(Cost) effective blood glucose monitoring

Kevin Stead explains (cost) effective blood glucose monitoring.


With the rising cost of living in South Africa, it is imperative that we realise value in every rand spent. Especially when it comes to treatment and control of diabetes.

This becomes clear when reviewing the cost of healthy living and medication. It’s therefore important to understand why it is so essential to know and understand blood glucose control and why monitoring is so crucial to reduce cost, as well as prevent complications.

The situation in South Africa

Seven percent of South Africans, between the ages of 21 and 79, have diabetes. This means that 3,85 million South Africans in this age group may have diabetes.

The prevalence of diabetes in South Africa, in 2010, was estimated at 4,5% – a 155% increase in six years. The International Diabetes Federation (IDF) Diabetes Atlas indicates that the uncertainty range is between 3,6 and 14%. Data suggests that 630 000 to 2, 394 million people are undiagnosed in South Africa.

Financial implications

Cost per person per annum was approximately R5 000 in 2010 and R26 743,69 in 2015.

Sixty to 80% of people with diabetes in South Africa die before the age of 60 (loss of manpower).

The World Bank suggests that no more than 5% of a country’s gross domestic profit should be spent on health. In South Africa, 8,9% GDP is spent on health.

What is the solution?

What of glycaemic control? Complications? Education? Dr Shaukat Sadiko, IDF president, said, “Big talk and quoting statistics have little value if we do not do initiatives which improve the lives of all our people with diabetes.”

Testing in pairs

The average cost of a glucose strip is R3,76 (R188 medical aid reimbursement rate). So, testing can be expensive and seemingly worthless, especially in people living with diabetes who don’t understand how to use the information from their meter to control their glucose levels.

For example: A Type 2 diabetes patient will test their glucose level in the mornings only (fasting), only to discover six months later that their HbA1c levels are high (above 6,5%). So, where is the problem?

The blood glucose peaks are not being pinpointed, i.e. the after-meal glucose levels which only peak from 1,5 to 2 hours after meals.

If testing is performed in pairs, before and after meals, an accurate and immediate benefit is that the patient will see the effect that a meal has on their glucose levels. This in turn leads to an action to either reduce food intake, exercise, or increase medication to address the ‘spike’.

By alternating testing times (breakfast, lunch and supper), very soon a clear picture will emerge and a better understanding of the effect that testing with a purpose has on food and medication.

Yes, testing in the morning is important but testing in pairs on alternate days and alternate meals will provide a clear understandable picture of overall control.

A tin of 50 strips will be sufficient in most Type 2 diabetes patients to test 12 times a week. And, if utilised correctly, will result in the healthcare provider to easily access and manage diabetes patients effectively.

Education is the key. Many diabetes patients need to be educated on why monitoring is important as well as an understanding of the effects that food and medication has on blood glucose.

How does this make sense?

It seems nonsensical to cut down cost by testing in pairs. That means more glucose strips are used, right?

Yes, indeed. But, a random test means nothing to you, the patient, as well as your doctor. If random tests are done, they are a complete waste of money and strips.

Once your diabetes is controlled and you are on the correct dosage, etc. then and only then will testing protocol’s as per Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) apply.

However, usually diabetes patients that get one tin of strips per month, on medical aid, never uses them. So, by the year end, they end up with lots of unused, expired strips that are a complete waste of money.

On the other hand, if all 50 strips are used in a month, a comprehensive trend pattern is formed allowing the patient and doctor to intervene much sooner.

In effect, the question really is: Do I only test once a week in the mornings (complete waste of a strip) or do I use what the medical aid is paying for to get as much data per month on my “actual” glucose control?

Regardless, if patients test in pairs, even minimally (three times a week) then at least test with a purpose (before meals and after meals and a fasting).

What is the real issue?

The real issue is: do you, the diabetes patient, know what a Sunday lunch does to your glucose level? Do you know what effect the six beers you drank last night has on your glucose level? Or what the effect of exercising was? What happens to your glucose when you are sick?

Often than not, most don’t know and wonder why their HbA1c levels are so high, or suddenly get an abnormal high and don’t know why?

Another main issue is morbidity and the result of developing the complications. The cost of treatment is exorbitant so as the old adage goes, prevention is better than cure.

So, when we step back and look at the entire picture, isn’t it good sense to monitor effectively and prevent complications, or simply test at random, waste strips, be blissfully ignorant of glucose changes and hope for the best?

What it boils down to

It really boils down to the value you are spending on strips against the value of saving a few strips that would be better utilised. And, at the same time prevent a stroke, heart attack, kidney failure, blindness, amputations, etc.

SEMDSA guidelines

The diagnosis of diabetes is confirmed1

  1. In patients with symptoms of hyperglycaemia (excessive urination, rxcess thirst, blurred vision, weight loss) or metabolic decompensation (diabetic ketoacidosis or hyperosmolar non-ketotic state), when any one single test confirms that the:
  •  Random plasma glucose is ≥ 11,1 mmol/L
  •  Fasting plasma glucose is ≥ 7,0 mmol/L
  •  HbA1c is ≥ 6.5%
  • 2-hour post-load glucose is ≥ 11,1 mmol/L.

However, a glucose tolerance test is rarely needed in this category of patient.

  1. In an asymptomatic individual, when any one of the following tests, repeated on separate days within a two-week period confirms that the:
    •  Fasting plasma glucose is ≥ 7,0 mmol/L
    • 2 hr-post load glucose (OGTT) is ≥ 11, 1 mmol/L
    • HbA1c is ≥ 6,5%

If the diagnosis of diabetes is not confirmed with the repeated test, institute lifestyle modification and retest in three to six months.



References:

  1. SEMDSA guidelines 2018
  2. Centre for Diabetes and Endocrinology clinical guidelines 2018
  3. IDF IDF Diabetes Atlas. Seventh edition Brussels, IDF 2015, IDF Atlas Sixth edition, Brussels IDF. 2013
  4. Statistics South Africa. Midyear population estimates 2015 htpp://www.statssa.gov.za/publications/P0302/P03022015.pdf
  5. World Bank. Health expenditure, total (% GDP) 2016 htpp://data.worldbank.org/indicator/SH.XPD.TOTL.ZS 

MEET OUR EXPERT


Kevin Stead is a professional representative specialising in diabetes and diabetes management.


Header image credit by Freepik 

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Movement disorders associated with diabetes

People living with diabetes may suffer from an array of movement disorders that can cause pain and dysfunction. Physiotherapist, Saadia Jantjes, tells us more.


In the last issue, I discussed the importance of getting active and incorporating more movement into your daily life. But what if you’re experiencing joint or bone pain, discomfort or just have difficulty moving?

One of the barriers preventing people living with diabetes from implementing exercise into their daily routine is movement or musculoskeletal disorders that develop due to diabetes.

Diabetic patients may suffer from an array of musculoskeletal disorders that can cause pain and dysfunction. This could result in a negative effect on the management of their diabetes, stress and a decrease the quality of life.

Common examples of such movement disorders

Frozen shoulder

Frozen shoulder is frequently on both sides in diabetic patients. It’s characterised by severe pain, increased tightening, stiffness, and restricts the range of motions of the shoulder. It has an incidence of 10 – 20% in Type 1 diabetes patients and 7 – 32% in Type 2 diabetes patients. Other risk factors include past shoulder trauma, cardiac-, respiratory- and cerebral diseases. 

Carpal tunnel syndrome

This is a neuropathy that occurs frequently in the wrist and hand. Diabetes is the most common metabolic disease that causes carpal tunnel syndrome, found in 14 – 16% of patients. It is also seen more frequently in women than in men.

Symptoms include paresthesia (abnormal sensation) that worsens in the evenings in the thumb, index, and middle fingers of the hands, which wakes the person up from sleep.

Pain in the wrist and hand can cause clumsiness and poor control of hand movements. It can cause a decrease in work production as well as pain in manual workers, office workers and drivers.

Diabetic peripheral neuropathy (DPN)

Peripheral neuropathy is nerve damage which leads to numbness, loss of sensation, pain or impaired sensation in hands, feet and legs.

The dangers of having neuropathy include loss of balance and poor control of extremities which could result in falls and further injury.

The prevalence of numbness and poor sensation means that bruises, cuts and abrasions are usually gone unnoticed and untreated, leading to ulcers which could result in amputation if infected. It is the most common complication of diabetes; about 60 to 70% of people with diabetes will eventually develop peripheral neuropathy.

However, studies have shown that diabetic patients can reduce their risk of nerve damage by controlling their blood glucose levels through correct nutrition and exercise.

Charcot arthropathy

This is a result of diabetic peripheral neuropathy. It is a progressive and degenerative disease of the foot and ankle joints, which causes damage and deformities of the joint if left untreated. Charcot’s joints are typically seen in patients over the age of 50 who have had diabetes for many years and have existing neuropathic complications.

What to do if one of these sound familiar?

Consult your GP and he/she will point you in the right direction. You may need further tests done to get a proper diagnosis and a consult with a specialist, like a neurologist, orthopaedist, or rheumatologist.

It is important to note that I have only highlighted a few and more common disorders. If you are feeling any pain during exercise or at rest, whether it is constant pain or intermittent pain, the best thing would be to consult your GP and get it checked out. Exercise should not be painful.

I’ve been diagnosed with a diabetes associated movement disorder, now what?

This is where your multi-disciplinary team becomes involved. Not only will you need regular check-ups with your GP, nurse and dietitian, but this is where physiotherapy and occupational therapy become an integral part of your management of your condition as well.

It may all seem incredibly daunting and scary. But keeping yourself informed is one of the best tools when managing your diabetes. The management of your condition is critical in preventing movement complications.

When the control of diabetes is poor, higher levels of diabetic complications result. Pharmacotherapy, diet, and a regular physiotherapy programme should be the cornerstone of diabetes management.

It is imperative to have an appropriate exercise programme, overseen by a GP, as an integral part of diabetes management to reduce the frequency and severity of complications.

MEET OUR EXPERT


Saadia Kirsten Jantjes is a physiotherapist with a passion for health and wellness. With a second degree in Sport Science, exercise is one of her favourite rehabilitation tools, to not only rehab injuries but prevent injuries too. Saadia has her own private practice in Morningside, Johannesburg, while working at a Sub-Acute Clinic and furthering her studies in Pilates.


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Informing the uninformed – doctors and patients

Lisa Swaine gives us legal insight as to why doctors need to have a record of informed consent, and highlights that good clear communication is key.


1 April 2019 was certainly not a day for fools. The Supreme Court of Appeal gave judgment in the case of Beukes v Smith ((211/2018) [2019] ZASCA 48) for a surgeon whose information to his patient was called into question.

The decision highlights the value of keeping proper written records of explanations, discussions and advice leading to the informed consent to avoid protracted legal proceedings for both doctors and patients.

What is informed consent?

The introduction to the ethical guidelines published by the Health Professions Council of South Africa succinctly describes informed consent in this statement: “Successful relationships between healthcare practitioners and patients depend upon mutual trust. To establish that trust, practitioners must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention, even where a refusal may result in harm to themselves or in their own death. Patients must be given sufficient information in a way that they can understand, to enable them to exercise their right to make informed decisions about their care. This is what is meant by informed consent.”

Medical treatment cannot be provided in the absence of consent. Our courts have held that, to give proper informed consent, a patient must be informed of all material risks associated with the treatment.

What is material? If a reasonable person in the position of the patient, warned of the risk, would attach significance to the risk, it is material. To give proper informed consent, the patient must know, appreciate and understand the nature and extent of the harm or risk.

The claim in the proverbial nutshell

Dr Smith performed a laparoscopic (using multiple small incisions with ports to perform surgery with specialised instruments) hernia repair on Mrs Beukes. She sued him for damages alleging that he had negligently failed to provide her with sufficient information to enable her to give informed consent for the surgery.

Dr Smith’s alleged failure was to inform her that the hernia repair could have been done by way of a laparotomy procedure (older technique that relies on a single large incision, through which a surgeon uses his or her hands to directly perform the procedure).

His failure caused her to give uninformed consent to the laparoscopy during which her colon was perforated, resulting in her suffering complications and damages.

Mrs Beukes lost in the Gauteng Division of the High Court in Pretoria. The appeal was against that judgment.

Consultation, motivation, operation, complication

Against the backdrop of the surgery lay Mrs Beukes’ medical risk. She was a high-risk patient which meant that because of her health, lifestyle and medical history, the risk of her suffering complications related to surgery was high.

Mrs Beukes was referred to Dr Smith who consulted with her on 21 February 2012. He admitted her to the hospital as surgery was inevitable if she did not respond to conservative treatment. The issue would then be which surgery to perform.

After having consulted the referring doctor’s report and radiological reports, Dr Smith’s recommendation was that the laparoscopy would be the best option for Mrs Beukes in the circumstances.

Dr Smith wrote a detailed motivation for approval for the laparoscopy to Mrs Beukes’ medical aid in which the reason for his recommendation for the laparoscopy was stated and the general and specific advantages of the surgery were listed.

The laparoscopy was performed by Dr Smith on 23 February 2012. Mrs Beukes was discharged from hospital on 28 February 2012.

Three days’ post-discharge, Mrs Beukes was re-admitted to hospital with various complications associated with a perforation of her colon which included sepsis. She underwent three further surgical procedures and remained in hospital until 19 April 2012.

Trial and tribulation

The doctor’s version

According to Dr Smith, Mrs Beukes gave him informed consent orally on 22 February 2012, after he had consulted with her and explained the nature of each of the two options available, being the contemplated laparoscopic surgery and the laparotomy, and the material benefits and risks associated with both.

He had informed her that, in his opinion, the laparoscopy was the better option in the circumstances. He also testified that she had signed a written consent shortly before the operation on 23 February 2012, which formed part of the record and was a confirmation of the oral consent given the previous day following his explanation of both procedures.

The patient’s version

Mrs Beukes, on the other hand, denied that Dr Smith had explained both procedures to her. She insisted that, in her first consultation with Dr Smith on 21 February 2012, he told her that he would first consult with the radiologists on her scans and thereafter perform a “quick 15 to 20-minute operation” to repair her hernia with a mesh and in “two or three days” she would be home.

In her version, Dr Smith made the decision to do the laparoscopic hernia repair during the first consultation on 21 February 2012 before having consulted the radiologists. She also denied having signed the written consent. She testified that had she been informed that the hernia could also have been repaired through a laparotomy, she would have discussed her options with her family and would have opted for the less risky of the two procedures. But, she trusted Dr Smith and believed him when he told her that the laparoscopy was a simple procedure that would take 15 to 20 minutes and that she would be discharged from hospital in three days.

Expert opinions

The specialist surgeons who gave expert testimony on behalf of Mrs Beukes and Dr Smith agreed that Mrs Beukes was a high-risk patient, that under the circumstances, the laparoscopy was the better option; the procedure had been performed by Dr Smith without negligence; and that Dr Smith’s post-operative management of Mrs Beukes was acceptable.

Was informed consent obtained?

The only issue was whether informed consent had been obtained.

At the heart of Mrs Beukes’ contentions was the fact that there was no written record of the details of the informed consent discussion.

It was not disputed that no record had been made of the content of Dr Smith’s explanation to Mrs Beukes.

Mrs Beukes’ version was that, in the absence of evidence on the detail of her consultation with Dr Smith, the court had to conclude that Dr Smith had not given Mrs Beukes the necessary information as he alleged and further, even if he had given her some information, it was not sufficient to enable her to make an informed decision

Dr Smith’s evidence was entirely reliant on his memory of what had transpired over the relevant period. However, as found by the trial court, several aspects supported his version, such as his demeanour and diligence which were more consistent with his version that all had been sufficiently explained.

Added to this were the medical records which also supported his version as opposed to that tendered by Mrs Beukes. Mrs Beukes’ version was inconsistent with Dr Smith’s undisputed caring and diligent nature.

The medical records suggested that there had been a more substantive discussion between her and Dr Smith than she was willing to admit. The written representations made by Dr Smith to Mrs Beukes’ medical aid, after his consultation with her the morning before the laparoscopy, were consistent with his version and revealed that the material risks and benefits of the medical procedures occupied his mind. Nothing in the medical records contradicted Dr Smith’s evidence.

Judgment day

Fortunately for Dr Smith, the Appeal Court found no basis upon which to overturn the factual finding by the trial court that Dr Smith’s version was probable and that of Mrs Beukes was not.

The cost of not recording what is said

Unfortunately for Dr Smith, as it would appear from what was stated in the judgment, he was subjected to lengthy cross-examination from which he might have been spared had there been a written record or other record of his explanation, discussion and advice leading to the informed consent.

That is aside from the cost of the litigation to Dr Smith and by cost, I don’t just mean legal costs. Litigation is stressful and takes one out of one’s day-to-day professional practice. It comes with a high personal and economic price tag.

Keeping record not only protects the patient which is primary. It also protects the practitioner and may well avoid the risk of becoming embroiled in costly and lengthy ‘he said – she said’ debates.

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Lisa Swaine is a partner at Webber Wentzel. She is a dispute resolution and litigation specialist.


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Vaccines – pneumococcal and influenza

Dr Louise Johnson educates us on winter vaccines pneumococcal and influenza – for people living with diabetes.


What is pneumococcal disease?

Pneumococcal disease is caused by the bacterium Streptococcus pneumonia (S. pneumonia). This can cause infection in the respiratory tract i.e. lung, sinus or ears.

In vulnerable people, such as children, the elderly, and people living with diabetes, these bacteria can invade the bloodstream and cause meningitis and septicaemia. This may lead to deafness, mental disability and even death. People at extreme ages (younger than two years or older than 65 years) are particularly susceptible to the complications because of their underdeveloped immune system or aging immune system.

Pneumococcal bacteria are spread from person to person through close contact with respiratory secretions (sputum or saliva).

Why immunise?

It is estimated that immunisation approximately prevents 2,5 million deaths a year due to infections. It is also cost-effective to the health system and has saved more lives than the development of antibiotics.1

Antibiotic-resistance is a reality, and resistance to commonly used antibiotics is becoming a serious threat to medical treatment of infections.

In the age of antibiotic-resistant bugs, the prevention of disease through vaccines has become essential. It not only helps prevent infections in vaccinated people, but also prevents a “herd immunity” by helping to prevent transmission of the bug to close contacts of the sick patient.

Types of vaccines:

There are two different types of pneumococcal vaccines available:

  1. PPV23 (Pneumovax 23)

Pneumococcal polysaccharide vaccine is made from polysaccharide (sugar like) capsule of 23 different strains of S. pneumonia.

This capsule is the main target of the body’s immune response during pneumococcal infection. The body produces antibodies when exposed to the capsule (acts like an antigen).

The next time the immune system is exposed to the same antigen, the immune system is prepared and can rapidly produce killing-antibodies. This is due to the body having a “memory” of the antigen via specially produced immune memory B-cells.

Children younger than two years of age have an immature immune system and cannot produce memory cells to the capsule. Therefore, they should not get this vaccine.

  1. PCV13 (Prevenar 13)

Pneumococcal conjugate vaccine is like PPSV23. Though, a protein that induces memory cells, even in young children, joins the capsular polysaccharide.

Who should be vaccinated with which vaccines?

Pneumovax 23:

Persons older than 65 years.

People older than two years with chronic heart and lung disorders, diabetes, chronic liver disease, COPD, alcoholism, spleen dysfunction, asplenia (spleen removed), cancer, organ transplantation, HIV infection and smokers.

Prevenar 13:

Children aged: six weeks, four months, and 12 months.

Children with underlying medical conditions should get an extra dose at six months. This is part of the South African Immunisation Programme.

How to vaccinate?

South African guidelines to CAP (community acquired pneumonia)2

Vaccination is the key pillar of antibiotic stewardship.

  • All patients older than 50 years who are vaccine naïve should receive a single-dose of PCV13.
  • Every adult older than 50 years who have received PPV23 should receive a single-dose of PCV13 one year later.
  • All adults older than 65 years of age who are vaccine naïve should receive a single-dose of PCV13, followed a year later by PPV23.
  • Every adult older than 65 years of age who have received PPV23, should receive a single-dose of PCV13 at least one year later.
  • Younger adults (>18 year) who are vaccine naïve with severe underlying comorbid or immunocompromising conditions, including HIV infection, should receive a single-dose of PCV13, followed at least two months later by PPV23.
  • Younger adults (> 18 years) who have previously received PPV23 and have severe underlying comorbid or immunocompromising conditions, including HIV infection should receive a single-dose of PCV13 one year later.
  • All women who are pregnant in the period of influenza vaccine availability, should be offered vaccination with influenza vaccination of that year.
  • Adults older than 65 years of age should receive the annual vaccination for influenza.
  • Individuals with chronic diseases (diabetes, lung disease, heart disease, HIV infected individuals and morbidly obese (BMI>40kg/m2) are at high risk and should be vaccinated.
  • All healthcare workers should be offered annual influenza vaccination.

Who should not be vaccinated?

Pneumovax 23 should not be given to children younger than two years. Hypersensitivity to the products in the vaccine.

What are the side effects of the pneumococcal vaccine?

Side effects are very uncommon. Local side effects to the injected area: redness, soreness, or rash. Also fatigue, headache, chills and diffuse achiness.

What is influenza?

Influenza (also known as flu) kills between 6 000 and 11 000 South Africans per year. These deaths are 50% in the elderly and 30% in HIV infected people.

The highest rate of hospitalisation is in people older than 65 years of age, HIV-infected people, and children less than five years of age.

Patients with chronic diseases, such as diabetes, heart and lung disease and tuberculosis are also at higher risk of contracting influenza.3

Flu is a virus and is spread from person to person. It causes many different symptoms from headache, fatigue, muscle pain, shivers, vomiting and diarrhoea.

It spreads mainly by droplets when people cough, sneeze, or talk. You can also get flu by touching a surface or object that has flu virus on it and then touching your mouth, eyes or nose.

What is in the flu vaccine?

The flu vaccine contains three different types of inactivated flu viruses. This mean the virus is dead and can’t make you sick. The viruses in the flu injection are named for the year they were found and the place they were found. This year’s vaccine (2019) was updated with two new viruses. The current vaccine contains:

  1. A/California/7/2009(H1N1) pdm09 like virus
  2. A/HongKong/4801/2014(H3N2) like virus
  3. B/Brisbane/60/2008 like virus

Who should get the flu vaccine?

  • Pregnant and post-partum women (anytime during pregnancy).
  • People who are infected with HIV.
  • Healthcare workers.
  • People with chronic diseases (diabetes, lung, heart, kidney, liver, etc.)
  • People older than 65 years of age.
  • Residents of old age homes, chronic care and rehabilitation centres.
  • Children older than six months.
  • Adults and children in close contact with high-risk individuals.
  • Anyone wishing to reduce the risk of getting flu or spreading flu to others.

Who should not get the vaccine?

Anyone who had a severe allergic reaction to the vaccine, such as drop in blood pressure and difficulty in breathing.

Can I get the flu vaccine when I am sick?

Yes. You are safe to get the vaccine with mild cold or flu-like symptoms even if you have a fever. Though, if you are very ill (need to be admitted to a hospital) you should rather wait.

How effective is the flu vaccine?

The flu vaccine prevents only influenza and no other viruses. It is 60% effective in healthy individuals. The elderly and children younger than two years may not respond as well due to weaker immune system.4

Therefore, when looking at the bigger picture of population and personal health: be wise and vaccinate.


References:

  1. Plotkin SA, Mortimer E.A, Vaccines 2ndedition, Philadelphia:Wb Saunders, 1994
  2. J Thorac Dis 2017; 9 (6):1469-1502
  3. (nicd.ac.za) (www.cdc.gov/flu)
Dr Louise Loot

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Dr Louise Loot 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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Understanding the Somogyi effect and dawn phenomenon

Diabetes nurse educator, Christine Manga, explains the causes behind elevated fasting blood glucose readings in the morning: Somogyi effect and dawn phenomenon.


Both the Somogyi effect and dawn phenomenon will lead to elevated fasting blood glucose (glucose level after an overnight fast) readings in the morning. The target for fasting blood glucose levels is <= 7mmol/L. This said, the causes are very different.

Dawn phenomenon

The dawn phenomenon occurs in everyone. However, people without diabetes will not notice it because their body is able to counteract the effects. It is caused by natural body changes during sleep.

During the night, less insulin is produced and in the early hours of the morning, hormones, such as cortisol, growth hormone, epinephrine and glucagon, are all released. These hormones all act in the opposite way to insulin, resulting in elevated blood glucose levels.

Towards the early hours of the morning, the body releases stored glucose from the liver into the bloodstream to provide energy for the coming day. This will cause a further rise in blood glucose levels. According to the American Diabetes Association, the dawn phenomenon occurs between 5:00am – 8:00am. The dawn phenomenon is a natural phenomenon.

Somogyi effect

The Somogyi effect is usually management related and is a rebound hyperglycaemia (high blood glucose). It happens in response to a nocturnal hypoglycaemia (low blood glucose).

This hypoglycaemia can be caused by giving too much insulin at night, not having an evening snack, or from doing vigorous exercise in the evening hours. In response to the hypo, the body releases hormones to raise the blood glucose levels. These include cortisol, growth hormone, glucagon and adrenaline. When you wake, you will have elevated fasting blood glucose level.

So, which one do you have: Somogyi effect and dawn phenomenon?

Due to the causes being different, the management will also differ. To establish what is causing your elevated fasting reading, you will need to do some extra blood glucose testing.

Testing your blood glucose levels between 2:00am – 3:00am on a few consecutive nights will give you an answer. If you are experiencing hypos at this time of night, then you are experiencing the Somogyi effect.

If on the other hand, your blood glucose levels are normal at this time, then you are experiencing the dawn phenomenon.

The use of continuous glucose monitoring (CGM) would be extremely useful in detecting the cause of your elevated blood glucose readings. CGM is now becoming more affordable, but definitely is still not cheap. Speak to your doctor about wearing a sensor to assist you in making management decisions.

Prevention

Dawn phenomenon

To prevent the dawn phenomenon, you could:

  • Increase the amount of vigorous physical exercise in the evening hours.
  • Wear an insulin pump to administer extra insulin in the early morning hours. This would work well.
  • Reduce the amount of carbs and evening snacks.
  • Change insulin formulations to more concentrated ones. This can lead to improved fasting blood glucose levels.
  • Administer insulin later at night. This may also be beneficial.
  • There may be a need to change some of your diabetes medications, or possibly even add more.

Somogyi effect

Here are ways to prevent the Somogyi effect from occurring:

  • Reduce the amount of insulin given in the evening.
  • Once again, changing your insulin to a stronger concentration can prevent nocturnal hypos.
  • Giving the insulin earlier may also prove helpful.
  • Getting assistance with carb counting will help you to match the amount of insulin to the amount of carbs you eat, preventing overdosing of insulin.
  • Your doctor may need to assess your medication and reduce, or discontinue some.
  • Try to reduce the amount of vigorous physical activity in the evening.
  • It may also be necessary to have an evening snack before bedtime. The down side to this is that it may cause long-term weight gain.

The most important thing is that you know which one, the dawn phenomenon or the Somogyi effect, is causing your elevated fasting readings. You can only manage what you know.

eating time budget

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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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Depression and diabetes

Daniel Sher explores how diabetes and depression are linked, and gives some pointers for managing diabetes and depression together.


If you have diabetes, your chance of developing depression is two to three times higher than that of other people. As if we didn’t have enough to worry about already.

Why is this a problem?

Depression can make it harder for you to manage your glucose levels, often leading to diabetes burnout. Before you know it, you’re stuck in a vicious cycle of sadness, mood swings and poor blood glucose control.

What is depression?

Depression usually involves feelings of sadness, but depression and sadness are not the same thing. Rather, depression is a psychological disorder that affects a person not just emotionally, but also in terms of their thoughts and bodily functions.

Some of the symptoms of clinical depression include:

  • Ongoing sadness that doesn’t seem to ease up.
  • An inability to enjoy activities that previously brought you happiness.
  • Sleep disturbances.
  • Mood swings at home or at work are interfering with your relationships.
  • Concentration difficulties.
  • Suicidal thoughts and behaviours.
  • Inappropriate guilt and poor self-esteem.
  • Social withdrawal.
  • Changes in weight and appetite.
  • Low energy.
  • Less motivation to test your blood glucose, exercise and take insulin (diabetes burnout).

How common is depression in people with diabetes?

Time and time again, research studies have shown that having diabetes puts one at risk of developing depression. For example, a 2012 study showed that people with Type 1 diabetes are three times more likely to have depression; while people with Type 2 diabetes are twice as likely to be depressed.

Another 2019 study confirmed these numbers, leading the authors to say that reducing diabetes by 25% could stop 2,34 million cases of depression from happening. But, believe it or not, research shows that the relationship goes both ways. Having depression can also make a person more likely to develop (Type 2) diabetes.

Clearly, then, a close link between the two conditions exists. But why does this link exist? Why do depression and diabetes occur together so often?

Explaining the link between diabetes and depression

Injections. Finger pricks. Doctor’s visits. Lows. Highs. Dietary restrictions. Worry and fear. Yes, as people living with diabetes, we deal with a whole lot of stress. Is it really that surprising that we’re more likely to end up with depression?

Of course, living with diabetes comes with a psychological burden which in and of itself can trigger depression. But, the stress of diabetes alone doesn’t completely account for this link. This is where things get interesting.

Diabetes, depression and the brain

Recent research suggests that high blood glucose levels have a direct impact on the parts of the brain that affect mood and thinking. The researchers used a (fMRI) brain scanner to compare the brains of people living with diabetes versus people without the illness. The people living with diabetes were given some glucose to raise their sugars.

The scanners showed that when blood glucose levels went up, a certain brain chemical (glutamate) was released in parts of the brain that control thinking and emotions. Glutamate is closely linked to depression. The researchers also showed that people with worse glucose control over time had patterns of electrical activity in the brain that are linked to depression.

So, in other words, this study tells us that the link between diabetes and depression is not just a matter of increased life-stress: the two disorders are linked on a biological level. People living with diabetes experience changes in the brain that make depression more likely; and this is especially the case when blood glucose levels are high.

A vicious cycle

Many clients who approach me for help are stuck in a vicious cycle. They struggle to control their diabetes as well as they would like; and they soon start to develop signs of depression. The depression makes it harder for them to stay motivated and hopeful. They start to slack-off in terms of self-monitoring, diet and exercise. Their glucose control suffers as a result. This leads them to become even more depressed.

Why is this important?

For starters, if you are one of millions of people living with diabetes who is struggling with depression, know this: it’s not all in your head. The stress and strains of living with diabetes are very real. But, the illness also predisposes you to depression because of altered brain chemistry.

Now that we know this, it’s absolutely vital for doctors, patients and family members of people living with diabetes to know how to recognise the signs of diabetes and get help where needed. Treating both diabetes and depression together is vital.

How to get help

The good news is that this cycle can be broken. In most people, depression responds well to treatment. Let’s look at the two most common treatment options:

  1. Psychotherapy

Also known as talk therapy, counselling or just therapy. Speaking with a licensed mental health professional can help you to change the thoughts and behaviours that make depression more likely.

Cognitive behavioural therapy (CBT) is one of the most popular forms of therapy for treating depression. If possible, try to find a therapist who is experienced in working with people living with diabetes. It can really help to speak with someone who understands the struggles and nuances of living with a chronic illness.

  1. Medication

One of the most common forms of antidepressant medications is called a selective serotonin reuptake inhibitor (SSRI). Examples include Celexa, Lexapro, Zoloft and Zytomil. A 2006 research paper suggests that medication and therapy are equally effective in managing depression; and that the best outcomes usually occur when the two are combined.

  1. Lifestyle interventions

Therapists often include ‘behavioural modification’ to their treatment. This means empowering the client to make healthier choices when it comes to their diet, diabetes management and exercise patterns. Making positive choices in this regard can help you manage your depression and diabetes at the same time.

How to get help

If you are concerned that you may be developing depression on top of your diabetes, speak to your endocrinologist or general practitioner. Alternatively, you may want to make direct contact with a clinical psychologist or psychiatrist in your area. If possible, try to consult with a mental health professional who has experience in working with diabetes.

If you or a family member are suicidal, contact the South African Depression and Anxiety Group on their 24-hour suicide hotline: 0800 567 567.

Final thought

So, we now know that people living with diabetes are more likely to experience depression. Not just because their lives are a whole lot more stressful, but because diabetes, depression and the brain are all linked on a biological level. For those of us with diabetes, this means that we need to remain vigilant for signs of depression.

By getting the mental health treatment that you deserve, it’s possible to improve your overall quality of life and your blood-sugar control at the same time.


References

Bădescu, S. V., Tătaru, C., Kobylinska, L., Georgescu, E. L., Zahiu, D. M., Zăgrean, A. M., & Zăgrean, L. (2016). The association between Diabetes mellitus and Depression. Journal of medicine and life, 9(2), 120-125.

Chireh, B., Li, M., & D’Arcy, C. (2019). Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. Preventive medicine reports, 100822.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., … & Atkins, D. C. (2006). Randomized trial of behavioural activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of consulting and clinical psychology, 74(4), 658-670.

Endocrine Society. (2014, June 23). High blood sugar causes brain changes that raise depression risk. ScienceDaily. Retrieved June 19, 2019 from www.sciencedaily.com/releases/2014/06/140623092011.htm

Roy, T., & Lloyd, C. E. (2012). Epidemiology of depression and diabetes: a systematic review. Journal of affective disorders, 142, S8-S21.

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Daniel Sher is a registered clinical psychologist who has lived with Type 1 diabetes for over 28 years. He practices from Life Vincent Pallotti Hospital in Cape Town where he works with Type 1 and Type 2 diabetes patients to help them thrive. Visit www.danielshertherapy.com


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Tips for injecting insulin

Jessica Oosthuizen shares some useful pointers when injecting insulin.


Insulin therapy remains a fundamental and essential part of diabetes management. Many patients with Type 2 diabetes and all patients with Type 1 diabetes require insulin to keep blood glucose within target ranges.

However, this practice is still not performed optimally in many healthcare facilities, and insulin therapy is only effective if delivered into the correct tissue in the correct way.

The goal of exogenous insulin (insulin that is not made by the body but injected) is to reliably deliver the medication into the subcutaneous tissue, without causing any pain or discomfort and without any leakage of insulin.

The aim is to prevent injecting into the muscle. Injecting into the wrong space can affect the absorption and action of insulin. This can lead to unpredictable blood glucose control. To achieve this objective, it is important to select a needle that is the correct length.

What needles should be used for injecting insulin?

Studies have shown that shorter needles of 4mm are as safe and well-tolerated in comparison to longer ones.

Needles come with a different diameter and length. Those with a higher gauge number have a smaller needle diameter. Needles are available in 4-, 5-, 6- or 8-mm. Needles with a length of 12,7mm have an increased risk of intramuscular injection (which you want to avoid).

It is often assumed that a heavier person, with a higher BMI, may require a longer needle. However, we now know that 4-, 5- or 6-mm needles are suitable for all people with diabetes. Regardless of their BMI.

Insulin therapy should ideally be started using shorter length needles and these injections should be given at 90 degrees to the surface of the skin.

Children and teenagers

Children and adolescents should only be using needles with a length of 4-, 5- or 6mm. There is no clinical reason for using needles longer than 6mm. When injecting insulin into limbs, a skin-fold may be necessary, especially when using a 5- or 6mm needle.

Adults

In adults, including those with a high BMI in the overweight or obese category,  a needle that is 4mm, 5mm or 6mm in length should be used. There is no clinical reason to be using a needle >8mm. Patients who are using these needles should ideally change to a shorter needle. If this is not possible then lifting a skin-fold and/or injecting at a 45 degree angle should be adopted to avoid an intramuscular injection.

Injecting insulin into the muscle will cause: your body to absorb it too quickly; a more painful injection; and a shorter duration of insulin action time.

How many times can you use the same needle?

In a perfect world insulin needles would be used once and then safely discarded. Yet, realistically it’s common practice for needles to be reused. Especially, in a country, like South Africa, where resources are limited in both state and private sectors.

Although the risk of complications is relatively low in relation to the reuse of needles, some evidence does show that the reuse of needles can cause an increased risk of lipohypertrophy. This refers to swelling of the fatty tissue under the skin which causes fat lumps. It’s a relatively common side effect of insulin injections and can occur if multiple injections are given around the same area repeatedly.

Lipohypertrophy causes inconsistent and unpredictable insulin absorption, which can result in unexplained hypoglycaemia and glucose variability. It is for this reason that proper rotation of injection sites and regular changing of needles is essential.

Priming your pen

It’s important to remember that your insulin pen device should always be primed before the first dose and after every needle change.

Priming helps to remove any air bubbles that can collect during everyday use of your pen and ensures that you receive the full dose when administering insulin.

To prime your pen, dial up 2 units, hold your pen with the needle facing upwards and press down on the plunger. If you see drops of insulin come out at the top of the needle, then you know that your pen has been primed.

However, if you don’t see a flow of insulin then you must repeat the steps and continue until drops of insulin are visible at the top of the pen.

These same steps can be followed if you notice an air bubble in your pen. If an air bubble is present and you don’t remove it then you will not receive the correct dose of insulin.

You will notice this when you inject yourself. The air bubble causes a negative pressure when pointing the needle downwards into your skin and you will see a flow of insulin that is not injected and rather ‘spills’ out when removing the needle.

Final comment

Choosing the correct needles and ensuring removal of air when priming your insulin pen are two things that are easy enough to do. They can have positive effects on blood glucose control for people living with diabetes requiring multiple daily injections.


References

  1. FIT forum for injection technique in South Africa. Recommendations for best practice in injection technique. 1st 2014.
  2. Kreugel, G., Keers, J., Kerstens, M. and Wolffenbuttel, B. (2011). Randomized Trial on the Influence of the Length of Two Insulin Pen Needles on Glycaemic Control and Patient Preference in Obese Patients with Diabetes. Diabetes Technology & Therapeutics, 13(7), pp.737-741.
  3. Shah, R., Shah, V., Patel, M. and Maahs, D. (2016). Insulin delivery methods: Past, present and future. International Journal of Pharmaceutical Investigation, 6(1), p.1.
  4. Frid, A., Kreugel, G., Grassi, G., Halimi, S., Hicks, D., Hirsch, L., Smith, M., Wellhoener, R., Bode, B., Hirsch, I., Kalra, S., Ji, L. and Strauss, K. (2016). New Insulin Delivery Recommendations. Mayo Clinic Proceedings, 91(9), pp.1231-1255.
  5. Bahendeka, S., Kaushik, R., Swai, A., Otieno, F., Bajaj, S., Kalra, S., Bavuma, C. and Karigire, C. (2019). EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management. Diabetes Therapy, 10(2), pp.341-366.

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Jessica Oosthuizen is a registered dietitian and works in private practice at the Wits Donald Gordan Medical Centre. Being a Type 1 diabetic herself, since the age of 13, Jessica has a special interest in the nutritional management of children and adults with diabetes. She also has a key interest in weight management and eating disorders.


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Why glucose is the go-to

Jessica Oosthuizen explains why pure glucose is the preferred treatment for hypoglycaemia (low blood glucose).


“To fix a low blood glucose reading you need time, not more food.”

Hypoglycaemia remains a worry for many people living with diabetes and parents with children who have diabetes. It’s also one of the major limiting factors towards achieving good glycaemic control.

In diabetes management, when you are aiming for a blood glucose target of between 4 – 10mmol/L, it’s almost impossible to prevent hypoglycaemia all the time.

Hypoglycaemia can happen at any time of the day. Though, it may be more likely to occur before meal times, at the peak of insulin if the dose is incorrect, and during or after exercise.

Type 1 diabetes patients frequent hypoglycaemia the most. Followed by people with Type 2 diabetes managed by insulin and then people with Type 2 diabetes managed by sulfonylureas (antidiabetic drugs).

What is hypoglycaemia?

Hypoglycaemia means low blood glucose levels. It can be defined by:

  • A low blood glucose reading below 3,5 mmol/L. In children under six, this reading is below 4 mmol/L  because children may not be able to recognise symptoms or communicate with you.
  • Adrenergic and autonomic symptoms. These are symptoms caused by the body attempting to raise the blood glucose level. They include trembling, palpitations, sweating, dizziness, anxiety, hunger, nausea and tingling. These symptoms tend to start happening at a reading of between 2,8 and 4mmol/L.
  • Neuroglycopenic symptoms. These symptoms originate in the brain as a result of a deficiency of glucose in the central nervous system. These include difficulty concentrating, confusion, weakness, drowsiness, blurred vison, difficulty speaking, headache and dizziness. These symptoms are likely to occur at a reading below 2,8mmol/L.

Classifications

Hypoglycaemia can be classified as mild, moderate or severe.

In mild hypoglycaemia, self-treatment is possible and blood glucose can easily be rectified to normal values.

With moderate hypoglycaemia, your body will react with warning signs, involving autonomic symptoms. You will be able to self-treat to bring blood glucose levels up.

When having a severe hypoglycaemic episode, you will require assistance from another person to give you something to eat or drink, or a glucagon injection.

In severe cases, you may lose consciousness and have seizures. Glucagon is a naturally occurring substance, produced by the pancreas, which supports the production of glucose to correct the hypoglycaemic state. This response may be slightly defective in Type 1 diabetes.

What causes hypoglycaemia?

Low blood glucose is caused by an imbalance between the factors that raise and decrease blood glucose levels. Those causing an increase in blood glucose include food and counter-regulatory hormones (glucagon, adrenaline and cortisol) and those causing a decrease include insulin or oral medication and physical activity.

With new technologies, such as flash glucose monitoring systems and continuous glucose monitors (CGMs), we get a clearer picture of what the blood glucose levels are doing over a 24-hour period.

This is compared to the traditional self-blood glucose monitoring (SBGM) system whereby with a prick of the finger you get your blood glucose reading of that given moment. In the case of SBGM, if you test your blood glucose and see that your levels are low, you have no idea where they may be going from there.

With CGMs and flash glucose monitoring systems, we can see in the form of an arrow which way the glucose is trending. And, with some of the newer CGMs, the rate at which it is trending up or down.

Common reasons for a low blood glucose reading:

  • Delayed or skipped meal.
  • Eating too little carbohydrates at a meal.
  • Overestimated the carbohydrates eaten, if using carb counting.
  • If you have exercised or been physically active.
  • Taken too much insulin in relation to what your body needs.
  • New injection site, therefore, avoiding lumpy tissue where insulin absorption is unpredictable.
  • Consuming alcohol.

How to treat hypoglycaemia?

This will depend on various factors, such as the rate at which the blood glucose is decreasing by, how much active or unused insulin is on-board, and when you last ate something carbohydrate-based.

Active insulin is the time that insulin remains working in your body, it refers to a bolus injection and this is usually 3-4 hours.

Having pure glucose is the preferred treatment for hypoglycaemia. However, any carbohydrates that contains glucose will raise blood glucose levels.

It is important to test blood glucose first, treat with the correct amount of rapid-acting carbohydrates, wait 15 minutes and then retest your blood glucose. If you are still not feeling better and your blood glucose has not risen, then you should repeat with the same amount of glucose. 0,3g of glucose/kg will increase the blood glucose reading by approximately 2 mmol/L.

Studies have shown that 15g of glucose is required to get an increase in blood glucose of approximately 2,1mmol/L within 20 minutes.

Examples of 15g of carbohydrate for the treatment of mild to moderate hypoglycaemia:

  • 15g of glucose in the form of glucose or dextrose tablets.
  • 15ml (3 teaspoons) of sugar.
  • 150ml of regular soft drinks.
  • 15ml (1 tablespoon) of honey.

Danger of over-treating hypoglycaemia

Over-treating hypoglycaemia should be avoided as much as possible because this can lead to rebound hyperglycaemia (high blood glucose) and weight gain.

To fix a low blood glucose reading you need time, not more food. It is important to note that the liver is also responsible for glucose output and rebound hyperglycaemia.

Glucose has a quicker effect on the blood glucose compared to other types of carbohydrates. You should avoid food and drinks containing fat, such as chocolates, biscuits or milk. The fat in these food items will delay digestion in the stomach and the glucose will therefore take longer to reach the bloodstream.

Fructose (the fruit sugar naturally found in fruits) is absorbed more slowly from the intestine and is not as effective as glucose in raising blood glucose levels.

Why can’t hypoglycaemia be treated with ‘real food’?

Treating hypoglycaemia with ‘real food’, for example, a banana will completely depend on the situation at hand. With the use of CGMs, we may be able to use ‘real food’ more frequently to treat a lower blood glucose reading before reaching the hypoglycaemic range.

With SBGM, we are limited because we only have that one reading for that specific time and no other information to tell us where we are going. Because of this, eating something like a banana (without any active insulin), may cause an undesirable rise in blood glucose.

Diabetes is an extremely unpredictable disease and it may be impossible to prevent all future hypoglycaemic episodes. It is important to evaluate your current diabetes management plan with your endocrinologist, diabetes nurse educator and registered dietitian to reduce and prevent large fluctuations in blood glucose readings.


References:

  1. Wherret DK, Ho J, Hout C, et al. 2018 Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents. Can J Diabetes 2018; 42: 234 – 246.
  2. Yale JF, Paty B, Senior PA. 2018 Clinical Practice Guidelines: Hypoglycemia. Can J Diabetes 2018; 42: 104 – 108.
  3. Barnard K, Thomas S, Royale P, Noyes K, Waugh N. Fear of Hypoglycemia in parents of young children with type 1 diabetes. BMC Pediatrics 2010, 10:50.
  4. Hanas, R., Type 1 Diabetes in children, adolescents and young adults. 6th Class Publishing: Bridgwater, 2015.

MEET OUR EXPERT


Jessica Oosthuizen is a registered dietitian and works in private practice at the Wits Donald Gordan Medical Centre. Being a Type 1 diabetic herself, since the age of 13, Jessica has a special interest in the nutritional management of children and adults with diabetes. She also has a key interest in weight management and eating disorders.


Diabetes: where science, art and education meet

Louise Johnson explains that the art of living skilfully with diabetes in the new millennium is possible with your own skill, science and the help of a team.


The Oxford Dictionary defines art as “the creation of beautiful or significant things” and “a superior skill that you can learn by study and practice and observation.”

In the new millennium, diabetes patients can acquire this art or superior skill by diabetes education. This can be in any form of information from your diabetes nurse educator, doctor, internet support group or books on the subject.

Insulin saves lives

Historically, diabetes mellitus was a deadly disease in people living with Type 1 diabetes. Prior to 1921, when insulin was first given to Leonard Thompson, people living with Type 1 diabetes died.

There has been a radical change and growth in information and technology since 1921. People living with Type 1 diabetes now have basal and bolus analogue insulin.

An analogue is an insulin that works as close as possible to normal human insulin. Recently two new basal second-generation insulin were launched in 2018: Toujeo (glargine U300) and Tresiba (degludec).

Both have a working time of more than 24 hours. This is truly a once daily long-acting insulin without any peaks or intra patient variability. In practise, this mean that the sugar values will stay the same if you eat the same food every day. Thus, it allows for suitable background insulin to build on.

The short-acting analogues currently available are all very effective. NovoRapid, Humalog and Apidra all have a working time of approximately four hours and start to peak after 30 minutes. There is a new shorter-acting analogue in the pipeline and will be available later this year in South Africa.

Science and art meet at carb counting

Most people living with diabetes complain, from time to time, that they want to eat something ‘naughty’, without all the consequences of high sugars and feeling terrible.

The answer (if you don’t know it yet) is carbohydrate counting aka carb counting. This method calculates the carbohydrates per meal and establishes the correct amount of insulin via an easy mathematical calculation. Carb counting should be practiced by all diabetes patients on rapid insulin.

This scientific method both establishes the correct amount of insulin per carbohydrate meal as well as the correct dosage to correct sugar to a glucose target. Your doctor will determine this target value. The before meal and two-hour after meal values are important for good sugar control.

This art of food/insulin calculations are only possible with blood glucose values. Previously, the only method was finger prick. The more pricks and sugar measures, the better the sugar control.

The past few years have brought about five glucose sensors that can now do this for you. No more or very little finger pricking needed. This is made possible by continuous glucose monitoring.

It is a sensor that measures interstitial fluid sugar values every five minutes. This data is sent via a transmitter regularly. This data can be seen on cell phone apps or a reader specifically for this purpose.

The CGM system has arrows on the screen that gives an indication of sugars going up, down or staying stable. The real positive of this device is the reduction of finger pricking, accompanied with better hands on evaluation throughout a 24-hour period of the trend of the glucose.

All this technology is great but it is imperative to follow the correct procedure.

Insulin injection – the basics:

  1. Keep insulin in a cold area/fridge.
  2. Make sure it has not expired.
  3. Secure an insulin needle on a pen every second or third day. If you still use syringes then ensure you replace every second or third day. Blunt needles cause damage to the injected area. This can later lead to lipodystrophy (fat cells that are unresponsive and not functioning anymore, very lumpy).
  4. Rotate insulin injections areas every time to prevent this.
  5. Do not inject on scars or tattoos.
  6. Insert the needle at 90 degrees into fat tissue and not muscle. Be careful of upper arms and thighs if you are very thin. Make sure to pinch fat tissue between thumb and finger and not muscle.
  7. After the insulin dosage is injected, keep the plunger in for 10 seconds to get the whole dosage delivered.
  8. Do not clean with alcohol since this can interact with insulin. Soap and water is more than enough.

Glucose testing – the basics:

  1. Make sure your hands are clean.
  2. Check the machine and strips, to be sure they are the same brand, and that the strips are not expired.
  3. Replace lancets frequently to prevent damage to fingertips.
  4. Do not test on other sites than fingertips.
  5. Always keep a spare machine or battery at hand.

Other artful skills to learn:

  1. Adopting a diabetic diet.
  2. Regular aerobic exercises, such as walking, swimming, or running.
  3. Yearly visit to the eye specialist for a retina examination.
  4. Yearly visit to the podiatrist to examine feet and help with removing of corns, calluses, and abnormal nails.
  5. Visit a specialist physician once a year for heart and kidney evaluation. This is important to ensure all your values are on target.

Targets to achieve:

  1. Normal weight with a waist circumference below 80cm for a woman and 98cm for a male.
  2. Blood pressure equal to or below 130/80 mmHg.
  3. HbA1c below 7% (people with heart and kidney problems can have a value up to 8% but your doctor will establish your correct value).
  4. Triglycerides less than 1,2 mmol/L.
  5. LDL (bad cholesterol) less than 1,8 mmol/L.
  6. HDL (good cholesterol) more than 1,0 for a male and 1,2 mmol/L for a female.
  7. Urine albumin: creatinine ratio less than 30 mg/min. 

Type 2 diabetes

The tablet arena has increased dramatically over the past five years. The basis to all Type 2 diabetes treatment protocols should still be metformin.

The options in cases where metformin is not sufficient depend on the patient’s risk factors for heart attack, weight problems and cost.

  • DPP4i (Galvus, Onglyza, Januvia)

These dipeptidyl peptidase-4 inhibitor (DPP4i) drugs work on the incretin in the gut of diabetics and cause food to stay in the stomach. This causes increased satiety. In addition, the liver and pancreas secrete less glucose. The pancreas secretes the correct amount of insulin. This group of drugs makes patients sensitive to their own insulin.

  • GLP-1RA (Victoza, Byetta)

This glucagon-like peptide-1 receptor agonists (GLP-1RA) class of drugs are injectable incretins. They work the same way as the DPP4i but cause a greater loss of weight.

  • SGLT2i (Forxiga, Jardiance)

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is the newest class of drugs, especially for type 2 diabetes. They work in the top part of the kidney loop and prevent the reabsorption of sugar. This causes more sugar in the urine as well as lower blood sugar, lower blood pressure and 3 to 6kg weight loss.

In both Forxiga and Jardiance, there is sufficient data that showed improvement in mortality (risk to die) to both diabetics with previous heart attacks, strokes and heart failure and the group that only have the risk factors.

Dr Louise Loot

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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.