Diabetes complications – your screening check list

Diabetes nurse educator, Christine Manga, explains why screening for diabetes complications should form part of your diabetes healthcare plan.


Screening for diabetes complications

Diabetes is a disease that affects and damages the vascular system, large and small blood vessels. It is damage to the vascular system that leads to diabetic complications.

Large blood vessel damage is associated with increased risk of heart attack and strokes. Small blood vessel damage is associated with increased risk of kidney failure, retinopathy (blindness) and peripheral neuropathy.

Maintaining good blood glucose control can help with delaying and possibly preventing complications. But this alone is not enough. Blood pressure and cholesterol levels also need to be managed.

Screening for diabetes complications should form part of your diabetes healthcare plan. Regular screenings allow for early detection of complications before you are aware of the problem.

Most of the complications are ‘silent’ with symptoms developing after damage has occurred. All people with diabetes should undergo screening for complications.

Screening for retinopathy

Eyes should be screened annually. An ophthalmologist usually does the screening, though some optometrists have the training and equipment required to perform the test.

Drops are placed into the eyes to dilate (widen) the pupils so that the examiner can see the retina of the eye. The drops may cause your vision to blur and driving would not be possible for a few hours after the procedure.

Any abnormal blood vessels, scar tissue, new blood vessels, swelling, bleeding or fatty deposits in the retina will be detected. In addition, any damage to the optic nerve and cataract development would be observed.

A separate test will be done to measure the pressure of the eye. Increased eye pressure, a condition called glaucoma, can also cause blindness.

The results of the screening will show:

  1. No signs of the complications.
  2. Early signs of complications.
  3. Follow-up and treatment decision required. Treatment may not improve sight, but it can prevent further deterioration.
  4. More frequent check-ups required.

Early detection and treatment of eye complications is usually successful and can prevent vision loss.

Screening of peripheral neuropathy 

Peripheral neuropathy is pain, weakness or numbness in the feet and, occasionally, hands caused by nerve damage. It can also present as a burning sensation or pins and needles.

Due to damage of the small blood vessels, the nerves can’t receive nourishment. The blood vessel damage will cause ischaemia (poor blood circulation) in the lower legs and feet. This can further cause redness or a blueish tinge, swollen and sore feet. It also increases the risk of developing skin infections and skin ulcers.

Seeing a podiatrist (foot specialist) at least once a year is recommended. A podiatrist will examine your feet for blood flow, temperature, sensation and general condition. They may detect a ‘silent’ loss of sensation.

You will also be educated on good foot care. This will include the teaching of self-foot examination, proper nail cutting technique and the importance of foot moisturisation. Footwear choices as well as the appropriate type of shoes for your feet and how to wear in new shoes will be discussed.

Blood pressure and cholesterol screening

Blood pressure should be checked at least every three months. This can be tested at a routine visit to the doctor, your local chemist or at home on a home device.

Blood pressure targets should be personalised and discussed with your doctor. There are general guidelines that he/she will follow. Blood pressure and cholesterol management go hand in hand.

A lipogram, a full cholesterol test, checks all aspects of the cholesterol and should be performed annually. The reference ranges of results are different for people with diabetes who have more risk factors compared to the general population. Medication and dietary modification will be prescribed to manage these conditions if necessary.

Dental screening 

People with poorly-controlled diabetes are at a greater risk of developing dental problems, such as periodontal disease. Other oral manifestations could include a very dry mouth, a burning sensation in gums, delayed healing of mouth sores as well as an increased frequency and severity of infections.

Poor glucose-control exacerbates dental complications. The reverse is also applicable, periodontal disease worsens blood glucose control.

Dental treatment may need to be delayed until blood glucose levels are under control. A dental screening should be performed at least every six months.

Early detection is key

It is vital that screening is done on a regular basis for all possible complications. As stated earlier and cannot be emphasised enough, early detection is key to early management.

eating time budget

MEET THE EXPERT


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


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Why experts recommend urea for the treatment of dry skin

According to medical experts, urea, an organic compound, is the gold standard treatment for dry skin. We learn why this is so.


When it comes to treating patients, and giving advice on special conditions, doctors often turn to trusted medical bodies and their latest research for advice.

Dry skin (or xerosis cutis) is a common skin complaint, caused by internal and external factors disturbing the skin’s moisture balance. This skin condition is highly prevalent among the South African population. Yet, surprisingly, there was no standardised approach on how best to treat the condition until recently.

Medical experts agree on the best way to treat dry skin

In 2018, a group of renowned physicians published a medical paper on the Diagnosis and Treatment of Xerosis cutis. The report summarises the latest research findings in the prevention, diagnosis and treatment of dry skin and gives doctors practical advice on how best to treat the condition.

The medical paper states that dry skin can, in principle, be treated effectively. The decisive factor in the effectiveness of dry skin treatment is choosing the appropriate care product.

Moisturising should involve a combination of hydrating and lipid-replenishing ingredients, formulated to restore the skin’s natural barrier function in the best possible way and prevent skin from drying out further.

Urea – the gold standard treatment    

The paper explains that, “based on the available scientific data, urea is the gold standard for the therapy of xerosis cutis1.”

Urea has the advantage of being effective on two fronts; as a natural moisturising factor, it binds moisture into the outermost layers of skin. Plus, it also supports desquamation which is the natural process by which skin sheds dead skin cells. Healthy desquamation is linked to smooth skin.

The Diagnosis and Treatment of Xerosis cutispaper also explains that when urea is combined with other moisturising ingredients and lipids, the effect is even better: It states, “The combination of urea with ceramides, NMF and glycerol shows a significantly better effect than the effect of urea or the vehicle alone2.”

Eucerin UreaRepair PLUS

Eucerin scientists were the first to effectively include urea in a dermo-cosmetic product, and now have more than 25 years’ experience of maximising the benefits of urea in skincare formulas. Experience that includes more than 30 clinical and dermatological studies, involving 10 000 volunteers.

The lotions and creams in the Eucerin UreaRepair PLUS range offer people with dry skin exactly what the independent expert paper recommends. The formulas include:

  • various concentrations of urea (ranging from 5% to 10%).
  • other natural moisturising factors (NMFs), ceramides and gluco-glycerol.

The range is clinically and dermatologically proven to offer immediate and 48hour dry-skin relief.3

Urea and 17 other natural moisturising factors help the skin to attract and bind in moisture, thereby improving the symptoms of dry skin.

Ceramides repair and strengthen the skin barrier and thus reduce moisture loss.

Urea binds water into the outermost layers of skin and, at the same time, breaks down the connections between dead skin cells. This promotes desquamation and ensures a smoother skin surface.


References:

  1. Augustin M et al., Diagnosis and Treatment of Xerosis Cutis. JDDG, July 2018: Suppl 4, Volume 16.
  2. Weber TM et al., J Clin Aesthet Dermatol 2012, 5:29–39.

3. Beiersdorf. Data on file


For more information please visit www.eucerin.co.za


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Make your medical aid work for you

Sarah Nicholson, Justmoney’s commercial manager, offers ten tips to help ensure you enjoy the medical aid scheme benefits to which you’re entitled.


Extremely high medical costs mean that many South Africans prudently subscribe to a medical aid scheme. But how do you make the most of your selected package, which needs to meet your medical needs for the year ahead?

Read the fine print

You may have stayed with the same plan for many years. Take time to understand the rules and benefits, which may have changed since you first signed up.

Maximise your money

Take up preventative health screenings and tests, free vaccinations, and baby programmes. You may also decide to register for a programme to better handle a chronic condition.

Explore loyalty programmes

Benefits could vary from product discounts to travel and retail promotions, and subsidised gym memberships.

Spread out claims

Rather than blow your allocation early in the year on over-the-counter purchases, speak to your pharmacist and health practitioners about how to best allocate medical, optical, and dental purchases.

Keep your benefits for essential medicines and services to be used as the need arises. This is especially important if you have small children or sickly dependants.

Choose wisely

Build up a good relationship with your pharmacist, who can advise you on general health topics from seasonal allergies to stress management.

Ask your doctor to prescribe generics which cost less. Whether you are looking at over-the-counter medication, or prescription drugs, generics can cut your bill considerably. You can also shop around and compare prices.

On the record

Be meticulous about filing claims and saving correspondence.

Plan for a procedure

If you require an operation or specialist treatment, obtain pre-authorisation. Do your homework, get a quote from the hospital and medical practitioners before you are admitted. Determine if there will be a shortfall and plan how to fund this. Check if you can use designated healthcare providers on your medical aid’s network for cheaper negotiated rates.

Back a buddy

Oncology and other treatments can make one feel under par for a lengthy period. Ask a family member or friend to help you keep track of medical claims and submissions, or offer to do the same for them.

Conflict resolution

If you’re having difficulties resolving a problem with a call centre agent, find out if your medical aid has a walk-in service. Dealing with someone face to face can help resolve a problem quicker.

Saving grace

Should you have problems keeping up with payments,speak to your medical aid about alternative, cheaper plans. Don’t drop your medical aid completely as medical bills can be enormous.

If you don’t yet have a medical aid, do comparisons online or ask for advice from a qualified broker. This will help you to choose the scheme and plan that offers the best possible cover for your age and personal circumstances.

MEET THE EXPERT


Sarah Nicholson is the commercial manager for Justmoney. Justmoney is a personal finance website that provides busy and digitally savvy South Africans with easy access to financial products, services and information, including medical aid.


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Medical resolutions and planning for the next decade

Dr Louise Johnson updates us on the latest changes in the diabetes arena to help you plan your medical resolutions for the next decade.


The basis of diabetes treatment has always revolved around the ‘three wild horses’: diet, exercise, and medication. Going into a new decade, there are quite a few dramatic changes in this arena.

SMART

The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) 2018/19 consensus report has coined the acronym SMART. The goals that you and your doctor set must be SMART. This is:

S – Simple. Goals should be one step at a time and easy to follow.

M – Measurable. Blood pressure, cholesterol, HbA1c, fasting and postprandial (after meals) glucose, kidney function, eye       check annually, feet examination once a year by a podiatrist. Stop smoking.

A – Achievable. Goals should be small enough. A problem is like an elephant. You eat it bite by bite.

R – Realistic. Weight loss should be five to 10% of total weight and re-evaluated regularly.

T – Time limited. The time frame set on this is three months until goals are met. This is important with all goals set.

Goals for 2020 onwards:

Get your body mass index (BMI) between 18 and 24

This is calculated by length multiply by length (in meters). The weight in kg is divided by this number. For example: 1,6 x 1,6m = 2,56. Weight (80 kg) divided by 2,56 = 31,1. This is the BMI. There are a few diets to try to lose weight effectively.

The number one diet is still the Mediterranean diet. The Predimed trial (NEJM) showed weight loss and improvement in cardiovascular health with this diet.

The best weight loss diet for 2020 is still Weight Watchers. This is a low-carbohydrate diet with good nutrition.

Talk to a dietitian about the correct diet for you. The goal waist circumference for females is 80 cm and for males 94 cm.

People who battle to lose weight can consider bariatric surgery for permanent weight loss and reversal of Type 2 diabetes. Contact a qualified bariatric team for this.

Stop smoking

Vaping can be used as an interim measure to help stop smoking without gaining weight. Set a clear three-month goal of lesser nicotine vape liquid and then stop after month three.

Exercise

The newest data, in The Journal of the American Medical Association (JAMA), for 2020, showed that in 17 000 women, it was found that the cut-off to improve mortality is 4 400 steps per day.

There are many apps and smart watches available to assist in the achievement of exercise goals. Remember the guidelines for diabetic exercise is cardio-training (30 minutes) five times per week.

Blood pressure

Your blood pressure should be measured regularly and should not be above 140/90mmHg. Get yours checked at every doctor’s visit. Consider buying your own electronic upper arm blood pressure machine should you suffer from ‘white coat hypertension’ (high blood pressure in doctor’s office).

Lipogram

The risk of cardiovascular disease (heart attacks, strokes and peripheral vascular disease (leg blood vessels) are closely linked to low-density lipoprotein (LDL). The bad cholesterol. In people living with diabetes, the LDL should be 1,8 mmol/L or lower. Get your number and push to target. Remember there are a few different cholesterol-lowering drugs that your doctor can prescribe. Some have fewer side effects.

HbA1c

This is the three-month glucose average. In 2020, the range is from 6,5 to 8,0%. This variation depends on the duration of diabetes, existence of comorbid diseases, such a kidney failure and cardiovascular disease, and age. This range will be discussed and determined by your doctor.

Time in range (TIR)

This is a brand-new term for 2020 and equates to the percentage of 24 hours that your blood glucose can stay in the range decided on by your doctor. Usually 5 mmol/L to 8 to 10 mmol\L.

The TIR is important since this determines your glucose variability (GV). This means how much your glucose is going up and down, which can be easily monitored with a continuous glucose monitor (CGM).

The International Diabetes Federation (IDF) suggest that all Type 1 diabetes patients use a CGM.

Medication

Obtain the correct medication. This will be a tablet or injection that lowers blood glucose without gaining weight and without causing unnecessary hypoglycaemia (low blood glucose levels).

Immunisation

Get your Prevnar 13 injection to prevent streptococcus infections life-long and influenza injections yearly around the end of March to prevent influenza.

Mouth hygiene

See your dentist and get your teeth cleaned annually to lower inflammation.

For females

Regular bone mineral density tests are important since diabetes patients have an increased risk of osteoporosis. Also go for regular mammograms since diabetes patients have a 4-fold increase risk of cancer.

For men

Go for regular urology visits to examine the prostate since diabetes patients have a 4-fold increase risk of cancer. Should erectile dysfunction (ED) or impotence occur, visit your specialist physician, and cardiologist for a coronary evaluation since there is an increase in cardiovascular disease in men with ED.

Type 2 ‘hot-off-the-press-trials’

In the Type 2 diabetes portfolios, there is a new class with dramatic data. Most Type 2 diabetes patients should be on this class should they qualify.

Medication and trials

  • DAPAHF trial

The dapagliflozin heart failure trial is the most talked about trial of 2019. Dapagliflozin is a sodium glucose cotransporter 2 inhibitor (SGLT2i).

This class of drug works in the kidney on the proximal tubule (top absorbing pipe). It prevents the re-absorption of glucose into the circulation by blocking the enzyme SGLT2. This causes an increase of glucose in the urine. The amount of sugar lost is 14 teaspoons per day which equals 70g of carbs.

It is quite clear to deduct that this will cause weight loss (3 to 6kg), lowering in blood pressure and lowering in blood glucose. It also causes lowering in gout levels (uric acid).

The group of SGLT2 inhibitors that are available in South Africa is dapagliflozin (Forxiga) and empagliflozin (Jardiance).

The DAPA-HF trial was of interest because it looked at people with heart failure with poor heart function (less than 40%) with and without Type 2 diabetes.

This drug showed after 18 months of taking the active drug versus the placebo that heart failure occurrence was reduced by 16%. This is currently the ‘wonder drug’ in cardiology and diabetes and there are a lot of investigations to exactly establish all the mechanisms of action. Some people called it a ‘smart diuretic’ (tablet causing loss of water by producing more passing of urine). There are many more mechanisms involved.

  • CREDENCE trial

This trial was done with canagliflozin, a SGLT2i, in people with impaired kidney function. The estimated glomerular filtration rate (eGFR) (average kidney function) was between 30 and 60ml/min.

This trial was stopped early due to its phenomenal outcome. It improves the kidney function and the lower the number the better the result. The two drugs available in South Africa, dapagliflozin (Forxiga) and empagliflozin (Jardiance), will have their data at the end of the year and next year.

This is good news for all Type 2 diabetes patients. The data with these classes of drugs are still ongoing and should not be used in Type 1 diabetes due to the risk of diabetic ketoacidosis.

Smart things coming for Type 1 diabetes

The newer and faster short-acting insulins will launch in the last part of 2020.

There are two basal (background) insulins that last longer than 24-hours available: Glargine U300 (Toujeo) and Degludec (Tresiba). They both have less hypoglycaemia effects.

The newer, smart ‘artificial pancreas’ is available with a pump that stops insulin if glucose levels goes too low and increases insulin if glucose levels go too high. This is done with the help of a sensor that sends data via Bluetooth to the pump. Unfortunately, this is still very pricey.

Remember that every person living with diabetes is a unique individual and needs unique individual attention and treatment. Find your unique team and start working together.

Dr Louise Loot

MEET THE EXPERT


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.


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