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.


Meet your inner king, hero and court jester

Noy Pullen explains how you can access your inner king, hero and jester when tackling the management of your diabetes.


Motivation can be defined as one’s direction to behaviour, or what causes a person to want to repeat a behaviour and vice versa1. Motivation is a buzzword bombarding the modern individual. Back in the day, our parents and, certainly our grandparents, would never have been exposed to this idea of ‘being motivated’.

Words have their own magic living within them, so exploring a few of these words in popular culture reveal their own wisdom.

Motivation – has to do with ‘move’ and ‘motive’.

Change – would have been what was left over from a purchase.

Coach – in the past, a coach was a conveyance that took people to their chosen destination.

Creative – using an adjective as a noun adds to its power. Juggling these letters around to form the word reactive, gives you the opposite of what a creative implies.

Influencer – tries to get ‘in’ to you from the outside.


Looking throughout history

Whenever we hear the words ‘Once upon a time…’, we know we can settle down to hear a story – a story of heroism, wisdom and adventure.

The king

The regal king or ukumnkani led his people through times of plenty and famine, through war and peace, and solved problems brought to his throne by his subjects. People relied on his wisdom and knowledge of the inner and outer world.

The heroes

Then, there were the heroes (amaqhawe) doing the bidding for the king, bravely facing monsters and other enemies to bring peace and well-being to the kingdom.

The king (or head) knew about everything, but did not do anything; the hero (or limbs) fought for the king and for the stability and health of the whole country. But without the heart man in the centre, neither of these characters could function.

The jester

The fool (jester), wizard or iphakathi (the creative centre of the people) not only played jokes on the king but was his closest advisor. “The fool had the right to sit at table with his master and say whatever came into his head. He could be juggler, confidant, scapegoat, prophet, and counsellor all in one. Entertaining, but also offering criticism and advice couched in with…Laughter frequently turns the scale in matters of great importance. The jester’s detached stance allows him to also take the side of the victim, to curb the excesses of the system without ever trying to overthrow it. His purpose is not to replace one system with another, but to free us from the fetters of all systems2.”


What has this got to do with diabetes?

The good news is that we now each have access to our inner king, hero and jester. Look at any self-help category in a bookstore for irrefutable evidence that we have discovered these beings within us in this modern time. It is called identity.

A manual called The Diabetes Toolkit7, written by Buyelwa Majikela-Dlangamandla, is filled with simple but good information of all aspects of diabetes, for your inner king to come to terms with diabetes.

Two other books come to mind: The Obstacle is the Way3 is one where Ryan Holiday using techniques of the jester explores the ancient art of turning your tragedy into a strategy. Then, the charming book Be a Hero- Lessons for Living a Heroic Life4, by Alan Knott-Craig and Craig Rivett, uses delightful playful visuals, in the form of rules, guides, cartoons, quotes, powerful daily exercises, and useful lists to help you become creative, rather than reactive (by knocking yourself against the same old brick wall). Both these books can be read in an afternoon but their effects will last a lifetime.

Thanks to Friedrich Nietzsche, you will also find various comics which call forth the hero, such as Clark Kent becoming Superman (Übermensch). Superman knows everything, can do anything, even recognising his own vulnerabilities and, more importantly, senses through his heart when a fellow being is in difficulty and does only what is needed in that situation. He does not blame or question, or judge. He has pulled his own inner kingdom together. He, like the jester, helps his community out of the danger and seeks to free us ‘from the fetters of all systems’2.

Music of healing

Unfortunately, people – diabetes educators and many others – who want to assist those living with diabetes, out of the noblest of intentions and prior official training, treat the patient as though he/she needs to listen to an outer king, who gives him orders. Then, they expect him/her to act like a hero, vanquishing the dragon.

If only the diabetes healthcare provider or loved one could play their own court jester, and, in finding the patient’s own court jester, then their combined creative energy would create the wisest and most effective ways of meeting the immediate situation.

No wonder the fate of the entire nation was put in the hand of the jester. Everyones’ lives depended on it. The sense of humour can make the most desperate situation bearable, where wisdom and action meet in the heart.

Creative people know they are all jesters. What they do with paint, or music, or on the stage is not called ‘play’ for nothing. If the diabetes team players could find their way into an orchestra of ‘harmonious instruments’, they, together with the patient, would create the music of healing.

Identity is a journey 

In a recent interview, Glen Phillips, a musician, who recently suffered personal tragedy, characterised his own journey by saying, “I’m not sure if I’m entirely post-sabotage yet. It’s a process and old habits are hard to break…Part of getting out of self-sabotage is just avoiding the territory where I know I’m conflicted, so the more I concentrate on service and art, the better life gets. I can tour enough to make a living, and the less I stress about the business side of things, the more things seem to open up creatively…I think we could benefit more if there was some better encouragement for just being a citizen, a helper and healer, a good friend, a member of a community. I realise, there’s a power to money and success that can make things move in the world, but for most of us the work is less abstract, more about the people we touch and the love we give…If you feel entitled to some kind of immortality, it kind of sucks the passion out of making the most of the few days you have. The living days are where the gold is.6

Soweto-born, Elo Zar, another creative says one of her biggest struggles was, “Getting over myself. Self does not play a role when serving people and I’d like to do that – serve. Self-love is a struggle for all of us. I believe we ought to be reminded and supported to be different and to stay different… Identity is, after all, a journey5.

Tim Pullen, another creative in the musical and artistic realm, has this message for heroes like himself, who carry out the task of living with diabetes day to day: “It’s your diabetes. It’s your life. it’s your freedom. Enjoy it7.”

Track your progress each day 

Remember an artist, musician and sportsperson improves by playing often and by practising their chosen discipline regularly. They form new habits towards excellence.

To liberate your inner king, train your thinking

  • Think of a very simple object, like a matchstick, every day for five minutes. Just building up a logical picture of the object for a few minutes.
  • Keep a daily journal and review what has happened on that day, jotting down patterns and rhythms you noticed about yourself. Mark it with a blue dot.
  • Read biographies.

To liberate your inner hero, enliven your will

  • Do something no one has asked you to do, at the same time every day e.g. moving your keys from one pocket to another at noon.
  • Keep a diary of the main obstacle of the day, where you felt unfairly attacked, or given bad news, or accused of something which you had to defend, etc., and write it down. Mark with a red dot.
  • Watch biographies.

To liberate your inner jester, warm your heart

  • Keep a diary each day of extreme emotional outbursts from either yourself or others. Look for the trigger and write it down.
  • Keep a diary of your obstacle of the day (see above). Try to find what triggered your reaction – fear, hatred, doubt, jealousy, pain, boredom – and mark it with a yellow dot.
  • Get into a habit of asking people about their life stories in casual conversation. You will be fascinated no matter how difficult your relationship might be.

Reflect, assess and share

  • Compare what you wrote in your diary next to the blue, red and yellow dots over a period of a week. Look for clues of how to make some changes that you feel would help you find a new creative step. Let your inner king and hero know what you have discovered and have a conversation with them.
  • Write down what the king thinks. Add to this, what the hero wants to do about the situation and write down how you, the jester, feel. Come to some agreement and try it out.
  • Repeat this as a life-long practice in various creative ways.
  • Have fun and let people know how your journey is progressing. You never know you may be the hatching your own best-seller.

References

  1. Maehr, Martin L; Mayer, Heather (1997). ‘Understanding Motivation and Schooling: Where We’ve Been, Where We Are, and Where We Need to Go’. Educational Psychology Review. 9 (44
  2. http://www.press.uchicago.edu/Misc/Chicago/640914.html
  3. Holiday Ryan (2015) ‘The Obstacle is the Way -The ancient art of turning adversity into advantage’.  Profile Books
  4. Knott-Craig Alan; Craig Rivett (2015). ‘Be a Hero – lessons for living a heroic life.’ Fevertree Publications
  5. City Press13 August 2017 Phumlani S Langa
  6. http://www.brucedennill.co.za/music-interview-glen-phillips-appetite-empathy-fillip-integrity/
  7. Majikela-Dlangamandla Buyelwa (2016). ‘The Diabetes Toolkit’ manual. P22

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