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.

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.