Dr Angela Murphy helps us understand the recent changes in the guidelines for treating diabetes.

The purpose of treating diabetes is to improve the symptoms which result from high glucose levels and to prevent other complications in the future. Diabetes is a risk for heart disease, stroke, kidney failure, amputations and loss of vision. In fact, heart disease is the most common complication of diabetes, encompassing angina, heart attack and heart failure.

With good control, these conditions can be avoided. Achieving good control is the challenge for both patient and healthcare provider (HCP). We must never under estimate the benefit of a healthy lifestyle and this is always the building block in any treatment algorithm.

Controlled portions, choice of unrefined carbohydrates and good fats, as well as regular exercise are essential to have a holistic approach to managing diabetes.

When insulin was first discovered in 1922, it seemed the only feasible treatment for diabetes. It remains the cornerstone of treatment for Type 1 diabetes to this day. Although, there have been advances in types of insulin and ways to deliver it.

The initiation of treatment for Type 2 diabetes is generally straightforward in that most patients will be counselled regarding a healthy lifestyle and given metformin. Metformin reduces levels of blood glucose by decreasing the amount of glucose produced by the liver. It also improves the action of insulin, secreted by the pancreas, at the level of the muscle cell.

Many people, particularly those eating and exercising correctly, may control their blood glucose levels on metformin indefinitely. However, if the glucose levels and HbA1c start to rise, further treatment will need to be added.

At this point, the choice of medication becomes quite extensive. The critical question the HCP must now ask is: what is the right medication for the patient in front of me?

What is the right medication for the patient?

There are eight groups of diabetic medications with various types within each group. This means that the possible combinations of drug types and dosages can count into the hundreds. HCPs have for many years looked to clinical practice guidelines to assist in their choice.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) are sentinel voices in the world of diabetes. Many experts over many years have come together to work out diabetes management guidelines.

Most countries, including South Africa, will consult the content of these guidelines when drawing up local recommendations. In recent years, the experts from ADA and EASD have come together on several occasions to issue a Combined Consensus Statement on the management of Type 2 diabetes. The latest one, published at the end of 2018, suggested some basic changes to our approach of diabetes management.

2018 guidelines

The reason for the new guidelines is that it recognises the excess risk of cardiovascular disease in diabetic patients and takes into consideration the evolution of diabetes drugs, particularly with the advent of the sodium-glucose transport protein 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists.

SGLT2 inhibitors

SGLT2 inhibitors (Forxiga; Jardiance), also known as the gliflozins, act by blocking the re-uptake of glucose that has been filtered through the kidney. This results in excess glucose being excreted in the urine. The advantage of this glucose loss from the body is that this translates into a calorie loss as well which helps with some weight loss in the patient.

As the name of the medication suggests, not only excess glucose but sodium is excreted. The lowering of sodium helps reduce blood pressure and has beneficial effects on the heart.

Jardiance is registered in America for the indication of cardiovascular death reduction in the patient with Type 2 diabetes and previous cardiovascular disease (angina, heart attack, need for stents).

Forxiga has recently been shown to improve heart function in patients with heart failure; in both diabetic and non-diabetic subjects.

GLP-1 receptor agonists

GLP-1 (Byetta; Victoza) is a hormone secreted by the cells in the wall of the small intestine in response to food. The GLP-1 then stimulates the pancreas to secrete insulin and, thus, lowers post-meal glucose levels. The GPL-1 receptor agonist drugs also delay the emptying of the stomach and increase the sense of fullness which results in weight loss.

In addition, Victoza has proven to reduce the risk of a heart attack, stroke or death from these causes in Type 2 diabetic patients who have already had an event. The Federal Drug Agency (FDA) in America have added this benefit to the indications for the use of Victoza.

Cardiac protection changes how Type 2 diabetes patients are managed

The incredible cardiac protection these new medications offer in addition to diabetes control is so important that it has initiated a change in how we mange Type 2 diabetes.

It is crucial that HCPs identify the patients who would benefit from these medications as soon as possible. For this reason, the 2018 guidelines now advise that after initiation of metformin, patients should be divided into two groups.

The first group is those patients with atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD); i.e. patients who have already suffered from a heart attack or angina, had coronary stents, a stroke or have chronic decrease in kidney function.

The second big group is the patients who have not had heart or kidney disease to date. The latter group then gets subdivided into three main groups aiming for treatment that addresses a patient’s most pressing concern.

The groups identify those patients struggling with hypoglycaemia (low blood glucose), obesity, and those patients who need to keep costs of treatment down.

It makes sense that those patients with established ASCVD and CKD be given one of the classes of medication which have been proven to protect the heart from further events or a deterioration in heart function. As one would expect with a ‘designer drug’, the cost is significant and reimbursement from medical aids is not guaranteed.

SGLT2 inhibitors and GLP-1 receptor agonists do not cause hypoglycaemia. So, they would be possible choices in patients who need to avoid hypoglycaemia.

Dipeptidyl peptidase-4 inhibitors

Another group of medications, called dipeptidyl peptidase-4 inhibitors, also increase the natural GLP-1 levels and do not cause hypoglycaemia. The class of drugs most effective with weight loss is the GLP-1 receptor agonists, especially Victoza. However, much higher doses need to be used for weight loss management than just for diabetes management. A higher dose pushes up the cost.

South African setting

In South Africa, where most of the diabetes patients receive healthcare from the state and, in the current climate of escalating costs in the private healthcare system, cost effective medicine is essential.

The oldest group of oral medications used in Type 2 diabetes are the sulphonylureas (SUs) which increase insulin secretion from the pancreas.

The South African diabetes guidelines, drawn up by Society of Endocrinology and Metabolism of South Africa (SEMDSA), advocate the use of the newer generation SUs, such as gliclazide MR (Diamicron MR, Diaglucide MR and other generic formulations), as acceptable second-line treatment for Type 2 diabetes.

More than two million South Africans are living with diabetes. To improve their present and future health aiming for good glucose control is important. However, with increasing types of medication available to manage Type 2 diabetes, choosing the right drug for the right patient is becoming ever more important.

The newer agents have made it possible to improve long-term complications from the outset, by mechanisms other than just glucose lowering. It may not be necessary, or possible, for everyone to access these medications at present but the guidelines from both local and international societies will continue to guide the diabetes community to make the correct choice.

Diabetes Awareness in Happy Valley, Port Elizabeth on 30 September 2019

Martin and Elizabeth Prinsloo were invited to attend  a gathering of more than 100 senior citizens who were treated by the South African National Zakah Fund to an outing in our beautiful Happy Valley to enjoy the fresh air and the beauty of nature and, at the same, be encouraged and informed about living a healthy and happy lifestyle. Many of those who attended either had diabetes or had a friend or family member with diabetes. Some refreshing Spring showers greeted us early the morning, but the sun soon appeared to brighten the day. Soraya Boomgaard, a fitness coach, who is associated with our Springdale Diabetes Wellness Group demonstrated easy exercises everyone can do and then invited the more active people present to join her on the lawns for some fun exercises.

Did you know the earliest changes in the body caused by diabetes can be seen in the eye? Dr Stephen Cook advocates early screening of diabetic retinopathy.

Diabetes epidemic

According to reports on World Diabetes Day 2018, about 3,5 million South Africans suffer from diabetes, and a further 5 million are estimated to have pre-diabetes.

The diabetic epidemic presents a massive burden to healthcare services. Type 2 diabetes mellitus is said to be the fastest growing chronic disease in the world. South Africa, in particular, is badly affected.

South Africa faces a plethora of healthcare needs, and specialist services are few and far between. More so in the field of preventable blindness. According to Orbis Africa, there are only six ophthalmologists for every million South Africans.

One of the biggest challenges currently facing South Africa is the diabetic epidemic. Examination of the eye can provide important information regarding the state of health of the nerves and small vessels of the body. These changes can be observed in the retina of the eye. The changes are referred to as diabetic retinopathy.

Diabetic retinopathy

Diabetic retinopathy (DR) refers to damage and loss of function of the retina (back of the eye) due to uncontrolled diabetes, and without a healthy, functioning retina, the eye cannot see.

Having uncontrolled elevated blood glucose levels causes the blood vessels in the retina to ‘leak’ or close off, leading to damage, which, in some cases, can be permanent.

When diabetic retinopathy is detected the person is said to be retinopathy positive. This status provides extremely important information regarding the risk of future events, particularly heart attack.

Determining the person’s retinopathy status is the most important part of screening, as this provides the person and their healthcare team with their “score” in the struggle against the disease.

Screen for Life

The Ophthalmological Society of South Africa (OSSA) has developed a diabetic retinal screening programme, called Screen for Life (S4L). The programme aims to raise awareness and expand screening capacity.

The S4L programme trains optometrists and interested GPs in retinal screening. In addition, artificial intelligence (AI) software is also proving beneficial in some centres.

Screen for Life has several components, including the patient-held record, quality assurance and suggested management plans. A basic screening for diabetic retinopathy entails having a retinal photograph taken with a fundus camera. It is quick and painless. This photograph is then graded by an accredited grader who makes a recommendation on further management.

Every person living with diabetes needs to know their retinopathy status. This informs them, their family and carers, as to their risk of serious systemic illness, such as heart attack and stroke. The earliest changes in the body caused by diabetes can be seen in the eye.

The OSSA diabetic retinopathy screening programme has been developed to get the most out of every screening opportunity. The programme follows the outline of the Scottish (NHS) diabetic retinopathy screening system.

This system has a track record of being evidence-based and cost-effective. In addition, our programme incorporates innovative risk calculation and co-screening for glaucoma.

Apples and red flag communication

Screen for Life uses the #redflag communication strategy. The patient held record is used to document the communication. Apples and red flags are used as images to convey the communication.

There are three distinct prompt points that help motivate for lifestyle changes. Lifestyle changes, particularly diet, exercise and stopping smoking can prevent suffering and save lives. The first prompt is communicating the diabetic status.

Retinopathy negative persons are congratulated and an apple sticker given or drawn onto the record. They are encouraged to stay negative to keep the apple.

Retinopathy positive persons receive a red flag indicating increased risk of systemic complications, particularly heart attack. They are encouraged to make changes to reverse the disease process. A follow-up appointment is set up to establish the trend of change.

Progression shows that whatever steps have been taken, have not been enough to stabilise the disease. This prompts a second red flag communication.

Where sight-threatening diabetic retinopathy or other disease (glaucoma, age-related macular degeneration, etc.) is detected, a third red flag is given and the person is referred to an ophthalmologist.

The patient-held record serves as a score card which helps practitioners know which stage of disease their patients are at. The programme uses a quality assurance and education system for graders.

Use of AI

The system is also artificial intelligence (AI) ready. AI is an enabling technology. In the short-term, this will enable safer high-quality, high volume grading.

In the long-term, AI is expected to provide powerful predictive information regarding other conditions, such as cardiovascular and dementia risk.

Challenges facing SA

I am extremely concerned that in general, medical doctors are not using diabetic retinopathy screening to modify the medical management of our patients.

We are failing to provide DR screening as part of our primary healthcare. This means that valuable medical information regarding the current micro-vascular state and future risk is not being taken into consideration.

People living with diabetes are unaware of their retinopathy status. Our experience is, sadly, that by the time the person consults a doctor for decreased vision, the eye disease is already advanced.

Awareness of the need for screening is the main problem. Communication about the significance of any retinopathy is the second, and a lack of access to fundus cameras is the third problem.

The threat of blindness, heart attack, stroke and other end-organ failures help motivate for better lifestyle choices to control and manage the disease.

Research has shown that diabetic retinopathy is a powerful indicator of the future risk of these things happening. The complexity of the disease and the socio-economic situation of the person living with diabetes make it very difficult to make changes. Communication needs to be supportive and ongoing if it is to contribute positively to making changes last.

End-organ failure causing blindness

Ophthalmology is a specialist field. As such, it is easy to feel overwhelmed by the scale of the disease and isolate our inputs to managing the current tsunami of end-organ failure causing blindness.

In doing this, we may be ignoring the opportunity to contribute to the primary care of people living with diabetes. Diabetic retinopathy may be the first sign of diabetic disease. This may predate the onset of end-organ failure by many years.

Lifestyle changes early in the disease process have powerful and long-lasting beneficial effects. Our communicating the significance of the discovery of any retinopathy early in the disease may just provide the necessary prompt for someone to change on time to prevent suffering and loss of life.

Better control of risk factors is the best means of preventing end-organ failure. Diabetic Retinopathy is an important biomarker for the systemic disease burden.

For more information, visit www.screenforlife.co.za

Clinical psychologist, Daniel Sher, explains how cognitive behavioural therapy, a psychological tool, can help people with diabetes to thrive.

What is cognitive behavioural therapy?

Cognitive behavioural therapy (CBT) is a form of psychological therapy that is widely used by mental health professionals because it is so effective in treating a wide range of psychological conditions.

How does CBT work?

CBT helps people recognise and replace unhelpful thinking patterns. Often, dysfunctional ‘automatic thoughts’ flit through our minds, below the level of conscious awareness. If these thoughts are distorted or problematic, they may lead us to feel emotional distress.

This, in turn, can lead to behaviours, such as sleeping all day, binge eating or neglecting our responsibilities, that tend to worsen our mental health.

How can CBT help people living with diabetes?

• CBT can help people living with diabetes to address misconceptions about their self-management that tend to sabotage their efforts at looking after themselves.
• People with diabetes are at an increased risk of experiencing psychological disorders, including depression, anxiety and eating disorders. CBT has been shown to help people with diabetes in particular to improve their mental health. This, in turn, makes it easier to manage diabetes.
• Diabetes is a life-long condition. For this reason, ongoing support is needed: diabetes patients are at risk of relapse and burnout! CBT helps people to think about behavioural changes that are going to serve them in the long run.
• In recent times, in-depth scientific studies have been conducted on people with diabetes who get help via CBT. The research suggests that CBT can help people with diabetes improve their glycaemic control, experience a better quality of life and reduce the risk of long-term complications.
• CBT can reduce stress. When people are anxious or upset, cortisol (a stress hormone) is released into the bloodstream. Cortisol can negatively affect blood glucose levels. Furthermore, when we are stressed we are more likely to fall behind on our self-management and perhaps even engage binge eating or other unhealthy behaviours. By helping us to cope with stress and anxiety, CBT can help overall diabetes control.

What are the advantages of CBT?

• CBT is evidence-based. Over the years, a large amount of scientific research has been conducted to show that CBT is a powerful way of improving a person’s mental health.
• CBT is focussed on the present. While some forms of therapy involve looking at our past to understand our current difficulties, CBT is focussed on thoughts and feelings that affect one’s functioning in the here and now.
• CBT aims to empower the client. Often, having diabetes can make a person feel powerless. CBT can help one to develop practical skills which can empower a person to take back control.
• Compared to other forms of therapy, CBT is a relatively short-term intervention. For this reason, it is often considered to be one of the most efficient and affordable ways of getting help.

What are the disadvantages of CBT?

• CBT involves a structured programme, which may not always be suitable for people with more complex mental health difficulties.
• CBT requires motivation and commitment. It is only helpful for those who are willing to put in the time and effort. Ultimately, what you put in is what you get out.
• CBT is present-focussed. The downside to this is that CBT does not always pay enough attention to how our past has shaped us; and to how our unconscious mind affects our current functioning.

Where to get help

If you have diabetes and would like to get a bit of extra support, speak to a psychologist or psychiatrist near you. Keep in mind that CBT is a specialised skill that needs to be provided by a board-certified professional. Ideally, try to find a clinical psychologist who is trained in CBT and has experience in working with diabetes.

Sources:

Seyed-Reza, A., Norzarina, M. Z., & Kimura, L. W. (2016). The Benefits of Cognitive Behavioral Therapy (CBT) on Diabetes Distress and Glycemic Control in Type 2 Diabetes. Malaysian Journal of Psychiatry, 24(2).

Li, C., Xu, D., Hu, M., Tan, Y., Zhang, P., Li, G., & Chen, L. (2017). A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for patients with diabetes and depression. Journal of Psychosomatic Research, 95, 44-54.

Uchendu, C., & Blake, H. (2017). Effectiveness of cognitive–behavioural therapy on glycaemic control and psychological outcomes in adults with diabetes mellitus: a systematic review and meta‐analysis of randomized controlled trials. Diabetic Medicine, 34(3), 328-339.

Driessen, E., Smits, N., Dekker, J. J. M., Peen, J., Don, F. J., Kool, S., … & Van, H. L. (2016). Differential efficacy of cognitive behavioral therapy and psychodynamic therapy for major depression: a study of prescriptive factors. Psychological medicine, 46(4), 731-744.

Doug Potter shares the reason for his mom’s passing and goes on to educate us on the dangers of dehydration.

I am blessed with longevity on my dad’s side of the family, with his grandpa living to 104 and his mom two months shy of 101. I thought if I don’t get hit by a train or die in a car crash, I might break a new family record myself.

There were many family discussions around living and dying around our dinner table, with half of us in the medical field. We even signed up for Ancestry.com to see how far back we could chase this longevity gene and our string of good luck.

We never thought in a million years that one of us would die from something as simple as dehydration.

My mom

My mom, Nancy Potter, was a labour and delivery nurse. She worked from the time she was 21 till she retired at 70. When my parents retired, they travelled extensively from Europe to Africa and within the United States, where they lived.

On what would be her last vacation with my father, they went on a road trip along the New England states ending in Maine by the Canadian border. It was a typical trip by all accounts as they would stop about every three to four hours for fuel, a visit to a restroom, and a bite to eat and drink.

On this trip, she was more tired and thirsty and thought if she drank liquids every time, they would have to stop more so she didn’t and rather just slept.

By the time they had reached their destination, her kidneys were screaming in pain and she had to go to the hospital. She was admitted that night in Guthrie Robert Packer Hospital in Pennsylvania.

Kidney stones

One of the causes of kidney stones is constant low urine volume caused by not drinking enough fluids. Dehydration is a harmful reduction in the amount of water in the body.

In my mom’s case, the pain of the kidney stones caused a rise in her heart rate and blood pressure. She was being treated for kidney stones but within the next hour would go blind and become confused. When pressure is exerted in the brain, it causes swelling and dependent on what part of your brain swells shows a deficit in that area.

My mom’s brain swelled at the back and she was diagnosed with posterior reversible encephalopathy syndrome (PRES). Her symptoms got better and she could travel back with us to her home in Charleston, South Carolina.

There she was admitted to Roper St. Francis Hospital, in Charleston, and would remain there, off and on for the next few months.

Oddly enough, the hospital she was first admitted to and the one she eventually passed away in, were the hospital she trained at 57 years ago and the one she retired from.

When I look back on all this…it is something a bottle of water could have fixed. So, therefore, I am explaining the secrets of dehydration.

Dehydration

Mild dehydration – 5% fluid loss.

Moderate dehydration – 10% fluid loss.

Severe dehydration – 15% or more fluid loss.

• If you feel thirsty, you’re about 300ml in low to mild dehydration.
• You’re about 700ml in low to moderate dehydration, if you do a skin turgor test and pull the skin on the back of your hand and it releases slow.
• If your heart is beating 20 beats higher than normal or you have palpitations, you could have severe dehydration.

So, some advice for this summer

How much you need to drink each day relies on your medical conditions, your activity level and your body weight.

The formula is for every kilogram of body weight you should drink 30ml of water. I currently weigh around 100kg. So, I should drink 3,3 litres a day, or more if I’m jogging, or when it’s hotter.

The day my mom passed on changed my life and created a hole which will probably never get filled. So, if I’m to take something positive out of this situation, it would be to tell others drink more water and take care of their health. Mom, I will see you in 50 more years when I break that family record.

Peter Shrimpton helps us understand how the ego-mind vs. the true-self and how this battle affects our health and life choices.

Be honest. Have you ever heard yourself say, “From tomorrow, I’m going to manage my diabetes better? I’m going to be more health conscious, or start a new diet, or begin an exercise programme, or quit drinking?”

In short, from tomorrow you plan on being a whole new, improved you. Right?

The funny thing is, you really mean it in the moment when you make those claims, don’t you? You’re full of conviction and determined to make it happen. In fact, if anyone who knows you challenged you by sarcastically saying, “Oh sure, I’d like to see you go for a run at 6.00am, or stop drinking wine, or cut out junk food.”, you might find yourself becoming quite defensive. You may even get a little angry and shout, “Just you wait and see, I’ll show you, from tomorrow!”

But what happens when tomorrow comes? 

At 6:00am when your alarm clock rings, you roll over and hit the snooze button. You don’t get up and go for that run like you said you would. A little while later, you eat that leftover piece of chocolate cake in the fridge.

During the day, as much as you try to ignore it, that half a bottle of Merlot glares at you every time you walk into the kitchen. It seems to call out to you, “Drink me, drink me.” Needless to say, by sundowners you find yourself with a glass of wine in one hand and a ciggie in the other, while you frantically flip through a take-out menu.

Let’s face it, you didn’t stick to your plan so you may as well start again. From Tomorrow. Can you relate to this? Does it strike a chord in you?

If so, don’t panic! You’re not alone. We all do it. Every single one of us. But why?

Ego-mind vs. your true-self 

Let’s crack this nut wide open, shall we? It’s not just that you say you’re going to do something and then you don’t do it. It’s more bizarre than that! You do the opposite of what you said you were going to do.

For example, you say you’re going to eat healthily but then you go on a sugar binge. So, what gives? Do you have a split personality? Are you delusional? What’s going on? Why do you lose the plot?

The answer is simple, yet life-changing! You see, you may think of yourself as being one person because you wake up each morning, put your clothes on, go about your day, and engage with the world around you. It’s just you being you, but this isn’t the case. It may appear you’re responsible for what you think, say and do but this is an illusion. There is a hidden truth.

In fact, there are two, completely different people inside of you. Oh yes, it’s true! You have two distinct sides to yourself. They are opposites: the one is good for you, and the other is bad for you.

The one will make you sick (or sicker) and the other will sustain health and wellness. They’re called your ego-mind and your true-self.

Ego-mind

Your ego-mind is the mask you show the world. It’s who you pretend to be, not who you actually are. It’s what you’ve become. It’s who you think you should be, and who you want other people to think you are.

It tells you how to think, feel and act, and it wants to be in control all the time. It is also the culprit behind all your negative characteristics, and is therefore often referred to as your lower-self.

Be aware. Your ego-mind loves instant gratification and sensory stimulation, and will happily allow you to harm yourself and compromise your health in the present moment, if your actions satisfy your immediate desires or comforts your woes.

True-self 

On the other hand, your true-self is who you really are. It’s often referred to it as the higher-self because to access it, you must rise above your lower-self, the ego-mind.

It’s the part of you that is spiritual, eternal and divine. It’s the essence of your being. The core of your inner goodness. It is ever-present and always accessible.

When you reconnect with your true-self, you transcend the self-destructiveness, pain, misery, lack, fear, doubt and negativity of your ego-mind and you feel energetic, creative, alive and full of possibility.

Healing journey: make sense of the battle of ego-mind vs. true-self

Understanding these two facets of yourself is essential on a healing journey. It’s critical for you to be able to identify which part of you is expressing itself at any given time.

When you can tell the difference between the thoughts and feelings of your ego-mind, and the thoughts and feelings of your true-self, then, and only then, can you make conscious choices about your behaviour.

Trust me, your soul purpose in life is to find your true-self. When you live from your true-self you discover your true nature. You always do what’s best for you (and your loved ones) in the long run. You live in harmony with Mother Nature, abide by the natural laws, cut out your vices, and promote health and healing in your body every day.

Think about it: each day you either promote health in your body or disease. What do you do?  Who is controlling your life – your ego-mind or your true-self?