Diabetes: where science, art and education meet

Louise Johnson explains that the art of living skilfully with diabetes in the new millennium is possible with your own skill, science and the help of a team.


The Oxford Dictionary defines art as “the creation of beautiful or significant things” and “a superior skill that you can learn by study and practice and observation.”

In the new millennium, diabetes patients can acquire this art or superior skill by diabetes education. This can be in any form of information from your diabetes nurse educator, doctor, internet support group or books on the subject.

Insulin saves lives

Historically, diabetes mellitus was a deadly disease in people living with Type 1 diabetes. Prior to 1921, when insulin was first given to Leonard Thompson, people living with Type 1 diabetes died.

There has been a radical change and growth in information and technology since 1921. People living with Type 1 diabetes now have basal and bolus analogue insulin.

An analogue is an insulin that works as close as possible to normal human insulin. Recently two new basal second-generation insulin were launched in 2018: Toujeo (glargine U300) and Tresiba (degludec).

Both have a working time of more than 24 hours. This is truly a once daily long-acting insulin without any peaks or intra patient variability. In practise, this mean that the sugar values will stay the same if you eat the same food every day. Thus, it allows for suitable background insulin to build on.

The short-acting analogues currently available are all very effective. NovoRapid, Humalog and Apidra all have a working time of approximately four hours and start to peak after 30 minutes. There is a new shorter-acting analogue in the pipeline and will be available later this year in South Africa.

Science and art meet at carb counting

Most people living with diabetes complain, from time to time, that they want to eat something ‘naughty’, without all the consequences of high sugars and feeling terrible.

The answer (if you don’t know it yet) is carbohydrate counting aka carb counting. This method calculates the carbohydrates per meal and establishes the correct amount of insulin via an easy mathematical calculation. Carb counting should be practiced by all diabetes patients on rapid insulin.

This scientific method both establishes the correct amount of insulin per carbohydrate meal as well as the correct dosage to correct sugar to a glucose target. Your doctor will determine this target value. The before meal and two-hour after meal values are important for good sugar control.

This art of food/insulin calculations are only possible with blood glucose values. Previously, the only method was finger prick. The more pricks and sugar measures, the better the sugar control.

The past few years have brought about five glucose sensors that can now do this for you. No more or very little finger pricking needed. This is made possible by continuous glucose monitoring.

It is a sensor that measures interstitial fluid sugar values every five minutes. This data is sent via a transmitter regularly. This data can be seen on cell phone apps or a reader specifically for this purpose.

The CGM system has arrows on the screen that gives an indication of sugars going up, down or staying stable. The real positive of this device is the reduction of finger pricking, accompanied with better hands on evaluation throughout a 24-hour period of the trend of the glucose.

All this technology is great but it is imperative to follow the correct procedure.

Insulin injection – the basics:

  1. Keep insulin in a cold area/fridge.
  2. Make sure it has not expired.
  3. Secure an insulin needle on a pen every second or third day. If you still use syringes then ensure you replace every second or third day. Blunt needles cause damage to the injected area. This can later lead to lipodystrophy (fat cells that are unresponsive and not functioning anymore, very lumpy).
  4. Rotate insulin injections areas every time to prevent this.
  5. Do not inject on scars or tattoos.
  6. Insert the needle at 90 degrees into fat tissue and not muscle. Be careful of upper arms and thighs if you are very thin. Make sure to pinch fat tissue between thumb and finger and not muscle.
  7. After the insulin dosage is injected, keep the plunger in for 10 seconds to get the whole dosage delivered.
  8. Do not clean with alcohol since this can interact with insulin. Soap and water is more than enough.

Glucose testing – the basics:

  1. Make sure your hands are clean.
  2. Check the machine and strips, to be sure they are the same brand, and that the strips are not expired.
  3. Replace lancets frequently to prevent damage to fingertips.
  4. Do not test on other sites than fingertips.
  5. Always keep a spare machine or battery at hand.

Other artful skills to learn:

  1. Adopting a diabetic diet.
  2. Regular aerobic exercises, such as walking, swimming, or running.
  3. Yearly visit to the eye specialist for a retina examination.
  4. Yearly visit to the podiatrist to examine feet and help with removing of corns, calluses, and abnormal nails.
  5. Visit a specialist physician once a year for heart and kidney evaluation. This is important to ensure all your values are on target.

Targets to achieve:

  1. Normal weight with a waist circumference below 80cm for a woman and 98cm for a male.
  2. Blood pressure equal to or below 130/80 mmHg.
  3. HbA1c below 7% (people with heart and kidney problems can have a value up to 8% but your doctor will establish your correct value).
  4. Triglycerides less than 1,2 mmol/L.
  5. LDL (bad cholesterol) less than 1,8 mmol/L.
  6. HDL (good cholesterol) more than 1,0 for a male and 1,2 mmol/L for a female.
  7. Urine albumin: creatinine ratio less than 30 mg/min. 

Type 2 diabetes

The tablet arena has increased dramatically over the past five years. The basis to all Type 2 diabetes treatment protocols should still be metformin.

The options in cases where metformin is not sufficient depend on the patient’s risk factors for heart attack, weight problems and cost.

  • DPP4i (Galvus, Onglyza, Januvia)

These dipeptidyl peptidase-4 inhibitor (DPP4i) drugs work on the incretin in the gut of diabetics and cause food to stay in the stomach. This causes increased satiety. In addition, the liver and pancreas secrete less glucose. The pancreas secretes the correct amount of insulin. This group of drugs makes patients sensitive to their own insulin.

  • GLP-1RA (Victoza, Byetta)

This glucagon-like peptide-1 receptor agonists (GLP-1RA) class of drugs are injectable incretins. They work the same way as the DPP4i but cause a greater loss of weight.

  • SGLT2i (Forxiga, Jardiance)

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is the newest class of drugs, especially for type 2 diabetes. They work in the top part of the kidney loop and prevent the reabsorption of sugar. This causes more sugar in the urine as well as lower blood sugar, lower blood pressure and 3 to 6kg weight loss.

In both Forxiga and Jardiance, there is sufficient data that showed improvement in mortality (risk to die) to both diabetics with previous heart attacks, strokes and heart failure and the group that only have the risk factors.

Dr Louise Loot

MEET OUR 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.


Fighting fit: exercising with diabetes

Prof Martin Schwellnus gives us a rundown of how to form a safe exercise regime when living with diabetes.


Preventing and treating diabetes requires a lifestyle approach, of which exercise is a vital component. Before you start exercising, the first, and most important, step is having a full medical check-up. The main reason for this is to make sure that the prescribed exercise “dose” is safe.

Types of diabetes

Diabetes mellitus is a group of chronic diseases classified into four broad clinical classes:

  • Type 1 diabetes is characterised by the destruction of pancreatic β-cells, leading to insulin deficiency.
  • Type 2 diabetes is characterised by insulin resistance and a relative insulin deficiency.
  • Gestational diabetes is diagnosed during pregnancy.
  • Other types of diabetes may be caused by genetic defects, disease of the exocrine pancreas, and drug- or chemical-induced causes.

Preventing and treating diabetes requires a lifestyle approach, of which exercise is a vital component. But it also includes nutrition, psychosocial support, smoking cessation and education. So, don’t forget the other important elements of your strategy for managing diabetes.

Benefits of exercise in diabetes patients

Exercise improves many factors important in the prevention and management of diabetes. These include improved glucose control, muscle and liver insulin sensitivity and muscle glucose uptake; reductions in HbA1c; improved weight management, blood pressure, and overall cardiovascular health.

Before you start exercising, the first, and most important, step is having a full medical check-up. The main reason for this is to make sure that the prescribed exercise “dose” is safe Any treatment plan should be patient-centred, not disease-centred, which means you should be assessed and treated holistically.

Identifying any other health concerns is important. Since these may influence how you manage your overall health, and your ability to exercise safely and effectively. Once you have the full picture, a plan can be created that suits your specific needs.

This lifestyle intervention programme is usually directed by a physician trained in sport and exercise medicine and a physician specialising in diabetes management, together with a multi-disciplinary team. This team includes dietitians, biokineticists, endocrinologists, physiotherapists and others.

Your exercise/activity plan

Structured exercise is an important part of your lifestyle, and the FIT principles below give you an idea of the type of exercise you could include in your regime.

Having said that, your activity/exercise plan needs to take various things into account, including type of diabetes, age, activity done, medication use and the presence of any complications.

As such, your plan needs to be tailored to your specific needs. So, speak to a sport and exercise physician about the strategies you will need to adopt. You may be advised to participate in an out-patient setting, or you may be able to train by yourself. In most instances training is initially conducted in small groups, where sessions (usually three per week) are supervised by members of the lifestyle intervention team.

In addition, try to increase the amount of unstructured activity you do. This is the activity you typically do during your day, such as shopping, errands, household tasks, walking your dog and gardening.

If you feel you are not ready for a structured exercise programme, start by increasing your daily activity, and then start including short bouts of structured exercise. Since any activity will increase energy expenditure and improve glycaemic control, this is a great step in the right direction.

Recently, more attention has been paid to prolonged sitting as this has a negative effect on health, irrespective of how active you are. So, be aware of how long you sit during the day, and try to stand up and do some light activity for a few minutes every 30 minutes.

General exercise guidelines for adults with diabetes and pre-diabetes: 

F

I

T

Type of exercise Frequency Intensity Time

Progression

Aerobic

(cardio – walking, swimming, cycling)

3-7 days per week, with no more than 2 days without exercise.

Moderate (your breathing and heart rate is increased slightly) to vigorous (only do if already active, your breathing is heavy and heart rate increased). Build up to at least 150 minutes per week of moderate-intensity. For those already active, 75 minutes per week of vigorous intensity.

If you are starting an exercise regime, start with bouts of 10 minutes at moderate intensity. Increase intensity, frequency and durations slowly over time to at least 150 minutes per week of moderate intensity.

Resistance 

(body weight exercises, free weights, resistance machines or bands)

At least 2 (preferably 3) non-consecutive days per week.

Moderate (using weights that allow you to do up to 15 repetitions) to vigorous (using heavier weights allowing you to do up to 6-8 repetitions). At least 8-10 different exercises, doing 1-3 sets of 10-15 reps, to near fatigue.

Start with weights that allow you to do 10-15 reps per set. Increase weight only once you can do 15 reps consistently. When you increase the weight, reduce the reps to 8-10, then increase reps again over time.

Flexibility & balance

(stretching, yoga, tai chi, balance exercises)

2-3 days per week.

Stretch to point of slight discomfort, not pain. Balance exercises of easy to moderate difficulty. Hold static stretch, or do dynamic stretch for 10-30 seconds, 2-4 reps per stretch.

Increase duration and/or frequency slowly over time

Exercise guidelines during pregnancy with gestational diabetes:

 

Aerobic exercise:

Resistance Exercise:

During pregnancy with gestational diabetes: check with your doctor Up to 30min of moderate-intensity (if sedentary before pregnancy, start at a lower intensity). No more than 2 consecutive days without exercising.

 

5-10 different exercises, 1-2 sets of 8 -15 reps, up to 60 minutes. At least 2 but ideally 3 times a week, at moderate-intensity.

Monitoring and follow-up

All patients participating in a lifestyle intervention should be assessed regularly during exercise training sessions by a member of the healthcare team. Before each exercise session symptoms of diabetes mellitus (polyuria, polydipsia), other symptoms (cardiac, infectious disease), resting heart rate, resting blood pressure and blood glucose concentrations should be taken.

During the training session, rating of perceived exertion, peak heart rate, and peak blood pressure should be monitored.

After exercise, a blood glucose measure may also be taken.

All the measurements that were recorded during the initial assessment, before starting the lifestyle programme, should be repeated two to three months later. These results should be discussed and a revised strategy created for the subsequent few months. All patients with diabetes should be re-assessed at least once a year.

Cautions to keep in mind when exercising

  • Blood glucose responses are influenced not only by the type, timing, intensity, and duration of exercise, but also by many other factors. This variation in the way blood glucose responds to exercise makes it difficult to give generalised recommendations for the management of food (carbohydrate) intake and insulin dosing during and after exercise. Speak to your sport and exercise physician, doctor and/or dietitian about the strategies you will need to adopt.
  • Adults with diabetes are frequently treated with multiple medications for other conditions. Some medications may have a negative interaction with exercise and therefore dosage may need to be adjusted.
  • Older adults or anyone with autonomic neuropathy, cardiovascular complications, or pulmonary disease should avoid exercising outside on very hot and/or humid days to prevent heat-related illnesses.
  • Patients with autonomic neuropathy should undergo cardiac screening before starting exercise, and be monitored for hypoglycaemia and abnormal thermoregulatory responses during training.
  • High-intensity endurance and resistance training, jumping, jarring, head-down activities and breath-holding are not recommended for patients with proliferative diabetic retinopathy or severe non-proliferative diabetic retinopathy, due to the increased risk of triggering vitreous haemorrhage or retinal detachment.
  • Patients with peripheral neuropathy should practise proper foot care during activity. Non-weight bearing exercise is recommended, to decrease the risk of skin breakdown, infections and joint destruction.
  • During pregnancy, avoid sports with a risk of forceful contact or falling (basketball, rugby, horseback riding, gymnastics), exercising in a supine position after the first trimester, scuba diving, and prolonged intensity workouts that increase body temperature and perspiration. Stop exercising immediately if your experience vaginal bleeding, dizziness, headache, chest pain, muscle weakness, preterm labour, decreased foetal movement, amniotic fluid leakage, calf pain or swelling and dyspnea without exertion.

What does the Sport, Exercise Medicine and Lifestyle Institute (SEMLI) offer?

SEMLI at the University of Pretoria has a team of specialist sport and exercise physicians, qualified to assess your current health status and advise you on an activity programme that will suit you.

The multi-disciplinary approach of SEMLI means you have access to a variety of healthcare professionals, including biokineticists, physiotherapists, dietitians and psychologists, as well as sport scientists who can assist you along your journey to good health.

For more information contact us at:  info@semli.co.zaor 012 484 1749.  www.up.ac.za/sport-exercise-medicine-and-lifestyle-institute/


References:

  • Schwellnus MP, Patel DN, Nossel C et al. Healthy lifestyle interventions in general practice
  • Part 4: Lifestyle and diabetes mellitus. SA Fam Pract 2009; 51(1): 19-25
  • Colberg SR, Sigal RJ, Yardley JE et al. Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39: 2065–2079
  • Padayachee C, Coombes JS. Exercise guidelines for gestational diabetes mellitus. World J Diabetes 2015; 6(8): 1033-1044

MEET OUR EXPERT


Prof Martin Schwellnus is the director of SEMLI. He is a specialist sport and exercise medicine physician who regularly consults with athletes of all levels. He is passionate about promoting safe physical activity for all, as part of a healthy lifestyle.


My art of living with diabetes

When you think of art, what comes to mind? Creative art, colourful art, abstract art, black and white art? Art is different to every person, therefore, the art of living with diabetes is different to every person living with diabetes.


There are many different arts (ways) of living with diabetes. My art of living with diabetes include lifestyle, foodstuff and sports. I ensure my sugar readings stay under control so that I can be healthy and live a long and happy life.

I keep my blood glucose levels under control by making sure that I eat the correct foods. I include a large amount of fresh vegetables and fruit and, of course, protein. My favourite proteins are chicken and pork.

By doing this, my sugar readings do not get too high. By eating correctly, I don’t need to inject myself with insulin too many times a day.

In our household, we only drink sugar-free cool drinks and water, which means less sugar and less insulin injections for me. We also eat mostly home-cooked meals, which is healthier and better for my blood glucose readings.

I play a lot of sport which keeps me active and keeps me healthy and in shape, both physically and mentally. I’m a cricketer and a golfer. It takes at least four to six hours to complete a cricket game or a round of golf. So, I always keep healthy snacks and water with me to ensure my sugar level remains stable. However, I enjoy any sport as I enjoy being out in the fresh air.

My lifestyle also includes not watching too much TV, etc. and trying not to stress too much about school and exams. Stress can affect my sugar readings too.

I realise that different people have their own art of living with diabetes. It is your choice what art you use and how you use that art.

MEET OUR EXPERT


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


Be fabulite this summer for World Diabetes Day 

With this year’s theme for World Diabetes Day being diabetes and the family, we, at Parmalat, make life a little easier with Parmalat Fabulite range of yoghurt so the whole family can enjoy.


Parmalat Fabulite is a delicious fat-free yoghurt with no added sugar. It’s ideal to include in your family’s meal plan as one of the suggested three daily servings of dairy adults should consume.

You don’t have to miss out on filling treats in your meal plan. With fewer kilojoules than regular yoghurt, Fabulite yoghurt is a guilt-free and delightful snack that can be enjoyed by health-conscious consumers.

Fabulite has been part of the Parmalat family, known for its focus on quality, since its launch almost 10 years ago (in 2008). We are very excited to be endorsed by the GI Foundation of South Africa (GIFSA) and Diabetes SA.

The Parmalat Fabulite range is available in 175g and 1kg packs (Fruit: Black Cherry and Strawberry, and Smooth: Plain and Vanilla). The 6x100g variety packs are available in the following variants: Fruit – Strawberry, Black Cherry and Kiwi, and Smooth – Grapefruit, Vanilla and Strawberry.

DID YOU KNOW?

The 2017 statistics, from the International Diabetes Federation, the World Health Organisation and the Centre for Disease Control, paint a gloomy picture. Worldwide, there were 425 million adults with diabetes and it is estimated to be 629 million by 2045. 

For this reason, a smoothie made from the Parmalat Fabulite range is ideal for people living with diabetes, and is one step of managing your diabetes.

Fabulite Breakfast Smoothie

Start the day right with a special treat, packed full nutrients and good for your waistline.

Ingredients:
½ cup Fabulite plain yoghurt
1 large frozen banana
6 large frozen strawberries
1 slice fresh ginger root
1 cup skim milk
¼ cup wheat germ

Method:
Place all the ingredients in a blender and blend until creamy.

Recipe tip

Wholegrains could be a great addition to a smoothie to make it crunchier and up the nutrition stakes. Just ensure that what you add contains no hidden sugars that will contribute to increased blood sugar. And always remember to control the serving size! 

You can consider using oats or bran when making a smoothie, but keep an eye on the product’s nutritional info, sugar and carbohydrate content; when added up it should all still be within your daily allowed totals.

Another option for a fabulous Fabulite smoothie is adding some fresh blueberries and sliced almonds to a tub of Fabulite yoghurt of your choice.

World Diabetes Day

Don’t forget to be Fabulite this summer for World Diabetes Day – 14 November! Parmalat Fabulite can be bought from any of the major retailers.


For more information please visits www.parmalat.co.za


How is diabetes a family affair?

There is a saying, “When one person feels better, the whole family situation improves”, Noy Pullen explains why this is true.


Some years ago, I interviewed Credo Mutwa, the renowned traditional practitioner. He told me that when he was newly qualified, diabetes was hardly ever diagnosed among his patients. He said with the continuing growth of what he called American cold drinks and the American lifestyle, he noticed a marked increase in diagnosis of diabetes. 

When I first started writing for Diabetes Focus, in 1996, I would ask any random group of people in any social setting how many of them had diabetes in the family. If two people put up their hands, it was unusual. During the many years we have run Diabetes South Africa’s Agents for Change courses with healthcare providers and patients, I continued to ask this question. Presently there is always more than 80% of the group raising their hands.

How does diabetes affect you?

Type 3 diabetes is a term that has been used colloquially (even though there is a medical definition for it) in the diabetes community to include all those who do not have diabetes themselves, but are living with someone who has diabetes and are affected by the condition. It has become clear that diabetes affects more than 80% of our population. Everyone’s diabetes affects family, friends, colleagues, in fact the whole community. Diabetes affects us all. 

Challenges to lifestyle changes 

Participants who attend the first Agents for Change module become motivated to change something in their life. Most of them have families to consider. Many of them would also like their families to change. For example, habits that have led to obesity amongst family members, or perhaps an inactive lifestyle. Questions are asked – How does one change the habits of others? Is it possible? 

When the participants return for the follow-up module three months later, they fill in questionnaires which indicate a mixture of success stories and challenges. Some of them managed their goals, others found it difficult to change their own habits. While others met with resistance from the family, who, for example, did not want to eat more vegetables, or give up unhealthy options. Some participants’ lives are dependent on their families who are not prepared to make special dishes for them.  

Some risk factors to developing diabetes (which affects all family members eventually):

Age – over forty

Central obesity – waist circumference of over 88 for women and over 102 for men 

Family history – heredity factors

Alcohol consumption

Smoking

Side effects of certain medication e.g. steroids, statins and others

Inactive lifestyle

Consumption of high carbohydrates meals and fast foods

Stress levels

High blood pressure and cholesterol levels

Lifestyle changes will alter this picture. Yet this knowledge is clearly not enough to facilitate these changes. None of this information is new. We hear it on the radio, we see it on screen. How can we help change come about? Do we have to get diabetes before we make changes? 

The 5 As

These are based on a counselling style called Brief Behaviour Change Counselling1.

  • Ask about individual risk situations in the family; for a family chat and request permission to speak about your concerns.

  • Alert the person to what your concerns are, and add any information that you have agreed to talk about. Ask for support for any change that comes from the discussion.

  • Assess the relevance of the situation to others in the family – risk factors, possible outcomes. Determine the readiness of each member of the family to change.

  • Assist in making plans for agreed changes, behavioural skills and confidence to succeed e.g. graphs, charts, incentives.

  • Arrange for agreed appointments e.g. with the gym or dietitian, etc.; follow-up family check-ins, community based resources.


Reference:

  • https://www.ichange4health.co.za/wp-content/uploads/2016/01/HELPING-PEOPLE-CHANGE.pdf

Please contact Noy Pullen if you would like more information: linoia@web.co.za or 072 258 7132.

AGENTS FOR CHANGE IS A DIABETES SOUTH AFRICA PROJECT

MANAGED BY NOY PULLEN

Managing your diabetes at your matric dance

One of the biggest highlights of the Grade 12 year is the matric dance. Finding the perfect dress and splurging out on nails, hair and make-up and celebrating the last year of high school. Shelly Schutte, a Type 1 diabetes patient, tells us how she made the most of hers.


Shelly Schutte (28) lives in Fish Hoek and has had Type 1 diabetes for 18 years.

My matric dance

Whether you have diabetes or not, your matric dance is the perfect opportunity to treat yo-self. I matriculated almost 10 years ago now and overall, my matric dance is a night I remember with a great deal of fondness.

It took place at the Kelvin Grove Ballroom, in Cape Town, which is a stunning location. During the run-up to the event, we went to ballroom dance classes in the school sports hall. We had great fun attempting the Boogie to the dulcet tones of Katy Perry.

After the dance, we headed out to the club Velvet, where the “official after-party” was being held. It was honestly such a palaver at first. The club was too full and we ended up waiting on the pavement for almost half an hour. Not the glamorous night of dancing and partying we had been imagining!

Luckily, but somewhat embarrassingly, a friend’s dad, who had been our transport eventually came to the rescue. He had some words with the bouncer and got us in.

Although the after-party has much hype in the run-up to the event, it paled in comparison to the brilliant fun that was the dance itself. We happily headed home a little after 3am.

Six am saw us at the local beach for the traditional matric breakfast, with many pale-skinned, dark-eyed students wandering into the restaurant at various times. Some of whom had apparently slept on the beach itself.

How to enjoy your matric dance

As a Type 1 diabetic, events like a matric dance can often come with an extra layer of stress. I often wish I could just have a diabetes timeout every now and then. A chance to a have an evening completely free from the responsibility that is being your own pancreas.

Alas, science has yet to gift us with a cure or a timeout card. However, it is completely possible for you, as a diabetic, to have a matric dance experience that is as wonderful and carefree as every other person in the grade. To this end, I offer a few pieces of advice:

  1. Be safe: face your number

We have a wonderful saying at the DSA diabetes camps: face your number. No matter how high or low your glucose level is. Once you know, you can fix it. This is especially the case on nights like the matric dance when it’s tempting to ignore the fact that you have diabetes. Test regularly throughout the evening.

Whenever I go out and know I will be moving from place to place or drinking alcohol, I set alarms on my phone to check my blood glucose or scan my Freestyle Libre every hour. Time flies by when you’re having fun and especially if you are dancing a lot, but remember dancing can make your blood glucose drop very rapidly.

Nothing is more of a mood-killer than crying in the bathroom because you’re recovering from a low. Test yourself so you can prevent extreme highs and lows throughout the evening and the associated complications.

  1. Appoint a dia-buddy

This is especially important if you are planning to drink alcohol. It is essential that you have a ‘dia-buddy’ – a close friend who knows exactly what to do if you experience a low or high. This person should also have your ICE details, in case you need medical help.

  1. Maintain your normal eating patterns on the night

Keeping diabetes under control is all about routine and predictability. Although the temptation to let loose for a night is probably strong, you will enjoy yourself way more if your blood glucose is not yo-yoing. Keep to your normal eating patterns, count your carbs and be careful with your insulin doses.

  1. Maintain healthy exercise and eating routines in the months before the dance

I have always struggled to keep my BMI in the normal range. Whereas my non-diabetic friends and family members seem to be able to be able to eat whatever they want. I simply was not gifted with a similar metabolism.

In the months before my dance, I was constantly fighting the urge to crash diet to lose those extra 3kg. If there’s anything I’ve learned since then, it’s that a steady routine of exercise and a predictable diet is the biggest gift you can give yourself as a T1 diabetic.

The incredible, stabilising after-effects of a workout at the gym can last for more than 24 hours, which can really transform my whole day into a calmer experience. Also, somehow, a salad always tastes better when I’m eating it after a workout. Exercise at least three times a week, adopt a carb-controlled diet and your body will look after itself in so many ways.

  1. Enjoy yourself

Most of all, you must enjoy yourself! Make beautiful memories and always remember that your diabetes does not define you…but you are braver, stronger and more brilliant because of it.

MEET OUR EXPERT


Shelly Schutte is the youth representative on the board of Diabetes South Africa. She loves spreading awareness and showing the world that she lives an amazing life with diabetes She is currently the Head of Department at a school for children with learning barriers.


Type 1.5 diabetes – a new diagnosis?

Dr Angela Murphy tells us about Type 1.5 diabetes, commonly known as latent autoimmune diabetes.


Mrs JM came to see me about her new diagnosis of Type 1.5 diabetes. She was concerned that she had never heard of this before and that it may represent a more dangerous type of diabetes. She specifically wanted to know if she was receiving the correct treatment. To be able to explain this diagnosis, let us go back to the very beginning.

Back to the beginning

Diabetes mellitus, a condition where blood glocose is high, has been described for thousands of years. It was initially diagnosed by testing for the sweet (mellitus) taste of urine.

Over time it became clear that not all diabetes is the same and so began attempts to classify the various types. This classification has changed over the years and we now categorise diabetes according to the cause of the diabetes. The four main types are:

  • Type 1

In this type, there is significant destruction of the insulin producing beta cells of the pancreas. This is usually due to an autoimmune process that attacks these cells but may occur without any sign of autoantibodies. The latter variant has a very strong family history and is more common in African and Asian populations.

  • Type 2

This is the most common form of diabetes occurring in 90-95% of cases. Usually there is a background of insulin resistance and then progressive loss in insulin secretion from the beta cells.

  • Type 3

This group has over several major subtypes with over 40 individual causes described. The group includes the maturity onset diabetes of the young (MODY) conditions which are single gene mutations; pancreatic diseases such as cystic fibrosis; endocrine disorders; side effects of drugs, such as HIV treatment or other rare genetic conditions.

  • Type 4

By definition, this is hyperglycaemia (high blood glucose) first detected in the second or third trimester of pregnancy. This type is better known as gestational diabetes.

LADA

As you can see, there is no Type 1.5 diabetes. The more accepted term for this type of diabetes is latent autoimmune diabetes in adults (LADA). LADA is a condition that occurs in adults between the ages of 30-50 years. Like Type 1 diabetes, there is autoimmune damage to the pancreatic beta cells. However, this seems to be at a much slower rate than in the young, typical Type 1 diabetes patient. Hence, the term latent.

Why is LADA called Type 1.5 diabetes?

LADA has features from both Type 1 and Type 2 diabetes, so it seems reasonable to call it Type 1.5. However, the cause of LADA is autoimmune beta cell destruction. So, for that reason it must be considered as a subtype of Type 1 diabetes.

We should always consider a diagnosis of LADA in a normal weight patient who has reasonable glucose control, using lifestyle interventions and/or oral medication only. It would be reasonable to test for LADA in such a patient.

LADA/Type 1.5 diabetes symptoms

Initially, patients may experience non-specific fatigue, decrease in concentration and hunger pangs after eating. More typical symptoms, such as weight loss, thirst and blurred vision, develop gradually over months, sometimes even years. Patients are often of normal weight and usually there is no family history of diabetes. They may have another autoimmune condition, such as thyroiditis, rheumatoid arthritis or coeliac disease. The patient is advised on a healthy lifestyle and usually started on oral medication to control glucose, which seems to help for a period. Ultimately, there will always come a point when insulin needs to be initiated.

Confirmation tests for LADA

The only way LADA can be confirmed is to do specific tests to look for the antibodies causing the damage, specifically the glutamic acid decarboxylase (GAD) antibody. A C-peptide level test can also be done to measure how much insulin the pancreas is still producing.

These are not routinely tested and it can be argued that doing these tests, does not necessarily change management. If the patient is having regular check-ups, including HbA1c measurement and testing glucose regularly at home, any deterioration in the diabetes will be detected. The decision to initiate insulin can then be made timeously.

However, we should consider the advantages of doing the antibody testing and establishing if LADA is present as seen below.

Protecting beta cell function

Some of the oral medications available to treat high blood glucose work by stimulating the beta cells of the pancreas to increase their insulin production.

In LADA, this may have the negative effect of speeding up the deterioration of the beta cell and shortening the latent period: patients would need to start insulin sooner.

Metformin is the best oral diabetic medication to begin with as it has no pancreatic action. Rather, metformin decreases the production of glucose in the liver.

Preserving beta cell function

There is evidence that early insulin treatment may assist the beta cells so that they can continue producing insulin for longer periods. A Japanese study looked at 4000 patients with LADA and found that those treated with early insulin took longer to be fully dependent on insulin compared to those patients on oral medications.

Prevention of ketoacidosis

Ketones are formed by the body when fat is used for fuel. The body does this when there is not enough insulin to move glucose out of the blood stream and into the working cells of the body. Unfortunately, these ketones cause the body to become acidotic which is very dangerous.

Patients with LADA could be made aware that a persistent increase in their blood glucose might be heralding the time to start insulin. In this way, there would be less delay and thus, less chance of developing ketones.

Table 1 – Comparison of Type 1 and Type 2 diabetes

DIABETES ADULT ONSET AUTOIMMUNE DIABETES TYPE 2
Type 1 Latent Autoimmune
Autoantibodies YES YES NO NO
Insulin required at diagnosis YES NO NO VARIABLE

MEET OUR EXPERT


Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence as well as a specialist with the Centre for Diabetes Excellence (CDE) network.


LesDaChef – living with diabetes

Five months ago, Lesego Semenya, aka LesDaChef, was diagnosed with Type 1 diabetes. We caught up with the 36-year-old chef to see if his love for food has changed.


Lesego Semenya (36) stays in Meredale, JHB south, Gauteng.

Who is LesDaChef?

I’m a former process engineer. I used to wear a tie and suit every day for six years before the madness hit me. After I quit the corporate scene I travelled around SA for a year. Once I got tired of that I enrolled at Prue Leith Chef’s Academy in June 2009. I studied towards a Grande Diploma in Food and Wine (basically I’m a chef with an expensive signed cardboard that says I am).

Whilst at the academy, I entered a World Cup Pie Designing competition run by the British High Commission. I won; the prize was a trip to London to cook in one of the best restaurants in the UK, Corrigans Mayfair.

I’ve cooked for TV shows, for celebrities, for politicians and high profile people. I’ve worked in restaurants, game lodges, as a private chef and in catering.

Tell us more about your diagnosis

I was diagnosed with Type 1 diabetes in April 2018, a few days after my birthday. My symptoms included fatigue, excessive craving of frozen food items, unquenchable thirst, running to the loo uncontrollably, struggling with sleep and sunken eyes.

I went to the pharmacy to get a vitamin B shot, thinking it was just tiredness from work. The pharmacist on duty told me to first do a blood glucose test.

After a few tests, the nurse at the pharmacy immediately told me to head to hospital. I was admitted for two weeks.

In your blog, you speak about not even knowing what type of diabetes your father had. Please explain.

Even though we knew my dad was diabetic, we kids didn’t know the type he had or what it meant. (He has Type 1 diabetes). As kids, you don’t really see any symptoms of diabetes in your parents. Especially, if they look after themselves well. Without obvious symptoms, we assumed it was a simple thing. We just knew the diet we had at home was different from our friends and relatives but we just thought it was because our father was a health freak. My dad didn’t really go into the details of what his diabetes was about.

Usually Type 1 is diagnosed in childhood. How did the doctors explain your diagnosis in adulthood?

Type 1 can happen at any stage of a person’s life. Internationally, doctors still don’t know what triggers it. My dad only got diagnosed with Type 1 in his 30s as well, like myself.

Are you aware of Type 1.5 diabetes?

No, I’ve only ever heard of Type 1 and Type 2.

What is Type 1.5 diabetes?

Type 1 diabetes diagnosed in adults over 30 may be Latent Autoimmune Diabetes in Adults (LADA), sometimes known as Type 1.5 diabetes. LADA is sometimes referred to as Type 1.5 diabetes. This is not an official term but it does illustrate the fact that LADA is a form of Type 1 diabetes that shares some characteristics with Type 2 diabetes. As a form of Type 1 diabetes, LADA is an autoimmune disease in which the body’s immune system attacks and kills off insulin producing cells. The reasons why LADA can often be mistaken for Type 2 diabetes is it develops over a longer period of time than Type 1 diabetes in children or younger adults. Whereas Type 1 diabetes in children tends to develop quickly, sometimes within the space of days, LADA develops more slowly, sometimes over a period of years. The slower onset of diabetes symptoms being presented in people over 35 years may lead a GP to initially diagnose a case of LADA as Type 2 diabetes. (Source: www.diabetes.co.uk)  Look out for our summer issue where we cover Type 1.5 in much more detail.

What insulin are you on?

The insulin I’m on at the moment is Insuman Comb 30/70. I also take Amlodipine (for high blood pressure) and Simvastatin (for high cholestrol).

You bought a Contour Plus glucose monitor? Explain why?

I was given a machine by the hospital, one made by On Call. I used it for the first 30 days after my diagnosis. Though, finding test strips for the machine became a problem. I then purchased a Contour Plus machine. It’s smaller and slicker then the standard machines out there and the strips are available at most pharmacies. It syncs with my phone and has a brilliant app that helps track your nutrient intake, your exercise routine and your sugar levels. This helps in keeping track of what foods spike your sugar levels and how you react to different things. It saves all the data to the cloud so even if you lose your phone your data is always available.

How have you been managing since your diagnosis?

My daily readings have been consistent and steady. There has been one high spike and one extremely low but these were linked to being busy with work and not being vigilant with my water intake and not eating regular small portions. Other than that, I’ve been coping well.

I’ve also slowed down my routine. I have stopped working on Mondays. I schedule my work and my life with more focus on working smart rather than working hard.

Do you find testing and injecting a hassle?

Not really. When I’m catering an outside event, or know I’ll be away from my house for the whole day, I take my insulin pen and test machine along. It’s a quick process and it’s become part of life now. I also am not shy about it. All my friends know and I take my shot and test in front of them…and explain what it’s all about if it’s the first time they see it.

How has your diet changed?

  • I avoid all white maize. So, no mealie meal for me.
  • I avoid processed sugar. Although, I do still taste desserts and cakes now and then but it will only be a teaspoon-sized taste.
  • If I drink alcohol, it’s only spirits or red wine only drink with one or two glasses max and always followed up by a bottle of water. I avoid any ciders, beers or cocktails.
  • Three times a day, I have fruit and never all at once. I avoid bananas, grapes and dried fruits. The less ripe the fruit the better.
  • I drink about three litres of water a day.
  • When I can, I source low-GI breads, -rice, -biscuits and -spices.
  • I only eat sugar-free and fat-free yoghurt.
  • Every morning I try have Mabele, if not then I have oats. The fibre and low-GI quality of these two cereals is good for diabetes control.
  • I watch the amount of salt I consume. Pre-mixed spice blends, like BBQ spice, are a no-no.
  • Condiments and overly oily food are also a no.
  • I don’t eat processed meats like sausages, sandwich ham, etc.
  • I have a love/hate relationship with sweeteners. I’ve yet to find one that doesn’t have an after taste. During my research, I’ve learned a few of these sweeteners aren’t good for you. So, I stay clear.

List the foods that you’ve found spike your blood sugar

  • Very sweet/low fibre fruit, such as strawberries, bananas and watermelon.
  • Popcorn and white starches, like crackers, chips, white bread and white rice.

Since getting diabetes, has it changed your mind-set of making food?

It has changed my mind about needles! Before, I was freaked out by needles and blood. Now I don’t even flinch at them. When I wake up each morning I drink water, prick my finger, do a blood glucose level test and then inject my insulin before having breakfast. It’s a daily routine, it must happen. If I skip breakfast, my sugar levels will plummet to critical levels.

I’ve had to get my mind into the concept of having regular meals throughout the day. Even when I’m not hungry I still eat a fruit or snack (a spoon of peanut butter or crackers). It has also affected how long I stay out if I go out. I can’t have dinner too late at night.

Something I’ve tried to explain over and over to deaf ears is that I’m a chef and the food I post on social media is work and not my lunch. Then people tag me in green, unappetising health-freak posts! I understand it comes from a good place but the information overload is real and sometimes some of the facts on these health-freak sites are incorrect. 

Have you been inspired to make tasty diabetic dishes?

Yes. I’ve always been health conscious in terms of the type of produce I use. Fresh and seasonal has always been a mantra for me but now I’ve become even more vigilant about ingredients and products I use.

I have been playing around with diabetic friendly recipes and dishes. More to keep myself away from the usual bland and boring stuff people normally associate with diabetic-friendly diets. I’ve been asked to put together a diabetes focused cookbook, which will focus on African taste.

Are you the designated cook in your household?

I live alone so I have no choice but when my girlfriend is around, we take turns.

What’s next on the table?

Currently, I do private events and functions. I also own a culinary business that does monthly classes and monthly chef’s table. Soon, I will be releasing my own product range. My first cookbook is coming out in October and there is a TV show in the pipeline for later this year.

MEET OUR EDITOR


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


Understanding the steps to diabetes self-management

We explore ways to help you learn and implement self-management practices.


The diagnosis of diabetes

If you or a loved one have just been diagnosed with diabetes, you may be feeling an overwhelming amount of mixed emotions. Diabetes is a complex and serious condition, and living with it every day can be challenging1. Part of that challenge is due to the fact that the management of diabetes will largely rest in your hands. This can be daunting. Be kind to yourself and remember that small positive steps every day will make a difference in the long run.

Getting started with self-management

Ideally, on diagnosis, you should have access to a team of healthcare professionals. This may include the treating doctor, a diabetes educator or coach, and possibly a dietitian.

However, in many cases you might only have access to a doctor and your time spent with him or her in consultation will be limited.

In the beginning, you may feel overloaded with information about what to eat, how much to exercise, when to take your medicine, how to test as well as confusing terminology, such as HbA1c, hyperglycaemia, hypoglycaemia, glycaemic control etc.

To help make sense of it all, diabetes educators have developed some key areas to focus on1:

  1. Healthy eating

Having diabetes does not mean you must give up your favourite foods. Over time and through experience, you’ll learn how the foods you eat affect your blood sugar. You should eat regular meals and make food choices that will help control your diabetes better1.

Work with a dietitian or diabetes educator to develop a healthy, balanced eating plan that suits your lifestyle. Remember that it is okay to treat yourself once in a while. You can also visit the Accu-Chek website and download the Accu-Chek portion plate which will give you some practical tips on healthy eating.

  1. Being active

Guidelines for the management of Type 2 diabetes refer to studies that have proven that regular physical activity significantly improves blood sugar control, reduces cardiovascular risk factors, and may reduce chronic medication dosages2. Regular physical activity may also improve symptoms of depression and improve health-related quality of life2. Try to include a combination of cardio and resistance training into your weekly exercise routine.

  1. Self-monitoring of blood glucose (SMBG)

The International Diabetes Federation (IDF) recommends SMBG as an effective means for patients with diabetes to understand more about their condition and the influence of events – such as exercise, stress, food and medication – on blood sugar levels3.

However, for SMBG to be effective, it’s recommended that you practice structured testing using a tool, such as the Accu-Chek 360 3-Day Profile Tool3 which can be found on www.accu-chek.co.za

Structured testing is testing at the right times, in the right situations, and frequently enough to generate useful information3. Always agree with your doctor or diabetes educator what your individual structured SMBG testing plan is.

Another aspect you should discuss with your doctor will be your target range for your blood sugar levels. In the beginning, understanding this range and what is considered out of range may be confusing, so you may want to make use of a meter such as the Accu-Chek Instant Meter which offers a support tool called the target range indicator (TRI)4.

A study done on the TRI showed that 94% of study participants were able to easily interpret their blood sugar values through the use of the target range indicator4. Furthermore, 94% felt that the support tool will help them discuss their blood sugar values with their doctor4.

  1. Taking medication

You may need to take medication to help keep your blood sugar (glucose) level steady. Diabetes can increase your risk for other health conditions, such as heart or kidney related problems, so you may need to take medicine to help with those too1.

  1. Problem solving

When you have diabetes, you learn to plan ahead to be sure you maintain blood sugar levels as much as possible within your target range goals – not too high, not too low.

As we know, things don’t always go according to plan and a stressful day at the office or an unexpected illness can send your blood sugar in the wrong direction. Days like this will happen from time to time. Here are some tips to cope1:

  • Don’t beat yourself up – managing your diabetes doesn’t mean being perfect.
  • Analyse your day and think about what was different and learn from it.
  • Discuss possible solutions. This can be with your doctor, your diabetes educator or even a face-to-face or online diabetes support group. Try joining some of the online diabetes communities out there, such as the Accu-Chek Facebook page which has over 148 000 members. You can join the conversation at AccuChekSubSahara.

Vaping and diabetes

Electronic cigarette (e-cigarette) or vaping is increasing worldwide. Their use is highly controversial from a scientific, political, financial, and psychological perspective. Louise Johnson examines these controversies.


Smoking

Tobacco smoking is a global pandemic affecting an estimated 1,2 billion people which poses a substantial health burden and cost. With nearly six million tobacco-related deaths annually, smoking is the single most important cause of avoidable premature death in the world7.

Tobacco-related death is mainly caused by lung cancer, coronary heart disease (disease of heart vessels), chronic obstructive pulmonary disease (emphysema), and stroke.

The research is clear on traditional cigarettes. Smoking can have a major impact on your diabetes risk. The Centre for Disease Control and Prevention (CDC) reported that tobacco smokers are 30-40% more likely to develop Type 2 diabetes. In addition, people with diabetes who smoke have an increased risk of complications.

Epidemiologic studies strongly support the assertion that cigarette smoking in both men and women increases the incidence of heart attacks, fatal coronary heart disease, and death. Even low tar and smokeless tobacco have been shown to increase the risk of cardiovascular events in comparison to non-smokers5.

Passive smoking with a smoke exposure about one-hundredth that of active cigarette smoking is associated with approximately 30% increase in risk of coronary artery disease compared with an 80% increase in active smokers4.

Cigarette smoking predisposes the individual to several different clinical atherosclerotic syndromes, including stable angina, acute coronary syndrome (heart attack), sudden death, and stroke. Aorta and peripheral atherosclerosis (plaque in blood vessels causing narrowing) are also increased and lead to intermittent claudication (leg pain when walking) and abdominal aortic aneurysm2.

Differences between smoking and vaping (e-cigarette)

Traditional cigarette smoking contains: nicotine but also tar; carbon monoxide; benzene; formaldehyde; lead; methanol; hydrogen; cyanide; butane; ammonia; chloroform; acetone; nitrosamines; aluminium; carbon dioxide; cadmium; arsenic; ethanol; vinyl chloride; radon; and 3 500 more chemicals and 50 more known carcinogenic substances that cause cancer.

The e-cigarette contains nicotine; propylene glycol (found in food and some medication used as a carry vehicle); glycerine, and food flavouring.

What are the effects of nicotine?

Nicotine stimulates specific receptors in the brain that produce both euphoria and a sedative effect. Individuals who have emotional dysfunction or attention deficits are more likely to start smoking and less likely to quit.

Nicotine is a sympathomimetic drug that releases catecholamine (adrenaline and noradrenaline). This causes a rise in blood pressure, heart rate and an increase in cardiac contractility. It also increases heart vessel constriction and can cause transient ischemia.

After smoking, nicotine raises blood pressure and pulse. It has a deleterious effect on insulin sensitivity in the fact that it decreases insulin sensitivity and can cause or aggravate diabetes.

It has a negative effect on the endothelial (inner lining) of the blood vessels. Increased cardiovascular effects have not been a problem when using nicotine alone and nicotine per se does not cause cancer1.

A suspected adverse effect on reproductive system causes foetal neuroteratogenesis (abnormal babies should the mother smoke or vape during pregnancy).

Though, nicotine has the beneficial effect of increasing attention, concentration, and lifting the mood. Some of these properties cause the addictiveness of nicotine3.

E-cigarette: What about the clinical evidence?

In a pilot study, it was shown for the first time that the smoking habits of smokers changed after using the e-cigarette. This study used 40 smokers that did not want to quit. The results showed significant reduction in smoking and abstinence without withdrawal symptoms.

The overall quit rate was 22%. Moreover, a 50% reduction in smoking was observed. The end results showed an overall 88% decline in the number of cigarettes smoked per day.

The only negative aspect was the initial difficulty in working the e-cigarette. It took considerable training for known smokers to manage the e-cigarette effectively to be satisfied with the results of vaping6.

This study is of significant interest since none of the participants were interested in quitting. This fact needs some more explanation.

Some of the possible answers to this question may be the following options. The e-cigarette replaces the ritual of smoking gestures, the opportunity to reduce a bad smell, to reduce the cost of smoking, and the perception of general well-being might have been responsible for their switching and quitting.

What does vaping do to blood glucose?

The nicotine in vaping can cause a raise in blood glucose due to the effect of increased insulin resistance. Diabetics using insulin may need more insulin to control blood glucose effectively and Type 2 diabetics on tablet medication may need an increase in dosage to prevent the raise in HbA1c (average three-month glucose test).

Conclusive thoughts

  • If you don’t smoke, don’t start vaping since the flavoured nicotine can be addictive.
  • If you do smoke, switch over to vaping to reduce all the other disease causing entities.
  • Remember moderation in all things.
  • An e-cigarette is a good device for quitting and more environmental friendly on people and animals than the traditional cigarette smoke.
  • More studies are still needed on long-term outcomes.

References:

  1. BenowitzNL (2009) ‘Pharmacology of nicotine: addiction, smoking induced disease, and therapeutics.’ Ann Rev Pharmacol. Toxicol. 49 p57-71
  2. Black HR (1995) ‘ Smoking and cardiovascular disease.’ In: Laragh JH, Brenner Bm editors. Hypertension, p2621-47
  3. Gehricke JH, Loughlin SE, Whalen CK et. al. (2007) ‘Smoking to self-medicate attentional and emotional dysfunctions.’ Nicotine Tab. Res, 9 (Suppl4) S523-S536
  4. Law MR, Morris JK, Wald NJ (1997) ‘Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence.’ BMJ, 315 p973-80
  5. Negri E, Franzosi MG, La Vecchia C et. al. (1993) ‘Tar yield of cigarettes and risk of acute myocardial infarction: GISSI-EFIRM Investigators.’ BMJ ,306 p1567-70
  6. Polosa R, Caponnetto P, Morjaria JB et. al. (2011) ‘Effect of an electronic nicotine delivering device (e-cigarette) on smoking cessation and reduction: a prospective pilot study.’ BMC Public Health, 11 p786
  7. World Health Organization (WHO) (2011) ‘Tobacco fact sheet N339’ Geneve, Switzerland.

Dr Louise Loot

MEET OUR 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.


Photo credit: www.blacknote.com