Back to school (with Type 1 diabetes)

Going back to school can be a stressful time for anyone. For people with Type 1 diabetes (T1D) this can be even more so, especially returning to school after a new diagnosis. It’s important that teachers are aware of T1D so they can ensure the wellbeing of their students.


Education

It’s so important that your school teachers are aware of your T1D and know what to do when you need assistance. If they are educated, they will be better prepared to help you.

It’s also advisable to keep a Glucagon kit at the school office, therefore it’s best to educate the school secretaries or the school nurse.

If you feel comfortable, it’s also great to make your friends aware. That way you can ask them for help too.

Educate your teachers on the symptoms of high and low blood glucose so that they can keep an eye out for you.

If you play sports, educate your coaches on how you may need to take breaks if your blood glucose drop and eat and rest until your blood glucose returns to a good level.

Know your rights

It’s important to educate your teachers that you need to eat during class. No excused from your teachers, you are the exception. If you write exams, make sure the teachers are aware of your T1D!

Be as open about your T1D as possible

The more open you are about your diabetes, the better. People are often very inquisitive and unfortunately T1D carries a lot of misconceptions so try to be as patient as possible

If you wear a medical device, wear it with pride

NEVER be ashamed of a CGM or pump being visible. People are more likely to ask you questions but use it as an opportunity to educate people and create a positive conversation about T1D.

Be prepared

Make sure you ALWAYS have glucose sweets or a juice box with you. Lows can happen at the most unexpected times. It’s also important if you leave the classroom to carry your ‘low’ treatments with you.

Drink plenty of water at school too. Pack your bag the night before; that way you are less likely to forget important things at home. Be prepared for more than one low a day and pack enough supplies.

Remember that your T1D doesn’t define you

Know that diabetes doesn’t make you different from everyone else 🙂

Click on the image to make use of a printable PDF from the JDRF which is a great resource to give to your teachers.

T1D

MEET OUR YOUTH WARRIOR


Sarah Gomm (16) has been living with Type 1 diabetes for nearly 13 years; diagnosed at age four.


Sarah’s story

My family knew something was wrong with me due to my symptoms of thirst and weight loss, etc. They took me to the doctor and I was immediately sent to the hospital where I was diagnosed with T1D. I spent a few nights in hospital where my family and I learnt all the ins and outs of T1D.

For the next eight years, I did insulin injections and finger pricks. My mom would come to my school during break to do my injections until I was able to do them myself.

The past five years, I’ve been fortunate enough to use a CGM and insulin pump, which I’ve found to assist in lowering my HbA1c and improve my overall control.

As I get older, I’m becoming a lot more responsible managing my diabetes and it’s made me a very independent person.

However challenging T1D can be, I still count it as a blessing. I have experienced so many amazing things I never would have, it’s made me mature and, most importantly, I’ve met so many amazing people.

T1D does not define me, though, it has made me the person I am today, and for that I am grateful!

Can people living with diabetes donate blood?

National Blood Donor Month was in June; with that we chat to Dr Nolubabalo Makiwane, from the South African National Blood Services (SANBS) about whether people living with diabetes can donate blood.


  1. Can diabetes patients using insulin (injection or pump) donate blood?

Yes, we accept donors who are using insulin to control their diabetes. Both those using injections or pumps. The most important factor is that their diabetes must be controlled and they must be well on the day they present to donate.

Insulin users should also not have any skin complications associated with using injections/pumps. We won’t allow a donor to donate blood, if they have a skin infection at the injection site, for example.

  1. Can diabetes patients using oral diabetes medication donate blood?

Yes, persons using oral medications and diet to control their diabetes are welcome to donate. Again, their diabetes must be well-controlled and they must be well when presenting to donate blood.

Most medication used to treat diabetes are classed as category B drugs. Therefore, are considered safe if one should opt to become a blood donor.

  • Understanding the categories of medication

Medications are assigned to five letter categories based on their level of risk to foetal outcomes in pregnancy. It can give one a good idea on the level of safety of a drug at a glance. This is of importance in transfusion as a fair percentage of SANBS blood products are used by pregnant women, women in labour or who are post-partum, and, of course, we also supply blood products for use in babies and children.

So, category A is the safest category of drugs to take. Category B medications are medications that are used routinely and safely during pregnancy. The C and D category drugs have shown positive evidence of human foetal risk but potential benefits of the drug may warrant use in pregnant women. Category X is never to be used in pregnancy. This is a classification based on the safety of a drug in pregnancy and lactation.

Pregnancy Category

Description

A No risk in controlled human studies: Adequate and well-controlled human studies have failed to demonstrate a risk to the foetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
B No risk in other studies: Animal reproduction studies have failed to demonstrate a risk to the foetus and there are no adequate and well-controlled studies in pregnant women or animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the foetus in any trimester.
C Risk not ruled out: Animal reproduction studies have shown an adverse effect on the foetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
D Positive evidence of risk: There is positive evidence of human foetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
X Contraindicated in pregnancy: Studies in animals or humans have demonstrated foetal abnormalities and/or there is positive evidence of human foetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
N FDA has not yet classified the drug into a specified pregnancy category.
  1. What are the medications that if taken, a person can’t donate blood?

Generally, SANBS doesn’t accept donors who are using medication that is classified as teratogenic. These drugs would fall into category X. These medications are known to cause malformations in unborn babies, or miscarriages. These include a lot of dermatological agents, like Roaccutane, Neotigason and etretinate.

Some anticonvulsant medication has been found to have teratogenic effects, such as valproic acid, phenytoin and phenobarbitone.

Some antibiotics and male hormonal medications are also classed as teratogenic. The list of teratogenics is, of course, much longer than this. However, what is of note is that there are no hypoglycaemic agents listed as teratogenic.

  1. Diabetes, unfortunately, has many side effects, such as heart problems, neuropathy, slow-healing, etc. Will any of these side effects stop people living with diabetes from donating blood?

Most definitely. If donors are people living with diabetes and they develop a complication due to their diabetes, we defer them until the complications are resolved, and until good control of the donors’ blood glucose level is re-established.

Persons who suffer from a hypoglycaemic coma (due to low blood glucose levels) are deferred for four months from the time of the episode. This is to ensure that their glucose control is adequate.

SANBS also doesn’t accept donors who develop diabetes as a complication of another disease process. For example, a donor who develops diabetes as a complication of acromegaly (a disorder caused by excessive production of growth hormone by the pituitary gland and marked especially by progressive enlargement of hands, feet, and face) would not be accepted for the procedure.

  1. Does SANBS encourage people living with diabetes to donate blood?

We encourage people living with diabetes to donate blood only if they are well enough to tolerate the procedures. At SANBS, the health of our donors is of very high importance. We do not collect blood from a donor if it would be detrimental to the health of the donor at all. This applies to our diabetic donors, even more so as they are at a slightly increased risk of developing infections and other complications.

MEET OUR EXPERT


Dr Nolubabalo Makiwane is a registered medical practitioner working in the transfusion medicine field. She is part of the medical team at the SANBS where she works to ensure that donor care is at its best.


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Highs and lows of diabetes

Aiden Nel, a teenager living with Type 1 diabetes, tells us about the highs and lows with diabetes.


The highs and lows of diabetes is a well-known term for any household that houses a person living with diabetes.

How many times have you, as a person living with diabetes, heard, “Is your reading high or low?” from a member of your family or friends. Yes, we have all experienced this at some stage and will continue experiencing it.

Well, the term ‘highs and lows of diabetes’ is not only associated with the blood glucose readings. To me, the highs and lows of diabetes can also be associated with experiences of living with diabetes but have the opposite meaning.

The ‘highs’ of living with diabetes can include the attention and concern that you receive from family and friends. It is a good feeling when your family and friends check on you and show concern. However, a ‘low’ would be when this is overdone and you feel that your family and friends don’t trust you.

Another ‘high’ is that you can control what you eat as a meal. If you don’t like the food that is being served then you can always say that you should not be eating that particular food. (Sneaky I know!)

The ‘low’ is that there are food items that you really want to eat, but these are the food items that you should not eat.

Though, regardless of how we feel about the highs and lows of diabetes, it’s a very important part of living with diabetes. If we are experiencing a high or a low in our readings or experiences, this statement of highs or lows will not change or disappear from our lives. Therefore, embrace this statement and live your life to the fullest.

MEET OUR EXPERT


Aiden Nel lives in Port Elizabeth. He is 15 years old and has Type 1 diabetes.


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Breastfeeding with diabetes

As a mom to be, we all want what is best for our baby. There is a huge amount of research that shows breastfeeding is best for baby and for mom. But, is this true when it comes to a mommy who is living with diabetes? The good news is, absolutely! 


Firstly, we know that breastfeeding can reduce the risk of the baby developing diabetes, as well as less likely to be overweight later in life.1It has been shown that breastfeeding protects against both Type 1 and Type 2 diabetes.2,3 Breastfeeding is also thought to play a role in reducing the risk of a mom developing Type 2 diabetes later in life.1

However, a mom already living with diabetes may be concerned that she may face different challenges when it comes to breastfeeding.

Mothers with gestational diabetes

When a mom develops diabetes during pregnancy (known as gestational diabetes mellitus), the impact can be a delay in her mature milk (growing milk baby needs until the day they wean) coming in.4 Under normal circumstances the mature milk comes in on day three. However, a mom who has developed gestational diabetes – her mature milk may only come in on day five to seven.

This means that baby gets colostrum (first stage of breast milk) for the extra few days, resulting in baby feeding often, or not settling after feeding. Although colostrum contains many nutrients, it isn’t really growing milk and some babies on colostrum will lose weight. Up to 10% weight loss is considered normal. Because of this, parents introduce formula top-up which can further delay the mature milk coming in. Formula top-ups can also result in lower milk supply long-term.

  • Differences in colostrum and mature milk

Mature milk and colostrum differ in the nutrient content. Colostrum being higher in fat and certain minerals whereas mature milk has a higher carbohydrate percentage. Colostrum comes in very small volumes with baby needing only about 5ml a feed whereas mature milk is found in much greater volumes.

On day 3, when the mature milk comes in, baby needs about 30ml per feed. However, a baby getting colostrum at this stage won’t be getting this volume from the breast. So, they don’t fill their tummy as easily. These babies need to eat more often to keep their tummy full on the smaller volume of colostrum.

Your body will provide what baby needs with slightly more frequent feeds and a mom who is aware of this will be happy to give baby the extra feeds needed. A mom not aware of this change may feel she is not making enough milk for her baby and may be tempted to give formula top-up. Working with a lactation consultant at this stage can help give mom peace of mind and a plan to ensure baby receives enough breast milk.

  • Caesarean section

Another challenge we see with moms who have gestational diabetes is that they are more likely to need a caesarean section birth. This can cause delays in initiating breastfeeding and contribute to a delay in the milk coming in. The good news is that this isn’t always the case, but it is important to be aware that it may happen.

To help with milk supply, mommy needs to feed baby often after birth, about every 2 – 3 hours. This will also help with the other challenge we find with baby after the birth if a mom has gestational diabetes: hypoglycaemia (low glucose levels).5

Feeding often will help to keep baby’s blood glucose levels up. When we look at a mom who had gestational diabetes, her post-birth glucose levels stabilise, and breastfeeding has an additional benefit in that it can help prevent the onset of Type 2 diabetes later in life. This is a known risk factor of gestational diabetes.6,7

Mothers with Type 2 diabetes

Studies have shown that mothers with Type 2 diabetes are more likely to experience low milk supply or at least a delay in increased milk volume.8 This is because insulin plays a role in milk metabolism.5,9

Breastfeeding, however, may help to stabilise a mom’s blood glucose levels. Mothers with Type 2 diabetes may be able to reduce their hypoglycaemic medication while breastfeeding. Most medication required to treat Type 2 diabetes is safe to take while breastfeeding.8

To be certain though, discuss this with your healthcare providers before your baby is born. Moms do need to monitor their glucose levels closely to start with, as breastfeeding can reduce maternal glucose levels which may in turn lead to mom experiencing hypoglycaemia.5As with gestational diabetes, we do find a delay in the onset of mature milk in moms living with Type 2 and Type 1 diabetes.10

Mothers with Type 1 diabetes

Breastfeeding rates in moms with Type 1 diabetes have been shown to be lower. The reasons are usually related to caesarean birth; delay in initiation of breastfeeding; and babies being born earlier in the pregnancy.

Earlier birth dates are associated with challenges with sucking coordination and latching issues.10 However, breastfeeding can assist in stabilising glucose levels in moms with Type 1 diabetes. These moms can then reduce the amount of insulin they are using.11

Managing milk supply with galactagogues

When looking at managing milk supply, many moms want to take medication to increase their milk supply. This is especially common when the milk is delayed as with diabetes. This medication is known as a galactagogue and it may be medical or natural.

Moms living with diabetes need to be particularly careful about taking galactagogues, unless guided by a healthcare provider. Many of the natural forms are readily recommended and easily available. However, some of them can impact a mom’s blood glucose levels.

Goat’s rue is an herbal medication used to increase milk supply, but it is also used to lower blood glucose levels. It may present as a benefit to moms living with Type 2 diabetes, but moms living with Type 1 diabetes should not use it. 12,13

Likewise, fenugreek, milk thistle and alfalfa to name a few have been used to increase milk supply and are also associated with reducing glucose levels. 14,15,16,17 It is strongly recommended that moms consult with their healthcare providers before taking any form of natural supplements to increase milk supply.

Lactation consultant

Working with a lactation consultant is important to rule out any other underlying issues that may cause low supply, such as a poor latch. Lactation consultants can also guide mothers with practical steps she can take to increase her milk supply, as well as assist in making sure baby is exclusively breastfed. Most importantly, moms living with diabetes can breastfeed and will reap the rewards of doing so.


References

  1. Erica P Gunderson. Breastfeeding and diabetes: Long-term impact on mothers and their infants. 2008 Aug: 8(4): 279-286 [NCBI]
  2. Gouveri E, Papanas N, Hatzitolios Al, Maltezos E. Breastfeeding and diabetes. Curr Diabetes Rev 2011 Mar; 7(2):135-42 [PubMed]
  3. Stage E, Hogardd H, Damm P, Mathiesen E. 2006. Long-term Breast-feeding in women with type 1 diabetes. Diabetes care 2006 Apr; 29(4): 771-774
  4. Wallenborn JT, Perera RA, Masho SW. Breastfeeding after gestational diabetes: Does perceived benefits mediate the relationship
  5. Diabetes and breastfeeding. https://www.laleche.org.uk/diabetes-and-breastfeeding/#gestational
  6. Diabetes and breastfeeding: what to know. https://www.webmd.com/diabetes/breastfeeding-and-diabetes#1
  7. Wein, H. Breastfeeding may help prevent type 2 diabetes after gestational diabetes. 2015. NIH research matters. National Institute of Health.
  8. Thursday’s tip: Breastfeeding if you are Diabetic or Insulin resistant. 2015. https://www.lllc.ca/thursdays-tip-breastfeeding-if-you-are-diabetic-or-insulin-resistant
  9. Factors leading to diabetes may contribute to milk supply problems for new mothers. 2014. https://www.sciencedaily.com/releases/2014/05/140505211037.htm
  10. Sparud-Lundin C, Weenergren M, Elfvin A, Berg M. 2011. Breastfeeding in women with type 1 diabetes. Diabetes Care 2011 Feb; 34(20): 296-301
  11. Breastfeeding with type 1 Diabetes. https://beyondtype1.org/breastfeeding-type-1-diabetes/
  12. Using Goats rue to increase your milk supply. Very well family. https://www.verywellfamily.com/goats-rue-and-increasing-the-supply-of-breast-milk-431841
  13. Goat’s rue. Drugs.com. https://www.drugs.com/npp/goat-s-rue.html
  14. Fenugreek and Diabetes. https://www.diabetes.co.uk/natural-therapies/fenugreek.html
  15. Ranade M, Mudgalkar N. 2017. A simple dietary addition of fenugreek seed leads to the reduction in blood glucose levels: A parallel group, randomized single blind trial. Journal List Ayu v.38(1-2); Jan-Jun 2017 PMC5954247
  16. Kazazis CE, Evangelopoulos AA, Kollas A, The therapeutic potential of milk thistle in diabetes. 2014. Rev Diabet Stud. 2014 Summer; 11(2): 167–174. Published online 2014 Aug 10. doi: 10.1900/RDS.2014.11.167
  17. Amraie E, Farsani MK, Sadeghi L, Khan TN, Babadi VY, Adavi Z. 2015. The effects of aqueous extract of alfalfa on blood glucose and lipids in alloxan-induced diabetic rats. Interv Med Appl Sci. 2015 Sep; 7(3): 124-128.
Laura Sayce

MEET OUR EXPERT


Laura Sayce is a certified lactation consultant (IBCLC) and doula in private practice. She is also the mom of two gorgeous girls. With both personal and professional experience, Laura has a passion to help moms meet their breastfeeding goals. She has been working in the birth and breastfeeding industry for 11 years.


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Depression and diabetes

Daniel Sher explores how diabetes and depression are linked, and gives some pointers for managing diabetes and depression together.


If you have diabetes, your chance of developing depression is two to three times higher than that of other people. As if we didn’t have enough to worry about already.

Why is this a problem?

Depression can make it harder for you to manage your glucose levels, often leading to diabetes burnout. Before you know it, you’re stuck in a vicious cycle of sadness, mood swings and poor blood glucose control.

What is depression?

Depression usually involves feelings of sadness, but depression and sadness are not the same thing. Rather, depression is a psychological disorder that affects a person not just emotionally, but also in terms of their thoughts and bodily functions.

Some of the symptoms of clinical depression include:

  • Ongoing sadness that doesn’t seem to ease up.
  • An inability to enjoy activities that previously brought you happiness.
  • Sleep disturbances.
  • Mood swings at home or at work are interfering with your relationships.
  • Concentration difficulties.
  • Suicidal thoughts and behaviours.
  • Inappropriate guilt and poor self-esteem.
  • Social withdrawal.
  • Changes in weight and appetite.
  • Low energy.
  • Less motivation to test your blood glucose, exercise and take insulin (diabetes burnout).

How common is depression in people with diabetes?

Time and time again, research studies have shown that having diabetes puts one at risk of developing depression. For example, a 2012 study showed that people with Type 1 diabetes are three times more likely to have depression; while people with Type 2 diabetes are twice as likely to be depressed.

Another 2019 study confirmed these numbers, leading the authors to say that reducing diabetes by 25% could stop 2,34 million cases of depression from happening. But, believe it or not, research shows that the relationship goes both ways. Having depression can also make a person more likely to develop (Type 2) diabetes.

Clearly, then, a close link between the two conditions exists. But why does this link exist? Why do depression and diabetes occur together so often?

Explaining the link between diabetes and depression

Injections. Finger pricks. Doctor’s visits. Lows. Highs. Dietary restrictions. Worry and fear. Yes, as people living with diabetes, we deal with a whole lot of stress. Is it really that surprising that we’re more likely to end up with depression?

Of course, living with diabetes comes with a psychological burden which in and of itself can trigger depression. But, the stress of diabetes alone doesn’t completely account for this link. This is where things get interesting.

Diabetes, depression and the brain

Recent research suggests that high blood glucose levels have a direct impact on the parts of the brain that affect mood and thinking. The researchers used a (fMRI) brain scanner to compare the brains of people living with diabetes versus people without the illness. The people living with diabetes were given some glucose to raise their sugars.

The scanners showed that when blood glucose levels went up, a certain brain chemical (glutamate) was released in parts of the brain that control thinking and emotions. Glutamate is closely linked to depression. The researchers also showed that people with worse glucose control over time had patterns of electrical activity in the brain that are linked to depression.

So, in other words, this study tells us that the link between diabetes and depression is not just a matter of increased life-stress: the two disorders are linked on a biological level. People living with diabetes experience changes in the brain that make depression more likely; and this is especially the case when blood glucose levels are high.

A vicious cycle

Many clients who approach me for help are stuck in a vicious cycle. They struggle to control their diabetes as well as they would like; and they soon start to develop signs of depression. The depression makes it harder for them to stay motivated and hopeful. They start to slack-off in terms of self-monitoring, diet and exercise. Their glucose control suffers as a result. This leads them to become even more depressed.

Why is this important?

For starters, if you are one of millions of people living with diabetes who is struggling with depression, know this: it’s not all in your head. The stress and strains of living with diabetes are very real. But, the illness also predisposes you to depression because of altered brain chemistry.

Now that we know this, it’s absolutely vital for doctors, patients and family members of people living with diabetes to know how to recognise the signs of diabetes and get help where needed. Treating both diabetes and depression together is vital.

How to get help

The good news is that this cycle can be broken. In most people, depression responds well to treatment. Let’s look at the two most common treatment options:

  1. Psychotherapy

Also known as talk therapy, counselling or just therapy. Speaking with a licensed mental health professional can help you to change the thoughts and behaviours that make depression more likely.

Cognitive behavioural therapy (CBT) is one of the most popular forms of therapy for treating depression. If possible, try to find a therapist who is experienced in working with people living with diabetes. It can really help to speak with someone who understands the struggles and nuances of living with a chronic illness.

  1. Medication

One of the most common forms of antidepressant medications is called a selective serotonin reuptake inhibitor (SSRI). Examples include Celexa, Lexapro, Zoloft and Zytomil. A 2006 research paper suggests that medication and therapy are equally effective in managing depression; and that the best outcomes usually occur when the two are combined.

  1. Lifestyle interventions

Therapists often include ‘behavioural modification’ to their treatment. This means empowering the client to make healthier choices when it comes to their diet, diabetes management and exercise patterns. Making positive choices in this regard can help you manage your depression and diabetes at the same time.

How to get help

If you are concerned that you may be developing depression on top of your diabetes, speak to your endocrinologist or general practitioner. Alternatively, you may want to make direct contact with a clinical psychologist or psychiatrist in your area. If possible, try to consult with a mental health professional who has experience in working with diabetes.

If you or a family member are suicidal, contact the South African Depression and Anxiety Group on their 24-hour suicide hotline: 0800 567 567.

Final thought

So, we now know that people living with diabetes are more likely to experience depression. Not just because their lives are a whole lot more stressful, but because diabetes, depression and the brain are all linked on a biological level. For those of us with diabetes, this means that we need to remain vigilant for signs of depression.

By getting the mental health treatment that you deserve, it’s possible to improve your overall quality of life and your blood-sugar control at the same time.


References

Bădescu, S. V., Tătaru, C., Kobylinska, L., Georgescu, E. L., Zahiu, D. M., Zăgrean, A. M., & Zăgrean, L. (2016). The association between Diabetes mellitus and Depression. Journal of medicine and life, 9(2), 120-125.

Chireh, B., Li, M., & D’Arcy, C. (2019). Diabetes increases the risk of depression: A systematic review, meta-analysis and estimates of population attributable fractions based on prospective studies. Preventive medicine reports, 100822.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., … & Atkins, D. C. (2006). Randomized trial of behavioural activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of consulting and clinical psychology, 74(4), 658-670.

Endocrine Society. (2014, June 23). High blood sugar causes brain changes that raise depression risk. ScienceDaily. Retrieved June 19, 2019 from www.sciencedaily.com/releases/2014/06/140623092011.htm

Roy, T., & Lloyd, C. E. (2012). Epidemiology of depression and diabetes: a systematic review. Journal of affective disorders, 142, S8-S21.

MEET OUR EXPERT


Daniel Sher is a registered clinical psychologist who has lived with Type 1 diabetes for over 28 years. He practices from Life Vincent Pallotti Hospital in Cape Town where he works with Type 1 and Type 2 diabetes patients to help them thrive. Visit www.danielshertherapy.com


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Irene Aarons – accepting diabetes with words

Poet and writer, Irene Aarons (nom de plume – Irene Emanuel), tells us how writing poetry about her medical conditions, including Type 2 diabetes, has helped her comes to term with them.


Irene Aarons (75) lives in Port Elizabeth, Eastern Cape. She has three children, four step children, three grand-children and nine step grand-children.

Irene not only has Type 2 diabetes. She has chronic allergic asthma; a hernia; high blood pressure; rhinitis; osteoarthritis, and she is on medication for all these conditions.

Though, she explains that the upside of all the above is that she has material to work with; many of her poems are about medical matters.

“I live the best life that I can, by finding the funny side of any limitations that there are. The poetry process gives me the chance to make light of a serious condition. By writing it down, I understand that this illness (diabetes) is not the end of my life but the beginning of new experiences. Poetry gives me an understanding that there is life after all my ailments; and whatever else finds me.”

“I always know that there are people far worse off than me. At least I am able to laugh at myself and write poetry that might make someone else laugh. One of my greatest joys is presenting a poetry talk to adults and children; to having them come up to me afterwards and telling me that my words have helped them in some way,” Irene explains.

Family history of diabetes

Irene was diagnosed with Type 2 diabetes in December 2008, at the age of 64. “I was vaguely expecting it as my mother, two uncles and an aunt all had diabetes. My oldest brother had Type 1 as well as his son. Since my diagnosis, another nephew has been diagnosed with Type 1. So, it definitely runs on the maternal side of my family.

After seventeen years of marriage to her second husband, Irene became a widow, in 2000, when he died of diabetic complications (Type 2). “My second husband was on dialysis for about three years, had lost the sight in one eye and was quite ill for a long time,” she explains. “He was diagnosed when he was in his twenties. But refused to take pills and carried on as if there was no problem at all. He lived life to the full and took no notice of his condition.”

“By the time I married him, he was still a heavy smoker and a fearless “anything-goes” person. When he finally gave in (I pressured him), it was too late. From his mid-fifties, he suffered from peripheral neuropathy, lost the sight in one eye, had a heart attack and then a multiple bypass, which made him give up smoking. His kidneys were damaged and he had to go for dialysis three times a week.”

“He died in his sixties. An early death which could have been delayed had he taken better care of himself. I supported him by going to support group meetings and ensuring that he followed a healthy way of eating. I helped him wherever I could by supporting him in his business and looking after all the children.”

Diabetes management

Currently, Irene is on 1000mg Glucophage twice a day. “Having diabetes is not a problem but rather a challenge. But a challenge that I accept to overcome every day,” she explains.

“The downside of diabetes is that I have to be cautious about what I am able to eat safely. I do cheat. But as I get older, I find that I eat less and very plain food. However, I admit that my downfall is a Steers hamburger, which I do treat myself to about once a month.”

Irene certainly does see the humour in everything. The proof is in the train of thought regarding diabetic food items. “I am curious as to why the cost of diabetic food is always so expensive, considering that half the ingredients are left out.”

She adds that she prefers Hermesetas sweeteners. But since they are imported from Switzerland, they seem to be harder to get. For this reason, she uses Equal sweetener instead.

Exercise doesn’t form part of Irene’s daily regime. Though, she adds “I do park far from mall entrances so that I can walk a fair amount. I do enjoy walking and sightseeing, especially if I am somewhere that I have not been before.”

Keeping busy is the way to go

The 76-year-old is officially retired. Though, she  keeps herself very busy. She is the bookkeeper for a family business, which involves at least two days a week. She also offers her time in two different charity shops, twice a week. Lastly, she always avails herself for talks, let it be on poetry or health.

“I have always been willing to talk to people on subjects, ranging from poetry to books, health, or whatever is needed. I have given talks at schools, clubs and societies. My favourite being schools because I have written poetry on rape, babies, abuse and topics that children can relate to. I am adamant that reading is the pathway to becoming informed and a useful member of society.

Publications

Irene has published four poetry anthologies. The poet has also had poetry and short stories published in both local and overseas books, as well as newspaper articles published in South Africa. She has won poetry awards and an award for general success in the publishing world.

See two of her poems below.

CHRONICALLY CHALLENGED

By Irene Emanuel

I’m working and walking

though chronically challenged;

I’m thinking and talking

though chronically challenged;

I’m laughing and crying

though chronically challenged;

I’m sitting and lying

though chronically challenged;

My insides are messed

and chronically challenged;

My outsides are dressed

though chronically challenged.

The list of what’s challenged

is endlessly long

is medical science

going to write me a song?

In medical books, I’m living proof,

though chronically challenged

I’m still waterproof.

I’ve asthma, diabetes and rhinitis too,

hernia, depression and no-one to sue;

Though chronically challenged,

and living on pills;

I know that my life

is still full of thrills.

So hit me again, what else is in store?

though chronically challenged,

at least I don’t snore.

 

PILLORIED

By Irene Emanuel

I am a rainbow ghost, see-through in the light;

A conglomeration of multi-coloured pills

that prevent me from becoming a real ghost.

The pills play music tattoos on my skeleton

as they race down my gullet, looking for signage

direction to the weak spot.

I wonder what the outcome would be if the signs got scrambled?

Would my diabetes become asthmatic?

Would my high blood pressure run into the blood thinner and become watery?

Would that increase the water on my lungs and cause flooding?

What would happen if there was a traffic jam?

Would the various pills just give up, dissolve into a heap and suffer a melt-down?

Would my body rebel, fight back, expel the pills, lie down and fade out?

A bitter pill to swallow is the fact that I am chained forever, to staying alive with pills.

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Laurelle Williams is the Editor at Word for Word Media. She graduated from AFDA with a Bachelor of Arts Honours degree in Live Performance. She has a love for storytelling and sharing emotions through the power of words. Her aim is to educate, encourage and most of all show there is always hope. Feel free to email Laurelle on editor@diabetesfocus.co.za


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Ramadan and diabetes: a collaborative approach to fasting

Dr Salim Parker gives a collaborative approach to Ramadan fasting.


One of the five pillars of Islam

Fasting from dawn (the meal in the morning is called Suhoor) to dusk (Iftaar) during the Muslim month of Ramadan is one of the five pillars of Islam. The Quran specifically instructs all mature and healthy Muslims that: “Oh you who believe! Fasting is prescribed to you as it was prescribed to those before you so that you may attain self-restraint.

Most Muslims start fasting from a very young age. Even though, it’s only obligatory when puberty is attained and it is a religious, social and community in most societies. The Islam religion follows the lunar calendar and Ramadan occurs 10 days earlier each successive year. This year (2019) it will be nearly the whole of May.

The sick are allowed to postpone the fast and may even be exempted from it, as stated in the Quran: “Whoever witnesses the month (of Ramadan) then he/she should fast. But, if any of you is ill or travelling – then he or she is exempted from fasting.”

Despite this concession many sick Muslims will fast despite learned religious scholars and medical professionals advising them not to. This applies equally to people living with diabetes and this article outlines some guidelines as to how to approach diabetics intending to fast.

Benefits of fasting

It’s known that there are several potential benefits of fasting during Ramadan. Feelings of compassion for the less fortunate and underprivileged are evoked in Muslims who fast. Though the hunger and thirst senses are heightened, the natural sense to eat or drink is controlled. This leads to a sense of having willpower and to be in control of the senses.

The long-term ideal is for Muslims to ultimately be able to resist daily unnecessary and potentially harmful forms of food as urged by the Quran to: “Eat of what is lawful and wholesome on the earth,’ and ‘And He (God) enforced the balance. That you exceed not the bounds; but observe the balance strictly and fall not short thereof.”

Fasting also offers a time to ‘cleanse’ the body and the soul. The person fasting is encouraged to develop a greater sense of humility, spirituality, and community involvement.

There are also indications of physiological benefits of fasting. Some studies indicate that intermittent fasting limits energy intake. This promotes weight loss in obese individuals, which could be cardio-protective. Insulin sensitivity is also increased.

A holistic approach needed

Currently, of the 366 million humans on earth living with diabetes, more than 50 million are Muslim. In 2015, diabetes was the leading cause of death amongst South African females, and the sixth most frequent one amongst males. Diabetes was the second leading cause of death overall in South Africa after tuberculosis that year.

Many South African Muslims living with diabetes will fast irrespective of their health status. It’s important that there should be synergy between the healthcare professionals, the Islamic scholars and the Muslims living with diabetes who want to fast. Several factors need to be considered:

  • Age of the person
  • Medications used
  • Insulin dependency or not
  • Co-morbidities
  • Recent complications
  • Whether living alone or not
  • Easy access to a glucometer
  • Social support

Lifestyle management

All Muslims living with diabetes should ideally have a pre-Ramadan consultation beforehand with their healthcare practitioner. Fasting and the management of lifestyle conditions go hand in hand and a holistic approach should be adopted.

Dietary intervention is essential and the inclusion of more fibre, complex carbohydrates, vegetables, legumes should be encouraged, as should sparing salt use.

There is increasing evidence that dates, a staple food type during Ramadan, may have beneficial effects on glucose and cholesterol levels during Ramadan and may lead to a decrease in cardiovascular risk factors. Dates, consumes in moderation, are rich in fibre and is high in fructose, which has a lower glycaemic index than sugar.

It’s known that not having breakfast, in the normal population, increases the possibility of being overweight by a factor of five, and increases the chance of developing diabetes. The consumption of the pre-dawn meal is hence paramount. Stopping smoking and optimising of medication and co-morbid conditions should be discussed as well.

Maintaining some form of exercise, such as the optional nightly Ramadan prayers (if possible and depending on level of fitness), is part of lifestyle maintenance.

Complications associated with fasting

Hypoglycaemia

Hypoglycaemia is the concern of most doctors and patients when fasting is contemplated by the Muslim living with diabetes. Several patients, especially the elderly, are not always aware when their glucose levels drop. In one study, 24 out of 29 subjects were not aware that their glucose levels were low.

Different patients will have different signs and symptoms at different levels, with a glucose level below 4 mm/L being dangerous in most instances. Signs are often subtle, such as slight inattentiveness, and may not be easily be picked up by household members. The easy availability of glucometers is paramount in all circumstances and it should be emphasised that checking the levels (finger prick test) does NOT invalidate the fast. If levels are low, the fast should be broken immediately with the religious edict that life and health are MORE important than obligations emphasised.

Hyperglycaemia

Ramadan, contrary to its intention, is associated with caloric excess. An abundance of savouries, pastries and desserts is the norm and people living with diabetes consume as much as others. Hyperglycaemia can thus occur and at times is difficult to distinguish from hypoglycaemia, based on signs and symptoms alone.

The availability of glucometers is thus again important. Patients often fear hypoglycaemia and reduce, or even stop, their medication on their own. Coupled with the dietary excess, the chances of hyperglycaemia are increased and in some countries, such as Pakistan, more cases of hyperglycaemia than hypoglycaemia are seen during Ramadan.

Dehydration

Dehydration, especially if the diabetes is poorly controlled, is a possible complication of fasting during Ramadan. Polyuria (production of abnormally large volumes of dilute urine) and a reluctance to consume too much fluids at night (to avoid urinating) increases the possibility and the development of pre-renal failure, and thrombosis may have to be considered.

Risk categories1 

Category 1: Very High Risk

This include patients with one or more of the following:

  • Severe hypoglycaemia within the three months prior to Ramadan.
  • Diabetic ketoacidosis (DKA) within the three months prior to Ramadan.
  • Hyperosmolar hyperglycaemic coma within the three months prior to Ramadan.
  • History of recurrent hypoglycaemia.
  • History of hypoglycaemia unawareness.
  • Poorly controlled Type1 diabetes mellitus (T1DM).
  • Acute illness.
  • Pregnancy in pre-existing diabetes, or gestational diabetes (GDM) treated with insulin or sulphonylureas.
  • Chronic dialysis or advanced kidney disease.
  • Advanced macrovascular complications.
  • Old age with ill health.

Patients in this category MUST NOT FAST. If they insist on fasting, close monitoring and counselling is essential, with specific instructions given on when they MUST break their fast if necessary. They must be informed that they are putting their health and life at risk.

Category 2: High Risk

In this category are patients with one or more of:

  • T2DM with sustained poor glycaemic control.
  • Well-controlled T1DM.
  • Well-controlled T2DM on MDI or mixed insulin.
  • Pregnant T2DM or GDM controlled by diet only or metformin.
  • Chronic kidney disease stage 3.
  • Stable macrovascular complications.
  • Patients with comorbid conditions that present additional factors.
  • People with diabetes performing intense physical labour.
  • Treatment with drugs that my affect cognitive function.

Patients in this category SHOULD NOT FAST. If they insist on fasting they should also be closely monitored.

Category 3: Moderate/low risk

The following fall in this category:

  • Lifestyle therapy
  • Metformin
  • Acarbose
  • Thiazolidinediones
  • Second-generation Sus
  • incretin-based therapy
  • SGLT2 inhibitors
  • Basal insulin

These patients should be able to fast with sound advice being given first.

Medication adjustment

Each person living with diabetes will have unique circumstances and should be counselled individually. Explaining the risks and symptoms of hypoglycaemia and what appropriate actions to take must be emphasised.

Patients on medication need to be advised to change their dosages to accommodate the daytime fast. Some general guidelines are given below. But, again it must be emphasised that each Muslim who intends fasting must have advice tailored to their unique situation.

Metformin

Metformin has a low-risk of causing hypoglycaemia and generally no dose adjustment is needed. Some authorities advise taking two thirds of the total daily dose with the evening meal, with one third taken with the morning meal. The once-a-day formulation should be taken at the usual dose in the evening.

Sulphonylureas (SU)

The first-generation SUs had a high propensity of causing hypoglycaemia and should be avoided. The second-generation SUs are much safer. The general rule for stable patients living with diabetes is to take half the morning dose and the normal evening dose.

The other option is to switch evening and morning doses and reduce the morning dose. The once-a-day formulation should be taken in the evening, instead of the morning with a halving of the dose for the first few days. The dose can then be adjusted as needed.

Insulin

The dose of basal insulin or once a day premix should initially be decreased by 20% and given in the evening. When basal insulin is given twice a day, the morning dose should be given in the evenings with half the evening dose given in the morning. The same applies to premixes given twice a day. Insulin that is used three times a day should have the midday dose omitted and the morning dose halved. The dosages can then be adjusted as needed.

Other diabetic medications

These generally do not need dose adjustments. Once daily doses should preferably be taken in the evening.

Conclusion

Ramadan is an ideal time for people living with diabetes to implement lifestyle changes that would be in accordance with their religion and improve their health as well as their diabetes control.

Each patient must be consulted well before the commencement of Ramadan and their risks stratified according to their unique circumstances.

Access to glucometers is an important aspect of fasting, as well as knowing who should and should not fast, how and when to test for glucose abnormalities and when to break the fast. A collaborative approach between patients living with diabetes, religious scholars and medical professionals is the ideal approach to ensure the safety of those who want to fast, and to assure those who should not fast that their religion most certainly permits that.

 


Reference:

  1. JEMDSA 2017 Volume 22 Number 1 (Supplement 1) Page 119-136

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Dr Salim Parker is a general practitioner in Elsies River. He is an Honorary Research Associate: Department of Medicine, University of Cape Town and Immediate Past President: South African Society of Travel Medicine (SASTM).


Are there links between sugar, cancer and diabetes?

Dietitian, Berna Harmse, unpacks the evidence on the effects sugar has on our bodies and the direct and indirect links it has with cancer and diabetes.


Researchers are continuously investigating the connection between sugar and cancer. Unfortunately, the topic causes a lot of anxiety and misinformation in the media and on the internet. There is no strong evidence that directly links sugar to increased cancer risk, but there is an indirect link.

What is the indirect link?

All the cells in our body, including cancer cells, need sugar (glucose) from our bloodstream for fuel. We get this blood glucose from carbohydrate-containing foods, including fruit, vegetables, starch, wholegrains and dairy. Some glucose is also made in our bodies from protein.

Sugar doesn’t make cancer grow faster. As stated in a Mayo Clinic article, “All cells, including cancer cells, depend on glucose for energy. But giving more sugar to cancer cells doesn’t speed up their growth. Likewise, depriving cells of sugar doesn’t slow down their growth.”

Eating high-sugar foods increase our body weight and body fat, which is linked to some kinds of cancer. For that reason, the American Institute for Cancer Research recommends increased intake of wholegrains, vegetables, fruit and beans; and reducing intake of sugary beverages and sweets.

Influence on weight and metabolism

Let’s look at the influence on weight and metabolism. The Academy of Nutrition and Dietetics reinforces that much research shows that higher insulin (a hormone) levels and related growth factors may influence cancer cell growth the most, as well as increasing the risk for other chronic diseases.

Different types of cancer cells have high amounts of insulin receptors, making them respond more than normal cells to insulin’s ability to promote growth.

All the food we eat gets broken down to smaller bits, in the process we call digestion. Glucose sits in the veins, and insulin working like a key, unlocks the veins so the energy can get to the rest of the body to be used.

When insulin levels are high, it is a signal to the body that there is plenty of food available, and that these kilojoules should be used to grow and build reserves for future times of starvation.

Insulin levels rise quickly when we eat unrefined carbohydrates (white bread and sweets) and leads to a drop in blood glucose levels. Low blood glucose is the biggest appetite stimulant in the world. It makes you overeat, which again causes a release of more insulin and thus a cycle of eating more and gaining weight and body fat continues.

Inactivity and being overweight also increases insulin levels, and so insulin resistance is caused. If no intervention is launched at this stage, diabetes soon follows.

Is there a link between cancer and diabetes?

Research is being done to investigate the direct link between cancer and diabetes, with some researchers speculating that the underlying metabolic factors, like long-term stress and the inflammation that comes with it, underpins some of the patterns behind it.

So, what do I eat considering all this information?

If you can keep your food portions controlled and maintain your weight, you are on the right track.

Avoid refined carbohydrates, like take-aways, white bread products, and sweetened foods and beverages. Rather choose high-fibre carbohydrates, like wholegrains, fruit, vegetables and legumes. Higher fibre foods are the cornerstone of blood glucose management.

The five-a-day approach is still best – try to have at least two fruits and three vegetables per day, or vice versa. This ensures the adequate intake of antioxidants which plays a big role in terms of fighting and preventing chronic diseases.

Vegetables and salad should take up half of your dinner plate, and carbohydrate and proteins should be the side dishes of the meal.

Try to have breakfast every morning and do not skip meals

Aim to do some form of physical activity most days of the week.

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Berna Harmse is a private practicing dietitian in Cape Town, she holds a MSc in Dietetics and has a special interest in oncology nutrition. She is also an external lecturer at Stellenbosch University Division of Human Nutrition.