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.


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.

< 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.


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.


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.


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.


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.


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.


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

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How to get the best out of pharmacy care

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

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

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

 What you need to tell your pharmacist

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

 What you should ask your pharmacist

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

Five things you should know

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

Five golden rules of pharmacy

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

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

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

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Harvesting seaweed to treat diabetes and obesity

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

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

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

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

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

23 types of seaweed collected

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

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

Thankful for support

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

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

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

Sthandiwe Magwaza


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

Header image by FreePik

Tips for pre- and post-hospitalisation

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

Tips to manage your elective procedure hospitalisation

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

Tips to manage an emergency hospitalisation

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

Recovery time tips


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


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

Glucose management

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

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


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

Bone health for people living with diabetes

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

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

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

Bone modelling and remodelling

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

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

Bone modelling

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

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

Bone remodelling

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

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

Figure 1 bone growth[1]

Diabetes and bone health

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

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

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

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

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

Other factors of poor bone health

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

Hormone interference

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

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


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

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

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

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

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

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

Treatment for osteoporosis

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

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

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

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

Diabetes and the risk for osteoporosis

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

Protecting bone health

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

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

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


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

Header image by FreePik

Ode to Ozempic and friends

Dr Angela Murphy explains why people are using Ozempic off-label for weight loss resulting in a shortage for people with diabetes who need it for glucose control, not only in SA but around the world.

The twin pandemics of obesity and Type 2 diabetes have created a need to find a common management pathway. A healthy lifestyle is essential; no medication will override a poor diet or lack of exercise. However, for many people living with diabetes, medications are needed to control blood glucose levels and lose meaningful weight.

Definition recap

Diabetes – diagnosed when fasting blood glucose is ≥7.0mmol/L, and/or two-hour post glucose drink test is ≥ 11.1mmol/L and/or HbA1c >6.5%

Obesity – body mass index (BMI) which is calculated by dividing height squared into weight: > 30kg/m2 = obese and                                                                                                                                             25-30kg/m2 is overweight

It’s important to measure waist circumference in patients to ascertain the degree of visceral fat. It’s this fat which causes most of the metabolic complications, especially diabetes.

A novel hormone pathway

The incretin hormones are produced in the cells lining the small intestine in response to digested food entering there. These hormones alert the pancreas to make insulin to control blood glucose at mealtimes. This system has been found to be sluggish in Type 2 diabetes, so medications were developed to improved incretin hormone levels.

There are two main incretin hormones in the human body: glucagon-like peptide 1 (GLP-1) and gluco-inhibitory peptide (GIP).  The medications produced to increase GLP-1 levels are called GLP-1 receptor agonists and have made a significant impact on the treatment of both diabetes and obesity. They do this by:

  1. Stimulating the pancreas to increase insulin.
  2. Blocking the liver from producing glucose.
  3. Directly inhibiting the appetite centre in the brain.
  4. Decreasing how quickly the stomach empties which means a person feels full for longer.

In addition, some of the GLP-1 medications have been shown to protect the heart.

The GLP-1 receptor agonist medications

Most GLP-1 receptor agonists are given as a subcutaneous injection as they are rapidly destroyed in stomach acid. However, oral forms are now available overseas.

GLP-1 receptor agonists registered in South Africa for diabetes

  • Byetta (exenatide) – This was the first GLP-1 receptor agonist in South Africa. It’s given as a twice daily injection within 60 minutes of breakfast and dinner. It’s effective in lowering blood glucose after meals but doesn’t have much effect on weight.
  • Victoza (liraglutide) – This is given as a daily injection starting at a dose of 0.6mg daily and increasing to 1.8mg daily and has shown significant improvement in weight loss.
  • Trulicity (dulaglutide) – This is a weekly injection given with a single-use device so the needle isn’t visible. It comes in one dose of 1.5mg weekly and has excellent glucose lowering properties but doesn’t result in significant weight loss.
  • Ozempic (semaglutide) – This is a weekly injection where the dose is titrated from 0.25mg to 1mg depending on the blood glucose levels. Ozempic also lowers blood glucose levels effectively and has shown good weight loss.

GLP-1 receptor agonists not available in South Africa

  • Rybelsus (oral semaglutide) – This is the only oral GLP-1 receptor agonist available as a daily pill either in a 7mg or 14mg dose.
  • Mounjaro (tirazepatide) – Strictly speaking this is a dual incretin agent (it acts on both GLP-1 and GIP receptors). Clinical trials have shown it to be superior to all the above GLP-receptor agonists in controlling blood glucose and weight loss in patients with Type 2 diabetes.

GLP1-receptor agonist medications and weight loss

Registered in SA

Only one GLP-1 RA is registered in South Africa for weight loss:

Saxenda (liraglutide) – You will note it’s the same product as Victoza but when used for weight loss it’s marketed in larger doses and under a different name.

Clinical trials showed that meaningful weight loss was achieved at a dose of 3mg daily, significantly higher than the doses used to treat diabetes. The best results were achieved in subjects who had already lost at least 5% weight on calorie restriction before starting Saxenda. Then over the course of 56 weeks they lost a further 6kg of body weight.

Not registered in SA

Ozempic (semaglutide) is not registered for weight loss in South Africa. The molecule, semaglutide, is registered overseas for weight loss under the name Wegovy.

As has been seen with liraglutide, Ozempic needs to be given in higher doses for weight loss – up to 2.4mg weekly. The STEP clinical trials demonstrated weight loss of approximately 10 – 15%. STEP 4 particularly looked at what happened after the medication was stopped: after using semaglutide 2.4mg weekly for 20 weeks, subjects had treatment discontinued and had regained 6kg by the end of the trial. This emphasises the chronic nature of obesity management.

People are using Ozempic off-label for weight loss, including celebrities who posted on social media of its effectiveness. This, unfortunately, resulted in a run on the drug and stocks plummeted. The tragedy of this is that people with diabetes using Ozempic for glucose control have struggled to get their supply; a problem both in South Africa and around the world.

Mounjero is not yet registered for weight loss but there is no doubt that it will be (possibly under a different trade name) as clinical trial results show subjects are shedding up to 20% of body weight. This is the most effective weight loss medication to date.

GLP-1 receptor agonists side effects

The most common side effects are gastro-intestinal: nausea, vomiting, diarrhoea, abdominal cramps, and heartburn. These side effects can be reduced with the following measures:

  1. Eat small portions.
  2. Avoid fatty meals.
  3. Chew food thoroughly.

These medications should not cause hypoglycaemia (low blood glucose) but if they are being added to insulin or other oral diabetes medications that can cause hypoglycaemia (sulphonylureas), low blood glucose levels must be watched for. The other medications can be decreased in dose.

A history of pancreatitis is a contra-indication to using these medications and they are not registered for use in pregnancy or when breastfeeding.

If a person has a history of thyroid cancer, they may be advised not to use GLP-1 receptor agonists. However, it’s important to understand that this risk is theoretical based on rat studies. No case of thyroid cancer due to these medications has been described in humans.

Medical aid reimbursement

Many medical aids do reimburse for this group of medications for people living with diabetes. Certain criteria must be met, for example, glucose levels not well-controlled on other medications and an increased weight.

Your doctor will usually have to motivate to get cover under chronic benefits. Note: medical aids don’t recognise obesity as a chronic condition and will not cover medication to treat it.

The cost of Saxenda at a dose of 3mg daily is over R4 000 per month. This is a significant financial commitment. It’s vital to remember that Saxenda’s effects will be lost if the medication is stopped. Treating obesity should be approached in the same way as treating diabetes or hypertension: as a chronic condition.

The challenge

Managing the combination of obesity, diabetes and pre-diabetes can be frustrating. A balanced lifestyle is the cornerstone to this, but it’s difficult for people to constantly be told to eat less and move more and still see no meaningful changes.

There is a great need for a pharmacological intervention and the GLP-1 receptor agonists are a step in the right direction. However, their use is restricted by possible side effects, cost, and the need for them to be used as ongoing treatment.

It’s my opinion that the reason we fail to achieve meaningful and sustained weight loss is that there is a tendency to look for a cure for overweight or obesity. It’s a concern that many people will use GLP-1 receptor agonist medications for short periods and once they achieve some weight loss, or if lucky even their goal weight, they will stop. After some months weight regain will start and the perception will be that these drugs are no better than any weight loss agent that has come before.

The future

There is no doubt that the GLP-1 receptor agonists offer the best medical intervention for overweight and obesity to date. If they are used as part of a holistic approach to a healthy lifestyle then significant, sustained weight loss may be achieved. It remains to be seen if funders will reimburse for their use on chronic benefits and whether people will use them as a regular, chronic prescription drug.

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.


Dr Angela Murphy is a specialist physician and currently 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.

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Managing diabetes when you have flu

Diabetes nurse educator, Kate Bristow, shares effective tips to manage diabetes when you have flu.

Winter season is here and with it an increase in the incidence of colds and flu. For someone with diabetes, flu can be more than just an irritation as it makes managing blood glucose levels more challenging.

What is the difference between a cold and flu?

A cold is an upper respiratory tract infection. Common symptoms include: starting with a sore throat, followed by a runny nose and some congestion and then a cough. Fever is uncommon in adults.

Colds and flu do share many symptoms, but an infection with influenza also manifests with higher temperatures, body aches, and cold sweats or shivers. This may be a good way to tell the two apart.

Flu symptoms are normally more severe and come on quickly. Both are caused by viruses and generally need to run their course. If they progress to a bacterial infection, then an antibiotic may be necessary. Stay in touch with your healthcare team when you are unwell.

Fever Sometimes – mild Usual – lasts 3 – 4 days
Headache Occasionally Common
General aches and pains Slight Usual – often severe
Fatigue/weakness Sometimes Usual – can last 2-3weeks
Exhaustion Never Usual – especially at the beginning
Stuffy nose Common Sometimes
Sneezing Usual Sometimes
Sore throat Common Sometimes
Cough/chest discomfort Mild to moderate cough Common – can become severe
Complications Sinus congestion/middle ear infection Sinusitis, bronchitis, ear infection, pneumonia
Prevention Wash hands often and avoid contact with sufferers. Wash hands and avoid contact with sufferers,

annual flu vaccine,

possibly pneumococcal vaccine too.

Treatment Decongestants, pain relief medication. Decongestants,

pain relief medication.

Call your doctor – antiviral medication sometimes used.

How best can you manage your diabetes when you have a cold or flu?

When you are sick your body will make more glucose to give itself the energy to fight the infection, and to add to this you may make more of the stress hormone cortisol. Cortisol makes you more insulin resistant. This means that when you are sick you need more insulin and not less.

So, in effect what happens when you are sick is that your liver will produce more glucose and you will be more insulin resistant. It’s a double whammy for your body and your glucose levels. You will probably be thirstier and pass more urine in this case and the cells in the body will start looking for other ways to get energy.

The lack of fuel into the cells means that they will start looking for other energy sources and sometimes the body starts to break down fat to provide this. Fat is converted into ketones by the liver. Ketones are toxic to the body and can be very dangerous.

Look out for signs such as stomach aches, nausea and vomiting along with high blood glucose levels. This is called ketoacidosis and it’s important that you have an individualised sick day management plan that you have discussed with your healthcare team.

If you are not taking insulin

It’s still important to track your glucose levels even if you are not using insulin. Follow the guidance below:

  • Test your blood glucose more regularly; this includes during the night and 2 to 4 hourly during the day depending on your numbers.
  • Drink more water. You may be thirstier than normal. If you are feeling nauseous then sip steadily rather than gulping it down. It’s not necessary to eat if you are feeling nauseous. But do ensure you stay hydrated.
  • Take your medication as prescribed. Your doctor may ask you to stop certain oral diabetes medications when you are sick.

If you are taking insulin

  • Do not stop taking your insulin. You may need more rather than less due to the higher glucose levels.
  • If you are taking insulin to manage your diabetes and your glucose levels are high, check for ketones – see the symptoms of ketoacidosis below.


High blood sugar levels – you will be thirsty and may urinate more often.  This leads to dehydration and further stress on your body.

Possible signs of ketone build-up:

  • Nausea and stomach-ache and eventually vomiting.
  • Be aware of vomiting without diarrhoea.
  • Rapid breathing with no cough or fever
  • Abdominal pain – can be severe.

Call for assistance if you have symptoms that worry you or that are not responding to your efforts to treat them. If you have abdominal pain or difficulty breathing, go straight to the hospital.

  • Have a sick day plan in place as discussed with your healthcare team.

 Take medication as suggested by your pharmacist, nurse, or doctor to relieve the symptoms of your cold or flu.  Be aware that some preparations may contain some sugar – discuss this with the pharmacist. If you are not getting better or start to feel worse call your doctor.

 What you should have on hand

  • Blood glucose meter.
  • Glucose test strips.
  • Other medication.
  • Quick-acting carbs, such as fruit juice, sugary drinks or sweets.
  • Water.
  • Insulin and ketone test strips.
  • Glucagon.
  • Contact details of your healthcare team in case of emergency.
Sister Kate Bristow is a qualified nursing sister and certified diabetes educator.


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

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Foot disease and diabetes

Dr Paula Diab stresses that every complication of foot disease relating to diabetes is preventable and gives guidelines to spot these complications in early stages.

Foot disease is probably one of the most feared aspects of diabetes. Almost everyone has a horror story about a friend or neighbour or sometimes tragically, a relative, who developed foot disease, gangrene or needed an amputation.

The statistics relating to foot disease are horrifying but what is worse, is that almost every single complication related to foot disease is entirely preventable. It’s not normal for people with diabetes to get foot ulcers and then need an amputation; it’s only through poor diabetes management that you lose sensation and circulation in the feet.

Educating yourself and knowing the signs and symptoms to look out for can radically improve your chances at retaining healthy feet despite having diabetes.

What causes diabetic foot disease?

You may have heard about macro- and microvascular complications related to diabetes. This refers to whether the large (macro) or small (micro) vessels in the body are affected. Foot disease can be caused by both macrovascular or microvascular disease which it is probably why is such a common complication.

Macrovascular disease occurs when blood circulation from the heart is diminished either through excessive glucose or cholesterol deposits in the vessels or narrowing due to high blood pressure. This reduces the blood flow into the distal peripheries and the feet are usually the first to show signs of this lack of circulation. Smoking and other cardiovascular risk factors will also enhance this risk and further slowdown blood flow.

Microvascular disease caused by persistently high glucose levels affects the nerves in the feet. When these become damaged, you may feel pain, tingling or even numbness in the feet.

These two mechanisms can also occur simultaneously when a loss of sensation in the feet can make it difficult to discern when you have a blister, minor cut or injury on the foot. As these minor injuries are left untreated, infection can set in causing bigger wounds or even ulceration. Due to blood flow being restricted, healing is further delayed, and the wound progresses even more.

Sometimes infections become so deeply invasive that intravenous antibiotics, surgical debridement or hospitalisation are required. High blood glucose levels can cause the arteries to become stiff and prevent blood flow to the feet.

What are the signs and symptoms of foot disease?

The most common symptoms of damage to the feet is increased swelling of the legs and feet or a change in skin colour on the feet. This usually manifests as a purple discolouration of the skin around the ankles or mottling of the skin. You may also notice a decrease in the hair growth on the top of your feet or lower leg.

All these symptoms are due to the decreased blood flow and poor circulation of blood from the heart. Nerve damage initially causes burning or tingling in the feet and then develops into a lack of sensation and numbness. This may happen intermittently at first but then begins to become more obvious and more difficult to treat.

Delayed healing of wounds, cracks and blisters on the feet are more advanced signs of foot damage.

Please also pay careful attention to ingrown toenails, warts, corns, calluses, bunions and hammertoes. These minor deformities often result in abnormal gait (the manner in which you walk) and as a result puts pressure on areas of the feet where you would not normally. This results in damage to the nerves and further enhances the risk of microvascular damage.

There are also nerves in the body over which you have no control. These are called autonomic nerves and control functions such as digestion, sweating and temperature regulation in the body. They too can be damaged by diabetes and may cause dryness, cracks, fissures, blisters and callus formation in the feet, all of which may lead to secondary infections and damage.

How should you take care of your feet?

As with all complications of diabetes, the basic control of glucose levels is of huge importance. Check your levels regularly and seek expert advice when they are not in target. Regular exercise can also prevent foot disease and promote good blood flow in the feet.

All that we require with regard to exercise is that you are simply more active today than you were yesterday. Aim to do 20-30 minutes of moderate intensity cardiovascular activity a day on most days of the week. Walking, jogging, swimming, cycling or even sustained household chores, such as mowing the lawn or vacuuming, may count towards this activity.

Other important footcare advice

  • Wash your feet every day with lukewarm (not hot) water and mild soap.
  • Dry your feet well, especially between the toes. Use a soft towel and pat gently but don’t rub the feet too vigorously.
  • Keep the skin of your feet smooth by applying a cream or lanolin lotion, especially on the heels. If the skin is cracked, talk to your doctor about how to treat it.
  • Keep your feet dry by dusting them with non-medicated powder before putting on shoes, socks or stockings.
  • Check your feet every day. You may need a mirror to look at the underside of your feet. Call your doctor if you have redness, swelling or pain that doesn’t go away, numbness or tingling in any part of your foot.
  • Don’t treat calluses, corns or bunions without talking to your doctor first.
  • Cut toenails straight across to avoid ingrown toenails. It might help to soak your toenails in warm water to soften them before you cut them. File the edges of your toenails carefully.
  • Don’t let your feet get too hot or too cold.
  • Don’t walk barefoot. This is to prevent injuries to your feet.
  • Avoid putting your feet in front of a fire in winter to warm then, if they have lost sensation you could end up with burns or blisters which you do not feel.
  • Avoid using hot water bottles to warm your feet in winter as the bottle may be too hot and also cause blisters if your nerves are damaged.

Choosing footwear

You certainly don’t need high fashion or expensive footwear in diabetes. But you also don’t have to wear big bulky boots that look ugly. Here are important tips to consider when choosing your footwear:

  • Try not to wear shoes without socks as they protect the feet and prevent excessive sweating and pressure from the shoes.
  • Ensure that your socks are good quality and not worn or frayed that will cause damage to the feet.
  • Avoid open sandals or shoes where feet are not adequately protected from external injury.
  • Avoid high-heeled shoes and shoes with pointed toes that will change the architecture of the feet.
  • Wear well-padded socks or stockings in winter. Don’t wear stretch socks, nylon socks, socks with an elastic band or garter at the top, or socks with inside seams as these place undue stress on the skin and constrict blood flow.
  • Don’t wear uncomfortable or tight shoes that rub or cut into your feet. If you’ve had problems before because of shoes that didn’t fit, you may want to be fitted for a custom-moulded shoe.
  • Talk to your doctor or podiatrist before you buy special shoes or inserts.
  • Shop for new shoes at the end of the day when your feet are a little swollen. If shoes are comfortable when your feet are swollen, they’ll probably be comfortable all day.
  • Break in new shoes slowly by wearing them for no more than an hour a day for several days.
  • Change socks and shoes every day. Have at least two pairs of regular shoes so you can switch pairs every other day.
  • Look inside your shoes every day for things like gravel or torn linings. These things could rub against your feet and cause blisters or sores.

Seek help

If you do develop some type of wound on your feet, please get it seen to as soon as possible. Don’t wait until it’s too late before you seek help.

Your doctor, diabetic nurse educator or podiatrist can all examine the feet on a regular basis to test a variety of different functions and help prevent further injury and infection.

It’s also good practice to examine your own feet on a regular basis. Look for changes in skin colouration, hair growth and new sores or blisters that may have developed. Look at your feet at the end of the day when you remove your shoes and make sure that the shoes are not damaging your feet in any way. You should also make sure that a healthcare practitioner examines your feet at least once a year. If there are any concerns or changes, you should see a podiatrist immediately and treat the problem in its early stages.

The old adage prevention is better than cure is certainly true of foot disease. Regular exercise, monitoring your blood glucose levels and keeping them well-controlled and stopping smoking will go a long way to ensuring that you don’t land up under the surgeon’s knife or with complex infections.

Dr Paula Diab


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

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The miracle treatment: insulin

Insulin has been available for a century and has gone from poorly defined animal insulin to pure and precisely controlled formulations. Dr Louise Johnson tells us more about this miracle treatment.

History of insulin

The discovery of insulin, the miracle treatment, is attributed to a group at the university of Toronto, Canada. In 1922, a 22-year-old physician, Frederick G Banting, worked in a laboratory to test his idea that pancreas extracts will reduce blood glucose levels in diabetic dogs. Banting was assisted by a student, Charles Best. This led to the first successful test of insulin in a 14-year-old boy, Leonard Thompson.

In January 1922, this boy with diabetes received the first dose of purified animal insulin and his life was saved. Leonard Thompson lived another 13 years to be 27 years and he passed away due to bronchopneumonia.

What is insulin?

Insulin is a hormone produced by the beta cells of the pancreas called the islet cells of Langerhans, in a response to reduce blood glucose. It works on cellular level to allow sugar to enter each cell by opening a channel in the cell. Glucose enters the cells and is used inside the cell to produce energy. The organs that are highly insulin dependent are the muscle, liver and fat.

Who needs insulin?

All living creatures needs insulin for uptake of glucose to be used as a source of energy.

Insulin is the primary treatment for people living with Type 1 diabetes since they have no endogenous or own insulin. They were previously called insulin-dependent diabetes mellitus (IDDM).

People with Type 2 diabetes, previously called non-insulin-dependent diabetes mellitus (NIDDM), also requires insulin at some time during their disease. As time progresses, the amount of the beta cells of the pancreas diminish and a supplementation with once-daily insulin, called basal insulin, is needed.

In Type 2 diabetes with insulin resistance where more insulin is needed, supplementation would also be required. The treatment of Type 2 diabetes always included diet, exercise, metformin, other antidiabetic agents such as incretins, SGLT2 inhibitors and sulphonylureas. When the HbA1c is above 7.5% on these regimens’ insulin supplementation is needed.

How do miracle treatment injections work?

Insulin is injected in the subcutaneous fat layer (just beneath the skin) on the abdomen, upper thigh, arm and buttocks. Once injected in the subcutaneous layer, it’s not immediately absorbed in the bloodstream. The insulin molecule first dissociates into dimers and monomers before being absorbed.

Insulin initiation

Patients with Type 1 diabetes require insulin immediately and usually multiple daily dosages to cover both mealtime and sleeping glucose levels. This regime is called basal-bolus insulins.

The preferred method on insulin initiation in Type 2 diabetes will be to add a once-daily long-acting insulin when needed. If glucose targets are not met, then a mealtime insulin or bolus insulin will be added according to the need.

Types of insulin

  1. Basal insulin therapy
  2. Bolus insulin therapy
  3. Premixed insulin
  4. Concentrated insulin
  5. Inhaled insulin
  1. Basal insulin therapy

Manipulating various side chains of the insulin molecule has permitted availability of long-acting insulin, such as glargine, determir and degludec (Lantus, Basaglar, Optisulin, Toujeo, Tresiba).

These long-acting insulins are peak less with a long duration of action. Basal insulin slows the production of glucose from the liver. In a fasting state this will maintain glucose homeostasis.

In general, basal insulin is administered once-daily in 24-hour cycle at the same time every day. It’s important that basal insulin should always be administered regardless of food intake as this serves as the background insulin normally secreted by the pancreas.

NPH insulin (Protophane) is one of the oldest basal insulin and because of its shorter lifespan needed to be injected twice a day. It has been available since 1964. The primary advantage of NPH is financial as it is typically less costly than the newer long-acting insulins. The downside of NPH is that it does make a small peak which can lead to hypoglycaemic events.

  1. Bolus insulin therapy

Bolus insulin is rapid-acting insulin that can be given before meals to reduce mealtime peaks of sugar. The combination of basal and bolus insulin is a flexible regime.

The newer short-acting insulins are called analogues (Novorapid, Apidra, Humalog, FiAspart). Analogues differ from human preparation (regular insulin) by small substitutions in amino acid chains which in turn prevent formation of polymers or hexamers.

The onset and peak action of rapid-acting insulin analogues more closely resemble endogenous (own) human insulin secreted in response to a meal.

Due to the fact that it is rapid-acting insulin, it can be given before, during or directly after a meal. The mealtime dosage of insulin can be calculated according to the amount of carbohydrates in the meal. Patients with a varying appetite can increase, decrease or omit the mealtime insulin according to the carbohydrates in the meal.

  1. Premix insulin

Premix insulin preparations is a combination of short-acting and intermediate/long-acting insulin in a fixed ratio. Although this provides convenience for some and may be appealing to those who refuse to inject more than twice a day, it does not allow for flexibility in mealtime or changes in the ratio of short to long-acting insulin doses.

An example is Novomix which is a fix combination of 70% NPH (protophane) and 30 % Novorapid. Another example is Ryzodeg which is a combination of 70 % degludec (Tresiba) and 30% insulin aspart (Novorapid). The numbers expressed in the ratio after the insulin refer to the percentage of insulin in the premix solution. An example is Humalog 25 which has 75 % long-acting and 25% short-acting insulin.

  1. Concentrated insulin

Insulin that is two to three times more concentrated than the normal U 100 insulin is now available. The available concentrated insulin in South Africa is glargine U300 (Toujeo).

The positive effect of more concentrated insulin is that the volume that is needed to inject is smaller in patients that are severe insulin resistant and need high volume insulin.

Humalog U500 is a short-acting concentrated insulin that is available on special request in severe insulin resistant patients that need more that 200 units per day.

  1. Inhaled insulin

The least often used preparation is human insulin inhalation powder (Alfrezza), however this is not available in South Africa. It’s administered at the beginning of a meal. Lung function must be assessed before initiation and after six months and thereafter yearly. It’s contraindicated in patients with lung disease and asthma.

Insulin sliding scale

Although commonly utilised in hospitals when patients are acutely ill, it’s not recommended as a routine method of insulin management. The reason for this is that it causes extreme fluctuations of glucose values which are far worse than continuous slightly elevated blood glucose. The best method to use short-acting insulin is via carbohydrate counting before meals.

Side effects of the miracle treatment


The most severe side effect is hypoglycaemia. It’s important that all diabetic patients on medication know how to treat the symptoms of low blood sugar. Usually if glucose is below 4.0 mmol, 15 gram of carbs is indicated. This can be in the form of a small fruit juice.

It’s important that all diabetic patients on insulin have a glucagon hypo kit at home for their spouse or parent to administer should the patient not respond. Always recheck the glucose after an episode of hypoglycaemia and try to establish the cause. If hypoglycaemia occurs frequently speak to your doctor for a thorough evaluation.

Weight gain

It was clearly shown in the UKPDS study that patients on insulin gain 5 to 8kg over a 10-year period. To prevent weight gain, try to limit carbohydrates and prevent hypoglycaemia. Should you pick up weight speak to your doctor. Remember that underactive thyroid disease can be associated with diabetes.


Lipodystrophy is hardened fat tissue. This happens when you are injecting on the same place every time and it causes poor insulin absorption. To prevent this from happening, it’s important to rotate the injection sited daily

Insulin has now been available for 100 years and this miracle treatment for diabetes has saved many lives and prevents many complications if used correctly. Remember that insulin is not the enemy but in persons with diabetes, it’s your best friend.

Dr Louise Johnson


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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