Nourish your skin more in winter

Kate Bristow, a diabetes nurse educator, shares easy and practical tips to nourish and care for your skin during the colder months.


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Skin 101

Did you know that your skin is an organ? In fact, it’s the largest organ of the body, packed with blood vessels and nerves and is the centre for your senses (touch and pressure, pain and temperature).

The skin sheds about 40 000 skin cells every day and is a protective barrier that is capable of continually replenishing itself. Its primary role is temperature regulation, but it’s also a shield from disease, infection and the sun.

When we talk about the effects of diabetes on all organs in the body, this includes our skin. Your skin is a very good indicator of general health. If you notice skin changes have them checked out. Early diagnosis and treatment are essential in preventing complications from skin problems caused by diabetes.

How does winter affect your skin?

As we go into winter, the changes in temperature and humidity may change your skin’s texture and it will need a bit more care. Winter can make your skin drier and more irritated, and heaters will further dry out your skin.

If you suffer from eczema, rosacea or psoriasis, these conditions can flare in the winter. Note, these conditions are common conditions of the skin, not isolated to persons with diabetes.

Tips to take good care of your skin in the cold weather

  1. Go easy on cleansing of the skin – A daily wash/cleanse is important, but don’t wash multiple times in a day. Moisturising cleansers instead of foaming face wash will strip less of the natural oil off the skin. Also using a thicker moisturiser may help prevent dryness.
  2. Don’t forget the sunscreen – Shorter days and a weaker sun may make you slacker with using sunscreen. Although the UV rays are less, they are still there, and sunscreen remains an essential part of skincare management. Remember to re-apply it every two hours and pick shade where possible.
Did you know that sunscreen loses its properties of protection when it is expired? So, check the expiry date. A sun protection factor (SPF) of 30 or higher is recommended.
  1. Use a humidifier with heaters – If you are using a heating device, such as a gas heater or an air conditioner on heat, have a humidifier going in the same room to keep the skin more comfortable. Remember this rule applies for an open fire too.
  2. Avoid soaking in the tub – Long hot showers and baths which are so divine in winter can actually dry the skin out. So, try keep soaking in the tub to a minimum and keep the water lukewarm and not piping hot. Try to use your moisturiser while your skin is still damp to seal the hydration in. If you have a dry skin, this is important all year round.
  3. Switch to fragrance-free products – Certain products may be more irritable to your skin. Know how you react and if you have an irritable skin, avoid products, such as laundry detergent with fragrances.
  4. Take care of your nails – Often, we don’t look at our nails until it’s time to wear sandals but things like fungal infections can start developing in winter. Foot care and nail care is important; if you notice brittle, yellowing or nails lifting check in with a doctor.
  5. Wear gloves and keep your skin warm – It’s also a good idea to wear gloves for doing dishes or with use of any cleaning products.
  6. Remember your lips – Use a gentle lip balm on a regular basis. Try not to use products that sting or make your lips tingle.  Suggested ingredients include glycerine, shea butter, beeswax, olive oil, castor oil and coconut oil.
  7. Be patient with dry, cracked skin – If your skin is already irritated, please be patient; badly cracked and dry skin or broken skin barrier may take months to heal properly. If you suffer from any diagnosed skin conditions (rosacea, eczema, or psoriasis), it’s important to get specialised treatment from a dermatologist.
  8. Stop smoking – Smoking makes you look older and contributes to wrinkles. It also narrows the tiny blood vessels in the skin, decreasing blood flow and increases the risk of squamous cell skin cancer. In the words of the Mayo clinic, “The best way to protect your skin is to quit!”
  9. Manage your stress levels – This may be the hardest one, but stress can increase your skin’s sensitivity and trigger acne and other skin conditions. Try to get a balance: enough sleep, exercise and time to do the things you enjoy.
  10. Follow a healthy eating plan – Plenty of vegetables, whole grains, lean protein and some fruit. Drink enough water to keep your skin hydrated.

References:

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

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


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Vaginal yeast infections: all you need to know

Gynaecologist, Sumayya Ebrahim, educates us on vaginal candidiasis, also known as vaginal yeast infections, and its link to diabetes.


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Research has consistently shown that vaginal yeast infections are common in patients with both Type 1 and Type 2 diabetes. This is especially so if glucose control is not optimised.

Candida 101

Candida (or yeast) is a type of fungus that lives naturally in the body. We find it usually in the mouth, throat, gut and vagina. It also lives on the skin surfaces. Occasionally, when certain conditions exist in the body, this organism will multiply and cause an infection. This infection goes by the common name of thrush or candida.

What conditions favour the development of vaginal candida?

  • Pregnancy – due to the hormonal changes
  • Users of hormonal contraceptives
  • Diabetes – especially if control is poor
  • Recent antibiotic usage
  • Weak immune system – from HIV, chemotherapy or any immune-related illness

Lifestyle factors

Candida loves a warm moist environment. Below are some lifestyle factors to get candida:

  • Staying in a wet swimming costume
  • Not changing sweaty gym clothes like lycra
  • Using scented tampons
  • Using a vaginal deodorant
  • Unhealthy diet that consists of refined and processed foods and deficient in fresh fruits and vegetables

What are the symptoms?

Please note, vaginal candidiasis is not a sexually transmitted disease.

Symptoms can range from very mild to severe. In some instances, if the underlying problem is ongoing, the infection can recur frequently.

  • Vaginal or vulva itching and irritation
  • Sensation of burning during urination or intercourse
  • Vaginal rash, tiny blisters or even cuts
  • Redness and swelling of the vulva
  • Vaginal or vulva pain
  • Thick white vaginal discharge that resembles cottage cheese; this often has no odour

How is vaginal candida treated?

Treatment of vaginal candida involves either topical antifungal treatment like a cream to the skin or an ovule into the vagina. These are available over the counter.

Treatment usually lasts up to five days and resolves the problem. Oral antifungals are also available on script from your doctor. These can be used as an alternative for an early infection or be reserved for when candida recurs.

Prevention of vaginal candida

The best way to prevent vaginal candida infection is to avoid all the lifestyle factors that can act as triggers. In sufferers with ongoing diabetic challenges, the key strategy is good glucose control. Without good glucose control, candida overgrowth and symptomatic infection are never really kept in check.

Oral probiotics in the form of capsules or regular dietary unsweetened yoghurt with lactobacillus also prevents candida overgrowth.

Gynaecologists may also recommend vaginal probiotics inserted as a pessary directly into the vagina once or twice per week. This restores the good bacteria in the vagina called lactobacilli and allows the vagina to regulate its own pH. Thus, keeping it healthy. This in turn, helps to prevent ongoing or recurrent infection. A recurrent infection is said to occur if it happens more than four times per year.

Special considerations with diabetes

  1. New research shows that a new group of drugs to treat Type 2 diabetes, called sodium glucose cotransporter 2 (SGLT2) inhibitors, makes users more prone to develop recurrent candida infections. These include dapagliflozin and empagliflozin.
  2. Recent studies show that people with diabetes are more prone to having candida caused by strains different to the general population. In the general population, candida albicans is the most common yeast identified. In people with diabetes, the most common strain is candida glabrata; this strain has also been shown to be more resistant to successful treatment.
Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog Vaginations by Dr E on vaginations.co.za

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Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog Vaginations by Dr E on vaginations.co.za


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Navigating the post-meal rollercoaster

Dr Paula Diab shares valuable tips for keeping blood glucose spikes in-check to avoid the post-meal rollercoaster.


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Over nearly 20 years of assisting people managing their diabetes, I’m always humbled by how much there is to know about the disease. Not too long ago, I thought that if you could master the art of counting carbohydrates, then dosing insulin would be simple. 1 unit of insulin for every 15g of carbohydrates. 1 slice of toast = 15g of carbohydrates. What could be easier?

But if practicing medicine has taught me nothing else, it is that medicine is an art as much as it is a science. Seemingly simple maths does not always add up.

In listening to patients, I began to realise that they too were finding that this simple maths didn’t always work and that eating a burger with a side salad as a starter would sometimes work out better than eating just the burger alone. And then I had the opportunity to attend an international conference where I attended a lecture on macro-sequencing and the puzzle pieces slowly started to fit together.

One of the latest buzzwords or phrases in diabetes management is Time in Range (TIR). This refers to the overall time during the day that you spend within a particular target range. This range can depend upon your circumstances but is generally between 3.9 – 10.0mmol/L (70-180mg/dL).

If you are able to spend 70% or more of your time within this range, your risk of complications and overall prognosis in diabetes will be greatly improved. Studies have shown that kidney and eye disease are accelerated with greater post-meal peaks as well as these rises being an independent risk factor for developing cardiovascular disease.

Matching the action of insulin

Short-term glucose control is also negatively affected by these post-meal peaks which manifests in a decrease of energy, cognition (thinking) difficulties, mood swings and other physical and emotional abilities are affected.

As we then struggle to get the readings back into range, a common problem is that of overcompensating and causing what clinicians refer to as a rebound-low. A key component of remaining in range is therefore being able to manage your glucose levels after meal times and not just monitoring your fasting glucose levels early in the morning.

Keeping your glucose levels to remain in the target range with as little fluctuation as possible. In fact, if you are trying to get your glucose levels closer to that magic number of an HbA1c of 7%, managing your after-meal peaks is going to be all the more important.

It is normal to have fluctuations in glucose levels throughout the day even for people who don’t have diabetes. However, if the peak of the rise is too high or lasts too long, this may have adverse effects on your health. The idea in diabetes is to match the action of insulin with the consumption and digestion of carbohydrates.

Measuring and targets

Medicine is an art as well as a science. So, whilst most people will experience a peak about 60 – 90 minutes after starting their meal, this may vary from person to person and depending upon the meal eaten.

The next conundrum occurs when looking at what your targets should be. General guidelines suggest a post-meal peak of <10mmol/L (180mg/dL); however, this may also vary. Elderly patients or those with multiple co-morbidities may be encouraged to set their targets slightly higher to avoid the disastrous consequences of hypoglycaemia whilst pregnant women will be encouraged to have a much tighter range and not allow their post-meal peak to rise above 7.8mmol/L (140mg/dL) in order to prevent unnecessary damage to the foetus.

Peak management

  1. Selecting the correct insulin

Very often people think that all rapid-acting insulins are the same. The reality is that whilst most people (particularly with Type 2 diabetes) don’t notice a significant difference between insulin aspart or glulisine, for example, other people do react very differently.

There are also newer ultra-rapid insulins that will act even quicker as well as different formulations of insulin (inhaled insulin, not yet available in South Africa) that also work much quicker.

  1. Injection technique

The manner in which you inject insulin can also affect the way it’s absorbed and how quickly and efficiently it acts. Injected insulin works much faster when the injection site is warmed. This can be done by rubbing the site before injecting, exercising the muscle near the site or immersing the site in warm water.

In practical terms, your insulin may be absorbed quicker after a warm bath, after a run or on a warm summer’s day. Injecting directly into the muscle (anterior thigh or arm) is not usually indicated but if you are wanting insulin to work very quickly in the case of diabetic ketoacidosis (DKA) or treating a very high glucose level, this will certainly make a difference.

Remember that working quicker or faster doesn’t mean working for a longer time which will be discussed later.

  1. Pre-bolusing

Some people may have heard about the concept of pre-bolusing or injecting insulin prior to a meal. This can have a significant impact on squashing the peak that occurs after a meal, but you do need to be careful.

The aim is to get the insulin into your body and working at its maximum at the same time as your meal peaks. The exact timing of this will depend on multiple factors as medicine is an art, as well as a science.

High glycaemic index (GI) foods will peak quicker and therefore may require a bolus 15 – 30 minutes before the meal whilst lower GI foods may digest better when the insulin is given at the start of the meal. Higher pre-meal glucose values may respond better when mealtime boluses are more pronounced whereas lower glucose levels may benefit from insulin taken during or even after the meal.

  1. Other medications

The effect of insulin may be enhanced by other hormones, such as GLP-1 receptor agonists. These delay gastric emptying and keep carbohydrates from raising the blood glucose levels too quickly after meals.

Another drug, pramlintide (not available in South Africa) also helps to reduce appetite and squash the post-meal secretion of anti-insulin hormones in the body. Both of these medications will result in much more stable glucose levels and smaller peaks.

These are the pharmaceutical ways in which you can squash that post-meal peak but there are also quite smart manoeuvres you can try with simple lifestyle adjustments that will also have a significant impact.

Lifestyle adjustments

  1. Glycaemic index

As mentioned previously, lower-GI foods (pasta, beans, legumes) will digest slower and therefore have a flatter peak if you measure the glucose response.

Higher-GI foods (bread, cereal, potatoes, rice) are converted into glucose more quickly and therefore will tend to give a higher and more pronounced peak.

In addition to balancing the timing of your insulin, try to balance your meals with a combination of carbohydrates so that you do not only get a quick peak and then feel hungry again soon afterwards.

  1. Acidity

The addition of acidity to food has also been shown to reduce the post-meal spike. In practical terms, this can be in the form of sourdough bread as opposed to regular flour bread; adding vinegar or even tomato sauce as a condiment.

  1. Food sequencing

The order in which you eat your food has also been shown to be important in maintaining stable glucose levels. Having a salad or vegetables prior to your main meal will allow time for your digestive enzymes to be secreted so that when you eat your carbohydrates, your body is optimally-primed to digest these foods.

Fats will slow down the absorption of carbohydrates in the body. The most typical example is that of a cheesy pizza – very often insulin is given in split doses in this case to match the peak of the carbohydrate as well as the delayed peak of the fat in the cheese.

Proteins will also slow down the absorption of food in the body and contribute to satiety (fullness) therefore reducing the overall glucose load.

As always, a healthy balanced meal is recommended so experiment with your favourite meals and see what the impact can be on your post-meal peaks.

  1. Splitting meals

Other suggestions are to split the meal and have a portion of the meal 30 – 60 minutes after the initial meal. This is particularly useful if you are to embark on a large gourmet feast. The longer you take to eat the food, the more time your body has to digest it.

Even smaller meals can be broken down in this way by having a cup of coffee prior to breakfast and then eating the bowl of cereal and milk a while later.

Those who like to have a mid-morning or mid-afternoon snack may consider removing a serving of fruit from breakfast or lunch and having it between meals. In this way, the body is presented with smaller loads of carbohydrates more consistently which will certainly assist in more regular blood glucose levels. Please speak to your clinician about how to dose insulin if you are going to split your meals in this way.

  1. Exercise

If ever there was a solution to almost all problems, it is that of physical activity. Being active after eating will reduce post-meal peaks by slowing down absorption of glucose into the bloodstream. The body also uses the glucose consumed and actually becomes more sensitive to insulin as well. Ten to twenty minutes of mild activity (walk, household chores, etc.) is usually adequate.  

  1. Prevent hypoglycaemia

We’ve spoken often about the dangers of hypoglycaemia but one of the most overlooked problems is the vicious cycle that it creates. The body responds to low glucose levels by doing everything it can to counteract this potentially lethal situation. It empties the stomach quicker, food is digested quicker and blood glucose levels rise more rapidly. In addition, counter-regulatory hormones are released that stimulate glucose production in the liver. The end result – blood glucose levels peak and it becomes difficult to lower them again.

Take-home lessons

Its highly possible that by now your blood glucose levels have dropped, due to all the mental agility, or sky-rocketed, due to the stress response elicited by the body by reading all this information. Perhaps, they’re perfectly stable with no change at all.

If you take away one thing, remember that medicine is an art as well as a science. Sometimes, what looks like simple maths is actually a complex interplay of numerous different factors with even more unexpected outcomes.

Another good point to remember is to be alert to new ideas and thinking and constantly try to improve your knowledge and understanding of diabetes. What worked for the last 20 years, may not be the most ideal way to manage your diabetes and sometimes change is necessary and even helpful.

Experiment with your medication and food and find out what works best for you. Read through this article slowly and carefully and try one strategy at a time and get a good idea of the impact it has on your diabetes.

Obviously, all these strategies are much easier when using a continuous glucose monitor but you can get a very good idea by testing before and two hours after each meal and then discussing your findings with your diabetes educator or diabetologist.

Treat it as an interesting puzzle and try to solve the conundrums. Even experienced clinicians are sometimes forced to go back to the drawing board and ask for assistance. Managing the post-meal rollercoaster very often requires time, lots of trials and testing and a great team-effort.

Dr Paula Diab

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


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Time to understand time in range

Dr Angela Murphy expands on time in range and why it may become the most important of all glucose measurements in the future.


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It’s estimated that about a half a billion people are living with diabetes worldwide. Most of them will have Type 2 diabetes, with about 10% living with Type 1 diabetes.

Large scale studies have proven that good glucose control reduces the complications associated with diabetes: cardiovascular disease, such as heart attack and stroke, kidney disease, vision loss and amputations.

At the heart of this statement are the words ‘good glucose control’. Until now, two main parameters have been used to determine diabetes control:

  1. Home glucose levels
  2. HbA1c

Blood glucose measurement

Initial testing of blood glucose levels in the 20th century was done using urine test kits. These were difficult to interpret and had no real correlation with complications of diabetes. The introduction of the Ames dextrostix, in the 1960s, paved the way for home glucose testing as we know it today.

We now have a choice of efficient, accurate glucometers. It’s possible to get a glucose reading from capillary blood in mere seconds, allowing the person living with diabetes (PWD) to act timeously.

In 1999, the first continuous glucose monitoring (CGM) device was approved. For the first time, blood glucose levels were measured continuously over a 24-hour period. A sensor is worn by the PWD which transmits readings to a reader, insulin pump or a smartphone. The real time sensors will alarm if the glucose level becomes too high or drops too low. This can assist the PWD to take more accurate and frequent actions to improve glucose control. 

Figure 1:  CGM device showing current blood glucose level, arrow with direction of blood glucose rise and graph of previous 8 hour readings. (https://www.freestylelibre.com.au/getting-started-with-freestyle-libre-2)

HbA1c (glycated haemoglobin)

Researchers, Samuel Rahbar and Helen Rannay, found that haemoglobin (Hb) from blood samples of PWD had a specific pattern and this was named HbA1c.

HbA1c is formed when excess glucose in the blood attaches to the haemoglobin molecule, a process called glycation. Red blood cells are renewed on average every three months, so HbA1c is regarded as an average of blood glucose control over a three-month period.

Every PWD should be aware of their most recent HbA1c reading. Two landmark trials have proven that HbA1c correlates with complications.

  1. The Diabetes Control and Complications Trial (DCCT), which involved people living with Type 1 diabetes released its results in 1990. It conclusively showed that improved glucose control, defined as a HbA1c < 6.5%, reduced the risk of microvascular (small blood vessel) complications of the eyes, kidneys, and nerves.
  2. The United Kingdom Prospective Diabetes Study (UKPDS) confirmed these reductions in microvascular complications with good diabetes control in people living with Type 2 diabetes. Longer follow-up studies eventually showed the benefit in cardiovascular disease too.

Without HbA1c, this would have been nearly impossible to demonstrate.

Figure 2: Demonstrates the concept of a lower HbA1c: <7.0% being good, so it is green, whereas a higher HbA1c is dangerous and thus, is in red. HbA1c can be affected by several conditions that may make it less reliable, such as kidney failure, pregnancy, smoking and ethnicity (Quora.com).

Time to understand measuring glucose readings

Testing blood glucose regularly is an onerous task. It’s important therefore, to test with purpose.

Guidelines suggest that PWD treated with oral medications can measure blood glucose levels two to three times weekly. The timing of the test can vary from a fasting blood glucose to two-hour post-meal.

PWD using insulin will have to check their glucose readings more frequently. As a rule, the minimum tests should equal the number of injections per day. For PWD on four to five injections daily, this is taxing. However, we know that more frequent glucose testing does improve diabetes control.

How to understand continuous glucose monitoring

CGM devices are the machines of many a PWD’s dreams: a way of always seeing the blood glucose without having to open a conventional glucometer and prick a finger.

As the CGM devices became more advanced, they not only showed the current glucose reading, and of course the tracing of where the glucose had been but could predict where the glucose would go. In this way, PWD can be forewarned of hypoglycaemia or hyperglycaemia and take appropriate action to avoid these.

When this type of CGM technology works in tandem with insulin pumps, we see the makings of an artificial pancreas.

A CGM tracing can look like a rollercoaster. So where do we start to assess what the overall picture means?

Figure 3: CGM download showing blood glucose readings over a 24-hour period (Supplied by author).

Time in range

What data from CGM shows is that we cannot always rely on average blood glucose levels, even HbA1c, to fully assess overall diabetic control.  Averages do not show the extent of the high and low glucose readings.

Let me explain: if there are three blood glucose values of 6.0mmol/L, then obviously the average blood glucose is 6.0mmol/L. However, three readings of 12mmol/L, 2mmol/L and 5mmol/L will also give an average of 6.0mmol/L and yet only one reading is in the target range. This variation in glucose levels is called glucose variability.

CGM demonstrates patterns of glucose over a 24-hour period in detail so the swings in blood glucose levels are easily seen. The more frequently the blood glucose levels swing from highs to lows, the higher the glucose variability. There is concern that this variability can damage blood vessels and thus, may be implicated in diabetic complications.

Glucose targets

Based on data from all the large diabetes trials over the years, you can set targets for good diabetes control. This is not a one-size-fits-all range. Age, duration of diabetes, presence of complications, risk of hypoglycaemia and pregnancy all affect the target blood glucose levels.

In older PWD who have diabetic complications, particularly of the heart and kidneys, glucose levels are slightly higher than a young, newly diagnosed PWD.

Table 1: Glucose Targets set out by SEMDSA 2017 (Society of Endocrinology, Metabolism and Diabetes of South Africa).

In 2019, the International Consensus in Time in Range (TIR) defined the desired targets for CGM readings.  If blood glucose levels remain between the values of 4.0mmol/L and 10mmol/L 70% of the time (Time in Range – TIR), the corresponding HbA1c is around 6.5%. That equates to excellent diabetes control. Time below range (TBR) refers to readings < 4mmol/L and time above range (TAR) gives the percentage of time glucose readings are above 10mmol/L.

Figure 4: International Consensus of Time in Range (Battelino T et al., Diabetes Care 2019; https://doi.org/10.2337/dci19-0028)

Figure 4 illustrates the ideal range for patients with Type 1 and Type 2 diabetes and in pregnancy. Several medical aids will now consider reimbursement (with various levels of co-payment) for people living Type 1 diabetes who wish to use CGM devices.

Summary

To achieve good diabetes control, you try to get as close to physiological glucose levels as is safe. This has been proven to decrease both microvascular and macrovascular complications. Good control is not only a good average glucose, but also stability of glucose levels over time.  Time in range gives us insight into glucose stability and may become the most important of all glucose measurements in the future.


References

  1. ParkinG, Zhihong Jelsovsky, Bettina Petersen, Matthias Schweitzer, Robin S. Wagner. Structured Self-Monitoring of Blood Glucose Significantly Reduces A1C Levels in Poorly Controlled, Noninsulin-Treated Type 2 Diabetes. Diabetes Care Feb 2011, 34 (2) 262-267; DOI:2337/dc10-1732
  2. Battelino T, Danne T, Bergenstal RM, Amiel SA, Beck R, Biester T, Bosi E, Buckingham BA, Cefalu WT, Close KL, Cobelli C. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diab Care. 2019;1(42):1593–603.
  3. Gabbay, M.A.L., Rodacki, M., Calliari, L.E. et al.Time in range: a new parameter to evaluate blood glucose control in patients with diabetes. Diabetol Metab Syndr 12, 22 (2020)
  4. Hirsch IB, Welsh JB, Calhoun P, Puhr S, Walker TC, Price DA. Associations between HbA1c and continuous glucose monitoring-derived glycaemic variables. Diabet Med. 2019;36:1637–42.
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 is a specialist physician. Currently she sees patients at Sunward Park Medical Centre and she retains a special interest in endocrinology with 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.


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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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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.


Listen to this article below or wherever you get your podcasts.
Visit our channel mypod.zone/diabetessa

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.


Listen to this article below or wherever you get your podcasts.
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.

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 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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