Estée van Lingen tells you everything that you need to know about glucagon, the hormone that raises blood glucose to treat a low in diabetes.

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Most of you have heard about insulin and know what its function is in the body. But how many know what glucagon is and what it does?

What is glucagon?

Your body normally has a complex system to make sure your blood glucose is at optimum levels. If you have too much or too little glucose in the blood, it can cause certain symptoms and complications and in cases of people with diabetes, it can also be life-threatening.

Glucagon is a natural hormone that your pancreas makes that works with other hormones (like insulin) and bodily functions to help regulate your blood glucose levels.

Why is this important and how does it work?

Hormones are chemicals that co-ordinate different functions in your body by carrying messages through your blood to your organs, skin, muscles and other tissues. These signals tell your body what to do and when to do it.

Your pancreas is a glandular organ in your abdomen that secretes several enzymes to help with digestion and several hormones, including glucagon and insulin. It’s surrounded by your stomach, intestines and other organs.

Glucose is the main sugar found in the blood. You get glucose from carbohydrates in the food you eat. This sugar is an important source of energy and provides nutrients to your body’s organs, muscles and nervous system. Glucose is essential because it’s the primary source of energy for the brain.

Glucagon increases your blood glucose to prevent it from dropping too low (hypoglycaemia), whereas insulin, another hormone produced by the pancreas, decreases blood glucose levels. The alpha cells in your pancreas make glucagon and release it in response to a drop-in blood glucose, prolonged fasting, exercise and protein-rich meals.

How does it do this?

Glucagon helps blood glucose levels rise back up in multiple ways, including:

• Glucagon triggers the liver to convert stored glucose (glycogen) into a usable form and then release it into the bloodstream. This process is called glycogenolysis
• Glucagon can also prevent your liver from taking in and storing glucose so that more glucose stays in the blood.
• Glucagon helps your body make glucose from other sources, such as amino acids (protein building blocks).

If your blood glucose levels trend higher, your pancreas releases insulin to bring it back into range.

What is the difference between glucagon and insulin?

Glucagon and insulin are both important hormones that play essential roles in regulating your blood glucose. Both hormones come from your pancreas: alpha cells in your pancreas make and release glucagon and beta cells in your pancreas make and release insulin.

The difference is in how these hormones contribute to blood glucose regulation. Glucagon increases blood glucose levels, whereas insulin decreases blood glucose levels. If your pancreas doesn’t make enough insulin or your body doesn’t use it properly, you can have high blood glucose (hyperglycaemia) which can then lead to diabetes, if left untreated.

What tests check glucagon levels and what are normal levels?

Healthcare providers don’t typically order glucagon level tests for people with diabetes, but they may order tests to help diagnose some rare endocrine conditions.

Your healthcare provider may order glucagon blood tests to measure your glucagon levels if you’re having certain symptoms. During the test, a provider will draw a blood sample and send it to the lab for testing.

Normal value ranges can vary from lab to lab and depending on the duration of fasting and blood glucose levels. Always compare your results to the reference given on your blood lab report and talk to your healthcare provider if you have questions.

What conditions are related to glucagon function?

People with diabetes can develop an inability to release enough glucagon in response to decreasing blood glucose levels. Because of this, they’re more likely to develop frequently low or severely low blood glucose if they take medication that could cause low blood glucose, especially synthetic insulin and certain medications.

People with Type 2 diabetes may have glucagon levels that are relatively higher than what would be considered normal, based on blood glucose levels. This can contribute to higher blood glucose.

What are the symptoms of glucagon-related conditions?

Depending on the situation and condition, you can experience low and/or high blood glucose from abnormal glucagon levels.

Symptoms of low blood glucose (hypoglycaemia)

• Shaking or trembling
• Sweating or chills
• Dizziness and light-headedness
• Faster heart rate
• Hunger
• Confusion or trouble concentrating
• Nervousness or irritability
• Pale skin
• Weakness
• Tingling or numbness in your face/ mouth

If you experience these symptoms, it’s important to eat food with carbohydrates/sugar to treat it and bring your glucose levels up, and after that make sure you consume a healthy balanced meal. If this happens often, contact your healthcare provider.

Symptoms of high blood glucose (hyperglycaemia)

Not necessarily always caused by glucagon problems but more by not enough insulin or the body not being sensitive to insulin.

• Increased thirst and/or hunger
• Blurred vision
• Frequent urination
• Headaches
• Fatigue (feeling weak and tired)
• Unexplained weight loss
• Slow healing cuts and wounds

If you experience these symptoms, it’s important to see your healthcare provider.

When should you see your healthcare provider about glucagon levels?

If you have diabetes and are experiencing frequent episodes of low or high blood glucose, it’s important to contact your healthcare provider. Glucagon levels are not normally tested in people living with diabetes, but your provider might need to adjust medications.

While other glucagon issues are rare, if you are having symptoms, its essential to figure out the cause by talking to your healthcare provider.

MEET THE EXPERT

Estée van Lingen is a registered dietitian practicing in Randburg and Fourways, Gauteng. She has been in private practice since 2014 and is registered with the HPCSA as well as ADSA and served on the ADSA Gauteng South Committee for 2020 – 2022.

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Daniel Sher explores the mechanisms behind the relationship of moods and blood glucose and offers practical advice for parents and caregivers to better support their children.

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The interplay between mood and blood glucose in children with diabetes involves a complex relationship where physical health significantly influences emotional well-being and vice versa. This connection reminds us that we need to focus on more than just blood glucose management when it comes to diabetes, we also need to pay attention to the emotional side of this condition. 

Understanding blood glucose dynamics

Blood glucose is essential for the body’s cells and critical for brain function. In children with diabetes, the body’s inability to effectively regulate blood glucose can lead to significant mood and behavioural effects. Hyperglycaemia (high blood glucose) and hypoglycaemia (low blood glucose) can manifest various psychological symptoms that impact a child’s daily life.

For example, hyperglycaemia can cause symptoms such as fatigue, irritability, and difficulty concentrating. These can disrupt a child’s ability to engage in academic and social activities, potentially leading to frustration and lowered self-esteem.

Hypoglycaemia on the other hand, can lead to symptoms such as confusion, dizziness, irritability, and even severe outcomes like seizures. The acute nature of hypoglycaemia can induce significant anxiety and mood swings, affecting not only the child but also those around them.

Psychological impacts

Managing diabetes demands ongoing attention and adjustment, which can put a substantial mental burden on a child. The stress of constant monitoring and treatment can lead to psychological issues such as anxiety and depression, which can further complicate mood regulation. Diabetes distress, or burnout, can also hold a child and their family back when it comes to living a happy and healthy life with this condition.

Social challenges may also become evident. The visible aspects of diabetes management (such as technology, testing and taking insulin) can make children feel self-conscious and different, which can impact their social interactions and emotional well-being.

The bidirectional relationship

Mood and blood glucose levels influence each other in a bidirectional manner. Stress and emotional distress can lead to hormonal imbalances that may disrupt diabetes management, while unstable blood glucose levels can cause mood swings. Understanding this reciprocal relationship is crucial for effective management of diabetes in children.

How can we help kids cope?

Educational and supportive strategies

Education is crucial. Parents and children need to understand how diabetes can affect emotional health. Recognising the signs of blood glucose fluctuations and their emotional effects is the first step toward effective management. 

Holistic care approach

Management strategies should incorporate both medical and psychological support. Regular consultations with healthcare providers who understand the dual nature of diabetes care are essential. 

Establishing routine

Consistency in daily routines helps stabilise blood glucose and mood. Regular monitoring and timely adjustments in diet and medication are key to maintaining balance.

Open communication

Encouraging children to express their feelings about diabetes and its challenges is so important. Support from counsellors or participation in support groups can provide children with coping mechanisms and a sense of community. 

Inclusive and active lifestyle

Activities that integrate children with diabetes into wider social groups can enhance their self-esteem and emotional health. Physical activity not only helps in regulating blood glucose but also boosts mood through the release of endorphins.

Family engagement

Involving the entire family in diabetes care helps normalise the condition and reduces the emotional burden on the child. Shared meal planning and group activities can foster a supportive environment.

Comprehensive care

The relationship between mood and blood glucose in children with diabetes is central to overall health. By addressing both the emotional and physical aspects, caregivers can provide more effective support, enhancing both the child’s quality of life and their diabetes management.

Understanding and intervening in this bidirectional relationship is key to helping children manage their condition while maintaining a positive outlook on life. Comprehensive care not only stabilises blood glucose but also significantly improves mental health, offering a brighter and healthier future for children with diabetes.

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Monique Marais addresses the shame that people with diabetes can experience when loved ones question or misunderstand their food choices.

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There are several common misconceptions regarding what a person with diabetes should eat and what needs to be avoided at all costs. It is, however, important to note that dietary needs can differ among individuals, and people with diabetes should work closely with health professionals who understand the condition and can give relevant and practical guidance to create a meal plan that is appropriate for them.

It’s also recommended to approach conversations about dietary choices with sensitivity and empathy, especially when discussing restrictions. It may be counterproductive to point out what people are allowed to eat and what not and can affect the person living with diabetes on an emotional level. People living with diabetes often face enough challenges in managing their conditions without the added stress of feeling ashamed about their food choices.

It’s therefore more constructive to focus on positive and supportive communication and understanding their dietary needs. Encourage them to make healthier choices, provide information on balanced nutrition and highlight a variety of foods that are beneficial for their well-being. Educating yourself as a family member is vital to effectively support them in their journey, and this means eliminating inaccuracies.

Common misconceptions

• Sugar must be avoided completely

While it’s true that managing sugar intake is crucial for people with diabetes, it doesn’t’ mean they must eliminate sugar completely. The focus should be on monitoring carbohydrate intake, as carbohydrates directly impact blood glucose levels. The type and amount of carbohydrates, along with proper portion control, are important considerations.

• People with diabetes can only eat diabetic foods

Specialised diabetic foods are helpful, however, are not a must or an only and can be expensive. These products often still contain carbohydrates and kilojoules, and they may have sugar alcohols or artificial sweeteners that can have laxative effects if consumed in excess. A balanced and varied diet is more beneficial.

• Starchy foods are off-limits

Starchy foods like bread, rice and pasta can affect blood glucose levels, but when they are part of a balanced diet and consumed in moderation, the effect on the blood glucose levels is reduced. Whole grains are also a better option to include in your meal plan.

• Fruit is forbidden

Fruits contain natural sugars, but they also provide essential nutrients and fibre. Moderation is key, and it’s advisable for people with diabetes to choose fresh, whole fruits over fruit juices or dried fruits, which can be more concentrated in sugars.

• Skipping meals controls blood glucose

Skipping meals can lead to irregular blood glucose levels and overeating later. Regular, well-balanced meals and snacks are essential for managing stable glucose levels.

A family disease

Diabetes is known as a family disease, as it can affect many people within one family in various ways. It’s important for people with diabetes – and their family members and support system – to understand how different foods affect an individua’s body.

By understanding the condition, and specific red flags, you can avoid spikes in blood glucose levels, and will be able to have a more consistent average.

Approaching conversations with empathy and understanding can help create a supportive environment for people with diabetes to make informed and positive choices regarding their diet and overall health. This is important for family members and friends, but also for healthcare professionals. Have patience with your patients, work from where they are and support them in their journey. Take the time to understand where they are in the process and how you, as the healthcare professional, can support them to make effective and sustainable lifestyle changes.

As a loved one, you can support your family member by:

1. Understanding the impact that a chronic illness has on their emotional well-being. This is a long-term condition, and some days may be easier to deal with than other days.
2. Avoid blaming. Do not constantly nag your loved one about what they are eating and add more pressure, as it often leads to conflict in the relationship.
3. Ask your loved one what they need from you; support them in their journey.
4. Attend appointments with your loved one. This way you also get the feedback from the doctor and will be able to support them more effectively.

Learn to identify symptoms of high or low blood glucose levels so that you can intervene quickly and effectively.

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Christine Manga, a diabetes nurse educator, clarifies what diabetic amyotrophy is and the necessary information you need to know.

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Diabetic amyotrophy is also known as proximal diabetic neuropathy, ischaemic mononeuropathy, diabetic lumbosacral plexopathy, Bruns-Garland syndrome, to name but a few.

In 1890, neurologist Ludwig Bruns first described the condition in people with diabetes, usually poorly controlled. In 1955, another neurologist, Hugh Garland coined the term amyotrophy. For this article I will refer to it as diabetic amyotrophy.

What is diabetic amyotrophy?

Diabetic amyotrophy is a rare episodic and progressive form of diabetic neuropathy. It’s characterised by loss of unilateral (sometimes bilateral) proximal motor function, atrophy (wasting, shrinking) of muscles in the front upper legs, sensation of severe burning, weakness, and pain.

An extreme aching pain in the hips, thighs and buttocks are almost always present. This is often followed by weakness. Anywhere between 35 – 50% of affected people will report unintended weight loss. Getting up from a sitting position becomes difficult. This condition can be disabling with some people requiring wheelchair assistance for a time. Progression of diabetic amyotrophy is quick, taking a few months.

Causes

The causes are not fully understood. Possible causes include but are not limited to:

• A sudden reduction in blood glucose levels of a person with chronically raised blood glucose levels
• Initiation of anti-hyperglycaemic treatment
• An immune mediated vasculitis causing ischaemic (insufficient blood supply) damage to the nerves, and it has also been referred to as idiopathic.

Who is at risk?

Almost 50% of people with diabetes will experience diabetic neuropathy. However, diabetic amyotrophy only affects approximately 0.8 – 1% of people with diabetes. It affects more people with Type 2 diabetes compared to Type 1.

Onset is usually during middle age but can be seen in younger individuals. Males over the age of 50 with Type 2 diabetes are the most frequently affected. Duration and severity of diabetes are not predisposing factors. People with good glucose control can also experience diabetic amyotrophy.

How is diabetic amyotrophy diagnosed?

Diagnosis usually consists of a thorough history taking and physical examination especially of the lower limbs as well as reflex testing. To exclude other conditions with similar symptoms, such as nerve compression, a process of elimination is used.

A lumbar puncture, nerve conduction studies, and MRI scans may be performed. A blood workup will be done to assess diabetes control, vitamin deficiencies and inflammation markers.

Treatment

Treatment is pain management. However, it does not respond to conventional pain medication, rather anti-epileptic, antidepressants, such as amitriptyline, and nerve pain treatments. Recently steroidal medication has been used. It appears to increase recovery time but also causes an increase in blood glucose levels. There is still not enough evidence for its use. Good glucose control is to be strived for.

An improvement in diet, physical exercise, such as physio, and stopping smoking and alcohol aid in recovery. The physiotherapy can aid in nerve restoration.

Diabetic amyotrophy can lead to anxiety and depression. Education is of utmost importance, hence explaining the progression to possible severe disability, paraplegia, and extreme pain. Although, it will not reverse diabetic amyotrophy, regular foot examinations for injury, wounds and infection will prevent further complications. The goal of treatment is to improve quality of life.

Prognosis

Diabetic amyotrophy is self-limiting and the likelihood of full recovery is probable. The entire process takes a few months up to about two years. Sometimes, but not often up to three years. Reassurance and encouragement that it will resolve is vital.

Prevention

There is no precise way to prevent diabetic amyotrophy. The principles used to prevent general diabetes complications should be adhered to, including smoking cessation, good glucose control, limit alcohol intake, maintain a healthy BMI and regular check-ups with your doctor, dietitian, and educator.

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Lynette Lacock, an occupational health sister, highlights the role of the podiatrist in the healthcare team for those living with diabetes.

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

You may not be aware of how important it is as a person with diabetes to take care of your feet. Since diabetes can cause poor circulation and neuropathy, it’s essential to have your feet and lower extremities examined by a podiatrist regularly.

Podiatrists are doctors who treat conditions of the lower limbs, including feet and ankles. Therefore, they are the best healthcare professional to see routinely to prevent any future problems relating to feet and diabetes.

The saying prevention is better than cure rings true in this case.  Wounds are often difficult to treat when you have diabetes due to poor blood flow. You need to be vigilant when it comes to preventing sores and infections and you also need to be on the lookout for blisters or sores caused by ill-fitting shoes. If you have even a mild neuropathy in your feet, your shoes may not feel tight even though they are damaging your skin.

What can podiatrists assist you with?

• Routine foot exams

It’s crucial for all people with diabetes to have a professional exam of their feet and lower extremities on an annual basis. A trained podiatrist will be able to see things that you may have not noticed.

• Early detection and prevention

Detecting a blister or treating an open wound when it first happens is the key to preventing the problem from getting worse. Most people with diabetes have problems with poor circulation and neuropathy. Neuropathy is caused by nerve damage due to uncontrolled blood glucose. It causes you to have less feeling or sensation in an extremity. If you can’t feel that your shoe is too tight or rubbing in an area, then you can develop a blister or wound without even knowing about it.

• Mechanical assessment

A podiatrist can watch your gait or the way you walk to see if there is anything out of the ordinary. If there is, they can recommend a specialised shoe or orthotic to help prevent any damage from happening.  

• Foot wound and ulcer care

If you do get a wound or ulcer, the podiatrist is the best person to treat it. You may also need a course of antibiotics which they can also prescribe. Don’t ignore a blister, wound or open ulcer.  These are difficult to treat in people with diabetes and you want to take care of it immediately to prevent it from getting any worse. 

• Surgical procedures

Podiatrist can also perform any surgical procedures necessary to treat lower extremity deformities or to debride dead tissue to allow an existing wound to heal.

Multi-disciplinary care

Although podiatrists are the foot specialists, they are part of a team that works together treating diabetic foot and lower extremity problems. They collaborate with vascular surgeons if they feel you need to be referred because of poor circulation. And if they are aware that you are having problems controlling your blood glucose, they may refer you to an endocrinologist. They all form a team that play a part in keeping you healthy.

Now that you understand the role of the podiatrist, make an appointment to see one. Don’t put it off until something is seriously wrong. Rather try to prevent complications before they happen by having routine check-ups and keeping your blood glucose under control.

References

• https://www.cdc.gov/diabetes/professional-info/health-care-pro/diabetes-podiatrist-health.html#:~:text=Podiatrists%20play%20a%20key%20role,exams%20and%20treatment%20if%20needed.
• https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-020-0380-8
• https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diabetes-foot-care
• https://www.apma.org/diabetescare

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Dr Rakesh Newaj shares the tell-tale signs of the skin that can be indicative of underlying diabetes.

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

Diabetes, a multi-faceted condition marked by the body’s inability to regulate blood glucose levels effectively, can exert profound effects on various organs.

Most of the time, it’s discovered fairly late, when other organ complications, prompts the medical practitioner to do a blood glucose test. At this stage, some of the damage caused by unregulated blood glucose is usually irreversible. Fortunately, the skin, serving as a visible interface with the external environment, often reflects internal metabolic disturbances, offering valuable insights for diagnosis and management.

Acanthosis nigricans

One prominent cutaneous manifestation indicative of insulin resistance and impending diabetes is acanthosis nigricans. This condition manifests as velvety, hyperpigmented patches of skin, typically observed in areas such as the neck, axillae, and facial regions.

Despite rigorous hygiene practices, the distinct texture persists, prompting individuals to seek evaluation for underlying insulin resistance and diabetes. Treatment strategies encompass a holistic approach, including meticulous blood glucose control, regular physical activity, weight management interventions, and, in some cases, adjunctive therapies like chemical peels to address cosmetic concerns.

Dry skin

Individuals grappling with poorly-controlled diabetes often contend with troublesome dermatological issues, such as dry skin, particularly prevalent on the shins, accompanied by intense itching. This tends to be very persistent with bouts of scratching that leads to injuries on the skin.

Effective management entails meticulous blood glucose regulation alongside targeted interventions, such as the application of specialised moisturising creams, to alleviate discomfort and prevent complications. Sometimes the use of antihistamines and steroid creams can be very helpful in easing symptoms.

Skin tags

Moreover, the presence of multiple skin tags in regions like the neck, face, axillae, or groin may signal an underlying association with diabetes, often also linked to obesity. These tags can appear over a short period of time and can be very unsightly.

Treatment modalities typically involve the removal of these skin tags through cautery procedures, aiming to alleviate discomfort or improve the cosmetic look.

Skin infections

Diabetic individuals, owing to compromised immunity and metabolic dysregulation, frequently encounter recurrent skin infections. Bacterial infections commonly present as multiple sores scattered across the body, necessitating prompt medical attention and targeted antimicrobial therapy.

Conversely, rashes in skin folds should raise suspicion of fungal infections, such as candida. Another very common fungus infection in people with diabetes is called pityriasis versicolor. It appears as hypo or hyperpigmented patches mainly on the back and chest regions.

Addressing these infections may involve antifungal medications and meticulous hygiene practices to prevent recurrence. Additionally, diabetic individuals may contend with recurring vaginal yeast infections and oral thrush, warranting comprehensive management strategies tailored to individual needs.

Delayed wound healing

Prolonged hyperglycaemia can culminate in systemic complications, including impaired circulation and nerve damage, precipitating delayed wound healing and the development of diabetic ulcers.

In severe cases, chronic poor glycaemic control may precipitate toe gangrene, necessitating aggressive interventions, including amputations, to forestall further complications.

Diabetic dermopathy

Diabetic dermopathy is characterised by brownish skin discoloration on the shin. This type of skin lesion is fairly common and starts as pale macules which become darker in colour with time.

Many patients are unaware of its implications and try to ignore it at first till it becomes a cosmetic disturbance. The brown patches pose a therapeutic challenge to doctors due to their stubborn nature.

Diabetic blister

Sometimes patients present with a single blister on the lower leg, without a history of trauma. The blister appears overnight and can be fairly big. This is called a diabetic blister and warrants a full investigation to exclude the disease.

Necrobiosis lipoidica

Necrobiosis lipoidica can be considered as one of the cutaneous markers of diabetes. It presents as yellow atrophic patches, most often on the shins. Sometimes a red-brown rim may indicate activity at the border. Ulceration may also occur and is very slow to heal. There can be reduced sensation to fine touch in the affected area. The affected person needs to see a dermatologist to confirm the diagnosis and treat this condition.

Comprehensive management

While various other rare cutaneous signs may serve as harbingers of underlying diabetes, consultation with healthcare professionals is paramount for accurate diagnosis and comprehensive management. By adopting a multi-disciplinary approach encompassing lifestyle modifications, pharmacotherapy, and preventive measures, individuals can mitigate the impact of diabetes on skin health and overall well-being.

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