In South Africa HIV and tuberculosis are more common ones.
  3. Adrenal haemorrhage – This can be caused by trauma or severe illness.
  4. Infiltrations – Unusual conditions such as haemochromatosis (iron overload) and, rarely, cancer that has spread.
  5. Congenital disorders occur rarely.
  6. Medications – Ketoconazole (an antifungal) and etomidate (a sedative).

Clinical presentation

Addison’s disease can develop insidiously and be missed for a long time. Patients may complain of general feelings of fatigue, general body weakness, loss of weight, nausea and vomiting with abdominal pain, and dizziness.

On examining the patient, it’s important to test blood pressure lying and standing as a drop in blood pressure on standing confirms postural hypotension which is a feature of Addison’s disease.

Almost all patients will have areas of their skin that are dark in colour (hyperpigmented), especially in sun-exposed skin. This is due to the high levels of ACTH binding to melanocyte receptors which are responsible for pigmentation.

There really does need to be a high level of suspicion to diagnose Addison’s disease early due to non-specific presentation. Patients at increased risk of Addison’s disease are those with other autoimmune diseases as listed above.

Addison’s crisis

Some patients develop adrenal insufficiency rapidly, often after trauma or severe infection. They present critically ill with dehydration, severely low blood pressure, confusion and can go into shock. Areas of skin hyperpigmentation may be present.

Diagnosis

Adrenal hormone secretion is controlled by the hypothalamus and pituitary gland. The hypothalamus secretes corticotropin releasing hormone (CRH) which stimulates the release of adrenocorticotrophic hormone (ACTH) in the pituitary gland. ACTH then stimulates the release of cortisol from the adrenal gland. This is all controlled by a precise feedback loop.

Image by courses.washington.edu

To diagnose primary adrenal insufficiency there must be a low cortisol level and raised ACTH level. An early morning cortisol should be taken. Ideally this should be repeated on 2-3 occasions as a single test is not always accurate. Anti-adrenal antibodies can also be tested. There are further, more complicated tests which can be used if needed.

If an Addison’s crisis is suspected, the blood tests should be taken immediately in casualty, so that empirical treatment can be started, and the diagnosis reviewed later.

Imaging studies may help with the cause of Addison’s disease, e.g. an ultrasound or CT scan of the adrenals can show haemorrhage or infiltration. Autoimmune destruction of the adrenals will reveal small glands.

Treatment

The mainstay of treatment is to replace the hormones that aren’t being produced:

  • Glucocorticoid (cortisol) – hydrocortisone or prednisone given in divided doses.
  • Mineralocorticoid (aldosterone)– fludrocortisone usually daily.

In Addison’s crisis fluid replacement is critical and large doses of glucocorticoids will be given intravenously.

Maintenance

It’s important for patients with Addison’s to be aware of the impact any stress to their body will have on their chronic management of their condition. When the human body is stressed (due to illness, trauma), the adrenal glands produce more hormones to compensate.

A person with Addison’s disease must increase their medication dose during these periods to provide the same protection and avoid a crisis. They should also wear a medical alert bracelet so that if in an accident the emergency personnel will know to give life-saving cortisone.

The person living with Addison’s disease and Type 1 diabetes

Although the risk is there, this is an unusual combination. It’s not recommended to routinely screen people living with Type 1 diabetes for Addison’s disease. There are some factors that would increase the risk of the combination and indicate to the doctor that tests should be done. These risks factors are:

  1. Recurrent, unexplained hypoglycaemia – This would naturally mean the person is constantly decreasing their insulin dose.
  2. Repeat requests for a glucagon hypo kit prescription – Again the increased use of glucagon would indicate frequent and significant hypoglycaemia.
  3. Presence of diabetic retinopathy.
  4. Concomitant diagnosis of autoimmune thyroid disease.

The daily burden of care will still be directed at Type 1 diabetes. Studies have shown that overall people living with both Type 1 diabetes and Addison’s disease have a lower basal insulin requirement and increased mealtime insulin needs. This is related to the change in the insulin sensitivity due to cortisone replacement. There are further challenges when there is an intercurrent illness or other stress as this will affect both the corticosteroid requirement and the glucose levels. Similarly, if diabetes control is not good this will cause ongoing stress to the body and higher doses of glucocorticoid replacement may be required.

A specialist and latest technology are a must

For this reason, people living with both conditions should be given access to flash or continuous glucose monitoring, and the option of insulin pump therapy. Access to this technology will allow more regular and accurate adjustments to the insulin regimen.

A patient with the combination of Addison’s disease and Type 1 diabetes must be looked after by a specialist. They must have access to 24/7 advice and have a home protocol of what to do if unwell. In this way the complications of hypoglycaemia, diabetic ketoacidosis and adrenal crisis can be avoided.

Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.

MEET THE EXPERT


Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.


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Insulin dosing for fat and protein

Christine Manga, a diabetes nurse educator, explains the calculation of insulin dosing for fat and protein.


We are social creatures and food plays an enormous role in our lives. Many gatherings and celebrations revolve around food, promoting socialisation and fostering a sense of belonging. These events should be fun and exciting but instead they often present as daunting and challenging if you have diabetes, especially if you need to inject insulin.

Who needs to inject insulin?

Type 1 diabetes is the absolute absence of insulin. Insulin is required to facilitate the movement of glucose from the bloodstream into the cells for energy use and storage. People with long-standing Type 2 diabetes may also have less or no insulin reserves. This will necessitate the need to inject a rapid-acting insulin before eating a meal as well as a long-acting insulin at least once a day.

Carb counting is a commonly taught skill that involves calculating the amount of insulin required to match the amount of carbohydrates eaten at a meal. Your healthcare provider will assist you in working out a carb ratio and insulin sensitivity factor (ISF). This will be used at each meal.

Meals are more than just carbs

Fats and proteins also impact blood glucose levels by delaying the digestion and absorption of carbohydrates, often causing a delayed and prolonged hyperglycaemia (high blood glucose). It can be drawn out for as long as three to five hours post-meal.

Fat causes and worsens insulin resistance which would mean more insulin would be required. A meal that contains 35% or more of it’s total calories is considered a high fat meal. This amount varies in the literature.

There are vast differences in interpersonal and intrapersonal blood glucose responses to fat and protein. There is no uniform response to a meal. These differences can be caused by, but are most definitely not limited to carb ratio, ISF, exercise, weather, duration of diabetes, order in which food is eaten as well as overall health.

To establish how fat or protein affect your glucose, it’s imperative to monitor yourself for patterns. Measurements should be taken three- and five-hours post-meal. It’s possible to monitor with manual finger pricks, but continuous glucose monitoring (CGM) is really helpful in these situations. Pattern detection is far easier.

High fat and protein meals

Examples of high fat and protein meals could include bacon and eggs, burger with avo and chips, salmon with olive oil drizzled on roast vegetables, pizza, creamy sauce pasta, pastries. The list goes on.

It’s often the case that even when carb counting is accurate, a high fat and protein content in the meal will result in under dosing of insulin and a delayed hyperglycaemia. A study using a 50g protein example: 200g cooked steak and 30g carb meal received an extra 30% insulin delivered in a combination bolus. This amount improved post-meal glucose levels without any additional risk of hypoglycaemia. When the amount of insulin was increased to 45%, there was increased hypoglycaemia whereas a 15% increased dose still resulted in post-meal hyperglycaemia.

Whittington Health, followed on the NHS guidelines, suggest counting carbs for the high fat or protein meal and adding 20% extra insulin along with a correction, if necessary. If the meal contains no carbs and more than 50g of protein, count it as 10g of “carbs” and dose according to your carb ratio. If you’re consuming alcohol with the meal, make no adjustments.

Calculating is hard work

In my practice, I tend not to teach insulin bolusing for fat and protein. Carb counting is already an additional step someone with diabetes must contend with pre-meal. Working out the carb content of food can already be challenging. Add in trying to establish the fat or protein content of the meal too and then calculate the extra insulin required. That is hard work and adds to the diabetes burden, possibly causing distress and eventual burnout.

With saying that, there are carb counting apps that make provision for fat and protein. If you choose to follow a low-carb, high-protein, with or without high-fat diet, you will need to work out with your HCP the best insulin ratios to use. There will be a lot of trial and error, but a certain amount of insulin will almost definitely be required, albeit a small amount.

If you’re fortunate enough to be on a sensor-augmented insulin pump, you’ll be better able to negate the effects of fat and protein in the meals. Depending on the pump, there are different features that will accommodate for the extra insulin requirements. Insulin can be given as a dual or square wave bolus which is a bolus given over an extended period. Auto correction from the pump will assist in compensating for the delayed rise in glucose. These are very small bolus amounts delivered by the pump without the user needing to initiate them. The pumps are also able to modulate the basal rate to regulate the blood glucose levels. If you’re manually injecting, you may need to give two boluses to compensate for high fat or protein meals.

Your choice

The choice is entirely up to you, if you would like to take your diabetes management to this level. Many people who don’t bolus for high fat or protein are still extremely well-controlled with an excellent Hba1c only counting for carbs.

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

MEET THE EXPERT


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


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The highs and lows of calcium

Dr Angela Murphy explains the symptoms and the treatment for both low and high levels of calcium.


What is calcium?

It’s is a mineral necessary for the healthy functioning of bones and teeth. In addition, it’s necessary for normal blood clotting, muscle contraction, nerve function and heart rhythms. Most calcium in the body is stored in bone with only 1% found in blood, muscles, and other tissues.

The body gets calcium from eating foods rich in calcium, particularly dairy products, nuts and seeds and certain vegetables, such as kale. If the diet is low in calcium, then the body will start to extract calcium from bone which can cause bone disorders, such as osteoporosis.

Recommended daily requirements

The table below lists the recommended daily requirements for different age groups.

AGE MALE FEMALE
< 12 years 500mg/day 500mg/day
12-18 years 1000mg/day 800mg/day
>18 years 700mg/day 700mg/day

How are calcium levels affected?

Levels of calcium are controlled by the parathyroid glands, which as the name suggests, lie next to the thyroid gland in the neck. These four, small glands secrete parathyroid hormone (PTH) which acts in several places in the body:

  1. Gut – to stimulate uptake of calcium from food by activating vitamin D.
  2. Kidneys – to slow down the loss of calcium in the urine.
  3. Bone – to stimulate release of calcium from bone into the circulation.

The system should be balanced enough to keep enough calcium available to all the cells in the body, but not remove too much from the bones. When calcium levels are too high or too low, we always look to see what the PTH level is first and from there can decide the cause of the imbalance.

Hypercalcaemia (high blood calcium)

The most common causes are:

  • Primary hyperparathyroidism – This usually occurs sporadically, although sometimes there is a family history. In most cases, one of the four parathyroid glands have an adenoma which overproduces PTH. Sometimes the entire gland is enlarged, and this is called hyperplasia. Rarely more than one gland will be overactive. It’s rare for cancer to be a cause.
  • Malignancy – Some cancers produce a PTH-like hormone which then increases calcium levels in the blood. Other cancers cause direct damage to bone which releases too much calcium.
  • Hormonal disorders –  Such as an overactive thyroid gland or adrenal gland disorders.
  • Medications – Can also increase calcium levels. For example: lithium, certain water tablets and excess use of vitamin A and D.

There are less common conditions, such as prolonged illness in ICU, hereditary disorders and inflammatory conditions, which can also cause hypercalcaemia.

Symptoms

A traditional mnemonic categorises the main symptoms of hypercalcaemia: bones, stones, abdominal groans, and psychic moans. This summarises the main clinical features of high calcium levels:

  • Bone loss resulting in diseases, such as osteomalacia and a type of osteoporosis;
  • Kidney stones and decrease in kidney function;
  • Constipation and other gastrointestinal complaints;
  • Mood disorders, such as depression, and a general feeling of being unwell.

Treatment

Naturally, this depends on the cause as well as the actual level of calcium. If the levels are very high, the first step is to lower it with medication and intravenous fluids. The definitive treatment for primary hyperparathyroidism is to surgically remove the overactive parathyroid gland. This is a safe procedure in experienced hands with excellent results.

Hypocalcaemia (low blood calcium)

The most common causes are:

  • Hypoparathyroidism – Again this can occur sporadically but more commonly as a result of surgical removal of the parathyroid glands, radiation to the neck or a disease process that infiltrates the parathyroid glands.
  • Resistance to the action of PTH – This can occur in kidney disease and with certain drugs as well as a condition on its own called pseudohypoparathyroidism. This means that although the PTH level is normal, the body is resistant to its action and behaves as if there is no PTH to keep calcium levels stable.
  • Vitamin D deficiency.
  • Resistance to the action of vitamin D – This is a rare hereditary condition.

There are other illnesses which can cause a sudden drop in calcium levels, such as acute pancreatitis, but when treated the levels can normalise.

Symptoms

The classic symptom of hypocalcaemia is tetany. This is spontaneous muscle contractions resulting in spasm, especially of the hands or feet. There may also be a tingling sensation around the mouth and in the fingers. If the levels drop too low this may cause seizures. Chronic low calcium levels in children will affect growth and development.

Treatment

If levels are very low and especially if they have dropped suddenly, it might be necessary to give intravenous calcium. The goal of therapy is to maintain levels in the normal range, and to get to the correct dose of supplements may take some time.

It will usually be necessary to have vitamin D supplementation as part of the treatment. An average dose of calcium supplementation for hypocalcaemia is 1.5 – 3g daily. Long-acting vitamin D2 can be given weekly in many cases. Sometimes a shorter-acting vitamin D, such as calcitriol, needs to be used. If there is difficulty restoring levels to normal, you should be referred to a specialist.

Conclusion

For people living below the poverty line, dietary calcium deficiency can occur. Fortification of foodstuffs has helped to lower this risk. For example, a 100g of Pronutro porridge has 530mg of calcium.

Generally, low calcium due to poor absorption or dietary deficiency can be easily corrected. There is no benefit to taking supplements if you have normal calcium levels. High calcium levels must always be investigated and then the cause can be treated.

Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 17 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.

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Dr Angela Murphy qualified as a specialist physician in 2000 and joined the Department of Endocrinology and Metabolism at Charlotte Maxeke Johannesburg Academic Hospital. Currently she sees patients at Sunward Park Medical Centre. She retains a special interest in endocrinology and a large part of her practice is diabetes and obesity. She is a member of the Society of Endocrinology and Metabolism of South Africa and the National Osteoporosis Foundation and is actively involved in diabetes patient education. Living with diabetes in the family for 18 years has shown her that knowledge is power. Basic principles in diabetes must always be applied but people living with diabetes should also be introduced to innovations in treatment and technology which may help their diabetes journey.


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How to get the best out of pharmacy care

Medipost Pharmacy share an easy guide to using medicine safely and how to get the best out of pharmacy care.


Medication is a lifeline for South Africans living with chronic conditions and provides relief from illness and pain, but only when it is used safely and appropriately. Pharmacists are there to guide and advise you on all matters related to your medicine and your health. Make the most of their expertise with these simple tips.

“Medication can do more harm than good if it isn’t used correctly, and so it’s really important that everyone understands the basics of responsible medicine use, and pharmacy teams are ideally positioned to support patients,” says pharmacist Joy Steenkamp of Medipost Pharmacy, South Africa’s first national courier pharmacy.

 What you need to tell your pharmacist

  1. All your allergies
  2. Your existing health conditions
  3. All the medicines you are using, including prescription, over-the-counter and traditional medicines
  4. Report any bad reactions to medication
  5. If you are pregnant or trying to get pregnant

 What you should ask your pharmacist

  1. What is the medication prescribed for?
  2. How much and when to take your medicine?
  3. Are there side effects to be aware of?
  4. Is there anything you need to avoid while taking the medication?
  5. Advice for managing symptoms of common or short-term ailments

Five things you should know

  1. Keep medicines safely out of harm’s way in a cool, dry place away from sunlight.
  2. If antibiotics are prescribed, complete the course.
  3. Always check expiry dates and package inserts.
  4. Often, child and adult doses vary; be sure not to exceed the recommended dose.
  5. If anything to do with medicine is unclear, check with your pharmacist.

Five golden rules of pharmacy

  1. Never share your prescribed medication with someone else.
  2. Do not stockpile medicines.
  3. Medication abuse is dangerous, talk to your pharmacist if you are using more than you should.
  4. Don’t throw away or flush medicines; hand in expired or unneeded medications to Medipost’s courier drivers or at any healthcare facility with a pharmacy.
  5. You can tell a pharmacist anything without feeling embarrassed. As the most accessible healthcare professionals, they can offer guidance and advice when you need to see a doctor.

“Make sure you understand everything your doctor or pharmacist tells you about how to take your medication, and feel free to ask as many questions as you need to; it’s your health at stake. It can be very helpful to speak to a pharmacy professional in your home language to ensure you get the most out of these interactions,” Steenkamp says.

Apart from the convenience and safety of the free delivery of chronic medications, including treatment for high cholesterol, diabetes, and many other conditions, to any address in South Africa, Medipost Pharmacy also offers all registered patients access to telephonic clinical pharmacy advice in all official South African languages. Self-care medication is also available via the online shop.

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Harvesting seaweed to treat diabetes and obesity

S’thandiwe Magwaza received her Master’s in Biochemistry cum laude for her research on the use of seaweed to treat diabetes and obesity.


S’thandiwe Magwaza’s dissertation titled: Studies on the antioxidative, anti-diabetic and anti-obesogenic potentials of some marine macroalgae or seaweeds collected from the Southern and Western coastlines of South Africa, was supervised by Professor Shahidul Islam (University of KwaZulu-Natal).

She explained that obesity and Type 2 diabetes (T2D) have become significant global health concerns in recent years. “These conditions are associated with a range of serious health complications, including heart disease, stroke, kidney disease and certain types of cancer,” she said. “Understanding their causes, risk factors and management is crucial to improve public health and reduce the burden of chronic diseases.”

The prevalence of obesity and T2D has continued to rise in recent decades and is expected to triple in the next 30 years. They are not only a health problem, but they also impose an economic burden. These conditions are often linked as obesity is a major risk factor for the development of T2D. The pharmacological treatments have side effects and are expensive.

“There is great demand for natural anti-obesity and anti-T2D remedies owing to the fact that they cost less and have fewer to no side effects,’ said S’thandiwe. “A number of seaweeds go to waste although many medicinal plant extracts and their isolated compounds have been scientifically proven to possess anti-obesity and anti-T2D properties.”

23 types of seaweed collected

Her research evaluated the anti-obesity, anti-diabetic and antioxidant potentials of 23 types of seaweed collected on South Africa’s southern and western coastlines. They were evaluated using in vitro and ex vivo experimental models.

Seaweeds have been used to treat various ailments in East Asian countries for centuries. Yet the health benefits of seaweeds from South African coastlines are not well-explored. Seaweeds are rich in bioactive compounds including polysaccharides, polyphenols and peptides, which have demonstrated potential health benefits. Investigating these natural sources for their anti-obesity and anti-diabetic properties can lead to the development of safer and more sustainable therapeutic options.

Thankful for support

S’thandiwe has registered for a PhD and is currently continuing her research under Islam’s supervision. She thanked him for his academic guidance and paid tribute to colleagues at the Biomedical Research Laboratory for their contributions and assistance. She also acknowledged the National Research Foundation for financial support throughout her postgraduate studies.

S’thandiwe thanked her mother, Ntombenhle Ngcobo Magwaza, for her love, support, encouragement and prayers and for the sacrifices she made to ensure she had the opportunities she needed. She paid tribute to her late grandfather who ignited her love for education, noting that it was the one thing no one could ever take from her.

“I always use my breaks to spend time with my family as they are important for my mental and emotional well-being,” said S’thandiwe. “The memories we create together and the emotional connection I have with them serve as a source of comfort during challenging times.”

Sthandiwe Magwaza

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S’thandiwe Magwaza received her Master’s in Biochemistry cum laude for her research on the use of seaweed to treat diabetes and obesity.


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Tips for pre- and post-hospitalisation

Margie Young shares easy tips to help manage your pre- and post-hospitalisation.


Tips to manage your elective procedure hospitalisation

  • Confirm your surgery date
  • Confirm your authorisation with your medical aid.
  • Confirm your hospital pre-admission. Be sure to disclose that you have diabetes so that you will be one of the first on the list.
  • Confirm what medication you should continue or discontinue with.
  • Be prepared. Get your running around done ahead of time. Pack your bags, get your chronic meds and ensure you have extra test strips.
  • Focus on you, closer to surgery. Guard yourself, keep to immediate family and stay away from big gatherings. Hydrate, eat nutritiously and be compliant with your medication. Get good quality sleep.
  • If you tend to have hypos, have your own rescue remedy (juice, Coke, Super C’s).

Tips to manage an emergency hospitalisation

  • Be prepared for any emergency. This includes: an ICE tag or card with your eemergency contact details and a list of your medication and doses (even those meds that nobody knows about, like garlic tablets, or PDE5 inhibitors for erectile dysfunction).

Recovery time tips

IN HOSPITAL

  • Follow instructions.
  • Day 1 – 4 are considered the most critical days.
  • Remember to hydrate. Avoid sugary drinks.
  • Get moving – if possible. Major surgery usually recommends staying in bed for 24 – 48hrs post-surgery.
  • Good hygiene. Brushing teeth is a must.
  • Nap and sleep as needed.

AT HOME

  • Follow instructions.
  • Take your medication as prescribed.
  • Do not do too much too soon.
  • Nutrition is vital. Get enough of the right stuff to eat and drink.
  • Get moving. Move slowly if you must. Do the rehab exercises prescribed.
  • Good hygiene. To avoid unnecessary delay in wound healing.
  • Rest

Glucose management

Glucose levels will be variable, often due to many of the factors that affect your blood glucose, so be sure to test more frequently and adjust your insulin accordingly as medications alter the effectiveness of the insulin.

Margie Young is an insulin pump specialist at Medtronic. She has been involved in the diabetes arena for the better part of 20 years.

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Margie Young is an insulin pump specialist at Medtronic. She has been involved in the diabetes arena for the better part of 20 years.


Bone health for people living with diabetes

It’s common to hear about the relationship between diabetes and the eyes, kidneys and feet. But, did you know that diabetes can also affect your bone health?


People living with diabetes face a multitude of challenges in managing their condition and bone health shouldn’t be overlooked. Understanding the impact of poor bone health to people living with diabetes is crucial in achieving overall well-being and quality of life.

Bones plays an important role in your overall health, from being a protective shield to delicate body parts to providing structure and support. Bones need to be strong yet light enough to keep you moving. You depend on your bones for many aspects of your life, from the visible (walking and dressing) to the invisible (serving as storehouses for essential nutrients and minerals that the body needs).

Bone modelling and remodelling

Like all of your body parts, bones are active tissue, which means they are actively changing throughout your lifetime. When a child is born, they have few bones that assist in giving them shape (structure) and support, and as they grow the new bones are formed from the cartilage. Every milestone a child achieves results in stronger bones and muscles that enable them to grow in height and become stronger.

There are two bone-making processes involved in the development, growth and shaping of bones  as well as the continuous renewal of bone tissue throughout life.

Bone modelling

During childhood and adolescence, new bone tissue is formed and broken down at different sites throughout the body, allowing bones to grow in size and shape. The process is called bone modelling and continues until age 25 – 30 when the child reaches adulthood.

In some cases the process can be interrupted by health conditions such as Type 1 diabetes, which means people living with Type 1 diabetes might not have full bone maturity .

Bone remodelling

During adulthood, bone remodelling involves the removal and replacement of bone at the same sites to:

  • Replace old bone that can become brittle.
  • Repair small cracks or deformation.
  • Release calcium and phosphorus into the circulation when need arises (dietary inadequacy, pregnancy, lactation).

Figure 1 bone growth[1]

Diabetes and bone health

For people living with Type 1 diabetes, the main concern is bone fragility (ability of bones to break easily at low impact). According of The Lancet Journal of Diabetes and Endocrinology, bone fragility is a recognised complication of Type 1 diabetes. People with Type 1 diabetes have lower bone mineral density (BMD) and greater fracture risk than individuals without diabetes (more than five times for hip fracture and two times for non-vertebral fractures).

Bone fragility becomes a complication because when a person living with diabetes experience a fracture, to repair that fracture isn’t a straightforward process, as such they experience a delay which impacts the proper repair and healing of that fracture.

The research also shows that people with Type 2 diabetes who have complications such as diabetic eye disease or kidney disease are also at increased risk of fragility fractures despite having higher bone mineral density compared to people living with Type 1 diabetes.

Another complication of diabetes is nerve damage which results in impaired movement, increasing the risk of falls. Low blood glucose reactions may also contribute to falls and fractures.

The duration of diabetes also plays a role as those living with the condition for more than five years tend to be at a higher risk for fractures and poor fracture healing.

Other factors of poor bone health

Other factors that can increase the risk of falls and poor bone health that lead to fractures are low levels of calcium and vitamin D. The body parts as well as other substances within the body such as minerals and nutrients don’t work in isolation but work together, which is the case with calcium and vitamin D. They work together to build your bones. People living with diabetes tend to have low vitamin D levels. Vitamin D helps the body to absorb calcium, which the body needs to maintain strong bones.

Hormone interference

There are also important hormones that affect the quality of your bones. As a person living with diabetes and having low levels of the following hormones increases your risks of bone fractures.

  • Low oestrogen is known for causing bone loss. If you’re a woman in menopause, had a hysterectomy with ovaries removed, or  a younger woman with irregular menstruation or menstruation that has stopped for many months even years, you’re at risk of osteoporosis.
  • Low testosterone can also affect bone health.
  • Vitamin D is a true hormone that is made on your skin when exposed to sunlight. Most spend times indoors and don’t receive enough sunlight to activate this essential element the body needs. As you get older, the amount of vitamin D that your skin produces gets diminished.
  • Thyroid balance is important not only for your weight and energy level, but also for your bones. An overactive thyroid or taking too much thyroid hormone to replace an underactive thyroid can make bones brittle within a few months.
  • Extra parathyroid hormone made by an enlarged parathyroid gland in your neck is a common cause of fragile bones and osteoporosis.
  • High cortisol, a stress hormone made in your adrenals, may present a risk of osteoporosis.

Osteoporosis

Osteoporosis (loss of bone mass) is a silent condition. This is why many people may not know they’re at risk or think about prevention until they have a fracture in an unexpected way.

Osteoporosis causes your bones to become weak and more prone to a fracture as you get older. The hip, spine and wrist are most susceptible, but a fracture may occur in any bone.

It’s normal for women to start experiencing a decrease in bone density when they enter menopause. This happens due to hormonal changes and is generally a slow process. Breaking a bone after falling while in a standing position could be a sign of osteoporosis. Any fracture should prompt a discussion of bone health with your doctor.

Osteoporosis is diagnosed with a bone density test, a quick and painless type of X-ray, that provides information about bone strength and the risk of a future fracture. Many people are surprised to learn they have osteoporosis because they have no symptoms.

Unfortunately, osteoporosis can have devastating consequences. Falling may lead to a life-altering fracture and permanent disability.

Earlier screening is recommended for women with certain risk factors, such as a family history of fractures or the use of certain medications (steroids). Those who consumed very little calcium in younger years, had an eating disorder, smoke or consume excessive amounts of alcohol may also be vulnerable to accelerated bone loss. Women who are underweight are also at increased risk.

Treatment for osteoporosis

Medications used to treat and prevent osteoporosis should be tailored for each individual patient.

Most people think of calcium and vitamin D when it comes to bones. However, there are so many more nutrients that are essential for bones, including vitamin B12, phosphorus, magnesium, and vitamin K, to name a few.

It’s preferable to get your calcium from food sources. Though, if supplements are taken, two forms are available: calcium carbonate is absorbed most efficiently when taken with food while calcium citrate is absorbed equally well with or without food.

It’s recommended that patients divide their dose for optimal absorption, taking no more 500mg at one time. A calcium supplement can interact with various prescription medications, so you should talk to your doctor about the best way to take it.

Diabetes and the risk for osteoporosis

People living with diabetes risk losing bone mass at a more rapid rate than average. This is due to complications such as muscle weakness, vision issues, low blood glucose, neuropathy in the feet, and certain diabetic medications that causes bone loss. The factor that increases the risk of osteoporosis the most is sedentary lifestyle.

Protecting bone health

  • Being physically active helps keep blood glucose levelled and is important for bone health. Weight-bearing exercises (walking, jogging and stair climbing) can prevent bone loss and build muscle strength to prevent falls. Maintaining a healthy weight can help preserve bone mass, even as you age and living with diabetes.
  • Eating well-balanced nutritious meals. Avoid refined carbohydrates (white bread and sweetened drinks) that cause blood glucose levels to spike. Limit caffeine (coffee and energy drinks) as they may affect calcium absorption.
  • Having good diabetes control to prevent complications associated with falling, such as nerve damage, vision loss, circulatory problems, and hypoglycaemia (low blood glucose).
  • Quitting all tobacco products. Smoking reduces blood supply to the bones and other organs, increasing the risk of diabetes complications.
  • Limiting, if not completely avoiding, alcohol. Alcohol affects all parts of the body, including the bones, and may cause changes in blood glucose levels.

People with diabetes should have a bone density test to monitor bone mineral density every two years. Routine bone density testing isn’t recommended for men younger than 70 unless they have other risk factors. Since women have a higher risk of osteoporosis, it’s recommended that all women above 50 years of age and post-menopausal women younger than 65 years of age with risk factors get a bone density test.  

Motselisi R Mosiana is a radiographer and the founder of Qsight which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening.

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Motselisi R Mosiana is a radiographer and the founder of InsureSPR Health which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening.

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