Tag: Spring 2023 Treatment

hospitalisation

Tips for pre- and post-hospitalisation

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Margie Young shares easy tips to help manage your pre- and post-hospitalisation.

Tips to manage your elective procedure hospitalisation

  • Confirm your surgery date
  • Confirm your authorisation with your medical aid.
  • Confirm your hospital pre-admission. Be sure to disclose that you have diabetes so that you will be one of the first on the list.
  • Confirm what medication you should continue or discontinue with.
  • Be prepared. Get your running around done ahead of time. Pack your bags, get your chronic meds and ensure you have extra test strips.
  • Focus on you, closer to surgery. Guard yourself, keep to immediate family and stay away from big gatherings. Hydrate, eat nutritiously and be compliant with your medication. Get good quality sleep.
  • If you tend to have hypos, have your own rescue remedy (juice, Coke, Super C’s).

Tips to manage an emergency hospitalisation

  • Be prepared for any emergency. This includes: an ICE tag or card with your eemergency contact details and a list of your medication and doses (even those meds that nobody knows about, like garlic tablets, or PDE5 inhibitors for erectile dysfunction).

Recovery time tips

IN HOSPITAL

  • Follow instructions.
  • Day 1 – 4 are considered the most critical days.
  • Remember to hydrate. Avoid sugary drinks.
  • Get moving – if possible. Major surgery usually recommends staying in bed for 24 – 48hrs post-surgery.
  • Good hygiene. Brushing teeth is a must.
  • Nap and sleep as needed.

AT HOME

  • Follow instructions.
  • Take your medication as prescribed.
  • Do not do too much too soon.
  • Nutrition is vital. Get enough of the right stuff to eat and drink.
  • Get moving. Move slowly if you must. Do the rehab exercises prescribed.
  • Good hygiene. To avoid unnecessary delay in wound healing.
  • Rest

Glucose management

Glucose levels will be variable, often due to many of the factors that affect your blood glucose, so be sure to test more frequently and adjust your insulin accordingly as medications alter the effectiveness of the insulin.

Margie Young is an insulin pump specialist at Medtronic. She has been involved in the diabetes arena for the better part of 20 years.

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Margie Young is an insulin pump specialist at Medtronic. She has been involved in the diabetes arena for the better part of 20 years.

bone health

Bone health for people living with diabetes

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It’s common to hear about the relationship between diabetes and the eyes, kidneys and feet. But, did you know that diabetes can also affect your bone health?

People living with diabetes face a multitude of challenges in managing their condition and bone health shouldn’t be overlooked. Understanding the impact of poor bone health to people living with diabetes is crucial in achieving overall well-being and quality of life.

Bones plays an important role in your overall health, from being a protective shield to delicate body parts to providing structure and support. Bones need to be strong yet light enough to keep you moving. You depend on your bones for many aspects of your life, from the visible (walking and dressing) to the invisible (serving as storehouses for essential nutrients and minerals that the body needs).

Bone modelling and remodelling

Like all of your body parts, bones are active tissue, which means they are actively changing throughout your lifetime. When a child is born, they have few bones that assist in giving them shape (structure) and support, and as they grow the new bones are formed from the cartilage. Every milestone a child achieves results in stronger bones and muscles that enable them to grow in height and become stronger.

There are two bone-making processes involved in the development, growth and shaping of bones  as well as the continuous renewal of bone tissue throughout life.

Bone modelling

During childhood and adolescence, new bone tissue is formed and broken down at different sites throughout the body, allowing bones to grow in size and shape. The process is called bone modelling and continues until age 25 – 30 when the child reaches adulthood.

In some cases the process can be interrupted by health conditions such as Type 1 diabetes, which means people living with Type 1 diabetes might not have full bone maturity .

Bone remodelling

During adulthood, bone remodelling involves the removal and replacement of bone at the same sites to:

  • Replace old bone that can become brittle.
  • Repair small cracks or deformation.
  • Release calcium and phosphorus into the circulation when need arises (dietary inadequacy, pregnancy, lactation).

Figure 1 bone growth[1]

Diabetes and bone health

For people living with Type 1 diabetes, the main concern is bone fragility (ability of bones to break easily at low impact). According of The Lancet Journal of Diabetes and Endocrinology, bone fragility is a recognised complication of Type 1 diabetes. People with Type 1 diabetes have lower bone mineral density (BMD) and greater fracture risk than individuals without diabetes (more than five times for hip fracture and two times for non-vertebral fractures).

Bone fragility becomes a complication because when a person living with diabetes experience a fracture, to repair that fracture isn’t a straightforward process, as such they experience a delay which impacts the proper repair and healing of that fracture.

The research also shows that people with Type 2 diabetes who have complications such as diabetic eye disease or kidney disease are also at increased risk of fragility fractures despite having higher bone mineral density compared to people living with Type 1 diabetes.

Another complication of diabetes is nerve damage which results in impaired movement, increasing the risk of falls. Low blood glucose reactions may also contribute to falls and fractures.

The duration of diabetes also plays a role as those living with the condition for more than five years tend to be at a higher risk for fractures and poor fracture healing.

Other factors of poor bone health

Other factors that can increase the risk of falls and poor bone health that lead to fractures are low levels of calcium and vitamin D. The body parts as well as other substances within the body such as minerals and nutrients don’t work in isolation but work together, which is the case with calcium and vitamin D. They work together to build your bones. People living with diabetes tend to have low vitamin D levels. Vitamin D helps the body to absorb calcium, which the body needs to maintain strong bones.

Hormone interference

There are also important hormones that affect the quality of your bones. As a person living with diabetes and having low levels of the following hormones increases your risks of bone fractures.

  • Low oestrogen is known for causing bone loss. If you’re a woman in menopause, had a hysterectomy with ovaries removed, or  a younger woman with irregular menstruation or menstruation that has stopped for many months even years, you’re at risk of osteoporosis.
  • Low testosterone can also affect bone health.
  • Vitamin D is a true hormone that is made on your skin when exposed to sunlight. Most spend times indoors and don’t receive enough sunlight to activate this essential element the body needs. As you get older, the amount of vitamin D that your skin produces gets diminished.
  • Thyroid balance is important not only for your weight and energy level, but also for your bones. An overactive thyroid or taking too much thyroid hormone to replace an underactive thyroid can make bones brittle within a few months.
  • Extra parathyroid hormone made by an enlarged parathyroid gland in your neck is a common cause of fragile bones and osteoporosis.
  • High cortisol, a stress hormone made in your adrenals, may present a risk of osteoporosis.

Osteoporosis

Osteoporosis (loss of bone mass) is a silent condition. This is why many people may not know they’re at risk or think about prevention until they have a fracture in an unexpected way.

Osteoporosis causes your bones to become weak and more prone to a fracture as you get older. The hip, spine and wrist are most susceptible, but a fracture may occur in any bone.

It’s normal for women to start experiencing a decrease in bone density when they enter menopause. This happens due to hormonal changes and is generally a slow process. Breaking a bone after falling while in a standing position could be a sign of osteoporosis. Any fracture should prompt a discussion of bone health with your doctor.

Osteoporosis is diagnosed with a bone density test, a quick and painless type of X-ray, that provides information about bone strength and the risk of a future fracture. Many people are surprised to learn they have osteoporosis because they have no symptoms.

Unfortunately, osteoporosis can have devastating consequences. Falling may lead to a life-altering fracture and permanent disability.

Earlier screening is recommended for women with certain risk factors, such as a family history of fractures or the use of certain medications (steroids). Those who consumed very little calcium in younger years, had an eating disorder, smoke or consume excessive amounts of alcohol may also be vulnerable to accelerated bone loss. Women who are underweight are also at increased risk.

Treatment for osteoporosis

Medications used to treat and prevent osteoporosis should be tailored for each individual patient.

Most people think of calcium and vitamin D when it comes to bones. However, there are so many more nutrients that are essential for bones, including vitamin B12, phosphorus, magnesium, and vitamin K, to name a few.

It’s preferable to get your calcium from food sources. Though, if supplements are taken, two forms are available: calcium carbonate is absorbed most efficiently when taken with food while calcium citrate is absorbed equally well with or without food.

It’s recommended that patients divide their dose for optimal absorption, taking no more 500mg at one time. A calcium supplement can interact with various prescription medications, so you should talk to your doctor about the best way to take it.

Diabetes and the risk for osteoporosis

People living with diabetes risk losing bone mass at a more rapid rate than average. This is due to complications such as muscle weakness, vision issues, low blood glucose, neuropathy in the feet, and certain diabetic medications that causes bone loss. The factor that increases the risk of osteoporosis the most is sedentary lifestyle.

Protecting bone health

  • Being physically active helps keep blood glucose levelled and is important for bone health. Weight-bearing exercises (walking, jogging and stair climbing) can prevent bone loss and build muscle strength to prevent falls. Maintaining a healthy weight can help preserve bone mass, even as you age and living with diabetes.
  • Eating well-balanced nutritious meals. Avoid refined carbohydrates (white bread and sweetened drinks) that cause blood glucose levels to spike. Limit caffeine (coffee and energy drinks) as they may affect calcium absorption.
  • Having good diabetes control to prevent complications associated with falling, such as nerve damage, vision loss, circulatory problems, and hypoglycaemia (low blood glucose).
  • Quitting all tobacco products. Smoking reduces blood supply to the bones and other organs, increasing the risk of diabetes complications.
  • Limiting, if not completely avoiding, alcohol. Alcohol affects all parts of the body, including the bones, and may cause changes in blood glucose levels.

People with diabetes should have a bone density test to monitor bone mineral density every two years. Routine bone density testing isn’t recommended for men younger than 70 unless they have other risk factors. Since women have a higher risk of osteoporosis, it’s recommended that all women above 50 years of age and post-menopausal women younger than 65 years of age with risk factors get a bone density test.  

Motselisi R Mosiana is a radiographer and the founder of Qsight which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening.

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Motselisi R Mosiana is a radiographer and the founder of InsureSPR Health which offers preventative and wellness care, corrective exercise, health coaching, clinical bone density and whole-body vibration screening. 
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hypoglycaemic anxiety

Managing hypoglycaemic anxiety

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Dr Paula Diab discusses hypoglycaemic anxiety, its impact on diabetes management and provides practical strategies to help take control and reduce it.

Living with diabetes can present numerous challenges, including daily glucose monitoring; paying careful attention to what you eat and when you eat; and compensating for normal, everyday lifestyle challenges such as stress, exercise and hormonal changes. Added to these challenges is the ever-present danger of low blood glucose levels (hypoglycaemia). While hypoglycaemia can be concerning in itself, it can also trigger hypoglycaemic anxiety and stress which may even exacerbate glucose levels further.

Understanding hypoglycaemic anxiety

Hypoglycaemic anxiety refers to the fear or worry experienced by people living with diabetes regarding the possibility of experiencing low blood glucose levels. This anxiety can stem from concerns about the physical symptoms as well as potential complications associated with hypoglycaemia.

Symptoms associated with hypoglycaemia include dizziness, confusion, and even loss of consciousness. These may often be misinterpreted as an anxiety attack or exacerbated by associated anxiety.

A previous experience of hypoglycaemia will also have a significant impact on future decision-making. Additionally, the fear of not being able to manage or control these episodes can contribute to heightened anxiety levels.

This is particularly true for the elderly; people who live alone and those who have poor or unstable support systems. Even an adult living with a spouse at home may feel unsupported and anxious if the spouse’s work demands irregular working hours or shift work. Children who have unpredictable daily routines where one day involves a two-hour sport practise after school and the next day is more sedentary or when sports practise is suddenly cancelled, or the time moved, or some aspect of the exercise changed.

Even those who rely on served meals (old age homes, hospitals, boarding schools, work conferences, travel, etc.) may experience anxiety at not being in control of what food they have access to at any time.

Impact on diabetes management

Hypoglycaemic anxiety can have a significant impact on diabetes management. Anxiety and stress can lead to hormonal changes that affect blood glucose levels, potentially triggering a vicious cycle of unstable glucose control.

Fear of hypoglycaemia may also result in intentionally maintaining higher blood glucose levels to avoid low episodes, which can lead to long-term health complications. It’s crucial to address hypoglycaemic anxiety to maintain a balanced and healthy approach to diabetes management.

Strategies to prevent hypoglycaemia

As with most challenges in diabetes, awareness and education are key to gaining control. Understand the signs and symptoms of low glucose levels and discuss them with your healthcare team.

Learn to recognise your individual triggers and identify the steps to prevent and treat low blood glucose effectively. This may differ for each and every individual.

Insulin

The most common culprit is short-acting insulin as this is exactly what it’s designed to do. Long-acting basal insulins don’t generally have a high risk of hypoglycaemia. Particularly the newer basal analogue insulins are very stable and don’t have a high risk for hypoglycaemia.

Pre-mixed insulins may also cause hypoglycaemia as they have a short-acting component in them and if you haven’t eaten enough to compensate for the insulin, your glucose levels will drop. Try to opt for newer insulins that have a lower risk profile.

Delayed food intake

Skipping meals, delaying meals, or inadequate carbohydrate intake can cause a drop in blood glucose levels. It’s important to maintain a regular eating schedule and include balanced meals and snacks to provide a steady supply of glucose to your body. When planning and scheduling isn’t in your control (boarding schools, catered meetings, travel), make sure that you speak to your healthcare team and mitigate this risk as best you can.

Physical activity

Engaging in physical activity or exercise can lower blood glucose levels, particularly if you aren’t properly fuelling your body before and after exercise or if the activity level is more intense than usual.

Once again, a change in scheduling of exercise, may enhance your risk of hypoglycaemia so try to mitigate the risk as best you can and understand what changes can be made if necessary.

The combined anxiety of a change in routine added to the risk of hypoglycaemia with exercise may well be a perfect storm so try to plan your exercise and stick to the regime as best you can.

Alcohol

Alcohol can interfere with the liver’s ability to release stored glucose, leading to hypoglycaemia. It’s important to consume alcohol in moderation and with food to help prevent low blood glucose.

Again, an honest discussion with your healthcare team can prepare you for this risk and help you to make the necessary adjustments rather than being afraid of a potential glucose low and making incorrect decisions around your medication.

Illness

Factors such as illness, hormonal changes (during menstruation), and stress can affect insulin sensitivity. These changes can result in increased insulin activity, potentially leading to hypoglycaemia. Education and awareness are the key ways to understand how these events will impact you and what you need to do to avoid hypoglycaemia.

Mistakes

You are human. You make mistakes. Sometimes you may confuse your long and short-acting insulins or miscalculate a carbohydrate intake. Such errors often result in glucose lows. Know how to correct your mistakes and have emergency plans in place.

Insulin pump malfunctions

If you use an insulin pump for diabetes management, a malfunction or infusion site issue can lead to improper insulin delivery. This usually results in glucose levels to rise but the corrective action may be a bit too severe and you may end up with a rebound hypoglycaemia. Many of the newer pumps have cut-off alarms and suspend functions that can now predict hypoglycaemia and switch off insulin delivery to prevent the event occurring.

However, a past experience of hypoglycaemia may tempt the user to override the pump actions and this generates artificial machine learning. Disconnecting your pump and allowing it to deliver insulin outside of your body or manually overriding settings aren’t encouraged as this will result in incorrect decision-making in the future. Speak to your pump specialist about individualising these settings and ensuring they work best for you. Too many alarms and alerts can also result in alarm fatigue where users ignore warning signs and don’t act appropriately.

Medications

Certain medications, such as those used to treat other health conditions like beta-blockers or some antibiotics, can mask the symptoms of hypoglycaemia or affect blood glucose regulation, increasing the risk of low blood glucose. If you’re taking other medications, make sure that they aren’t compounding the problem and be aware of additional signs and symptoms to look out for.

Test, test and test again

Regular monitoring of blood glucose levels empowers you to detect and address potential fluctuations promptly. There is unfortunately no easy and cheap way around this. Regular finger-pricking and interpretation of the numbers can give you important information as to how various lifestyle events, medications and situations affect your blood glucose levels. The more often you test, the more you can predict future patterns.

As an example, if you test regularly before going to bed and know that you’re generally safe if your levels are around 7 – 8mmol/L, then you can be assured that your levels will remain at that level overnight and not drop low.

Not testing leads to too many unknowns and consequent anxiety that a potential hypo will occur which, in turn, leads to false decision-making. By keeping a close eye on your glucose levels, you can gain confidence in managing your diabetes and reduce anxiety associated with hypoglycaemia.

Managing anxiety

Once you’re aware of the nuances of diabetes management and have educated yourself on the effects of daily food intake, activity and hormonal changes, then you can start to plan and make the necessary adjustments that are required.

Try to build a strong support network which can provide a valuable source of encouragement and assistance. Identify one (maybe even two) person/s that you trust (and who you have educated on diabetes) who can call you out and alert you to signs of potential danger.

One of the many downsides of hypoglycaemia is that it affects your executive brain function and decision-making abilities. It can also make you irrational, irritable and angry. Very often, people who are experiencing a severe low glucose level will make decisions that they would not normally make simply due to the physiological changes in their body as a result of the low glucose. Have a trusted friend who can very directly comment on your behaviour and enforce correct decision-making.

Try to find your tribe. Connect with other people living with diabetes through support groups or online communities. Sharing experiences and seeking advice from peers who understand your challenges can help alleviate anxiety. Very often these community groups can provide sound advice and understanding when healthcare professionals are unable to. It’s difficult to empathise with the fear associated with a severe hypoglycaemic episode if you have never experienced it yourself.

Mitigate stress

We are all far too stressed. At this time of year, we’re usually mentally exhausted. Having navigated the cold winter months, the onslaught of public holidays in the first half of the year that wreak havoc with business practices and still just too many months left until the end of the year. Medical aid funds are often depleted at this time and people are unwilling to invest time and money into healthcare.

Although the end of the year may rehabilitate your medical aid benefits, it will do no more than that. There will be more breaks in business function, more stress, more curveballs. Try to incorporate stress management techniques into your daily routine, such as regular exercise, meditation, deep breathing exercises, or engaging in hobbies you enjoy.

Reducing overall stress levels can positively impact both your mental well-being and your blood glucose control and will go a long way to improved diabetes management in the long run.

If hypoglycaemic anxiety significantly impacts your quality of life and ability to manage diabetes, don’t hesitate to seek professional help. Mental health professionals with expertise in diabetes care can provide guidance and support to address anxiety-related challenges effectively.

Questions to ask yourself are:

  1. How confident are you that you can stay safe from hypoglycaemia when:
  • Exercising
  • Sleeping
  • Driving
  • Social situations
  • Alone

If you feel that you lack confidence in any of these situations, then seek professional assistance from your diabetes team before you encounter the problem. Ensure that you know how to avoid and respond to hypoglycaemia and this will greatly diminish your anxiety. Involve your family and friends and ensure that those close to you are also well-equipped to support you.

Conclusion

Hypoglycaemic anxiety is a common concern among people living with diabetes. However, by understanding the condition, implementing effective strategies, and seeking support when needed, you can regain control over your diabetes management and reduce anxiety surrounding hypoglycaemia. Remember, managing diabetes is a journey, and with time, patience, and support, you can overcome hypoglycaemic anxiety and live a fulfilling life while effectively managing your condition.

Dr Paula Diab

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Dr Paula Diab is a diabetologist at Atrium Lifestyle Centre and is an extra-ordinary lecturer, Dept of Family Medicine, University of Pretoria.

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