Making peace with your diabetes

Noy Pullen shares how she made peace with a life-threatening illness and offers guidance on how to make peace with your diabetes.


Have you ever looked back in your past at those people who made your life a misery? During the nineties, I was in England as part of a self-schooling course at the Centre for Social Development. Most of us were there because we wanted to make sense of the difficulties and hindrances that life had thrown at us. We did lots of biographic exercises to try to ‘read’ and write the real story of our lives

When you look back at your life whether it be the last 70 or the last 20 years, you can trace a thread that belongs uniquely to you. No one else has had the experiences you have had, all in service of your own development.

During the past months while everyone has had the opportunity of reassessing their lives, I joined an online creative writing group. Our writing prompt, Sally, offered the theme Memoirs. Every week she gives us a written topic to compose during the week about our lives which she reads and gives valuable feedback on how individual each one is when writing about a common topic. She shares our stories with the others in the group.

On Wednesday mornings when we ‘meet’, she gives us an impromptu speaking prompt to share. We have another opportunity to see and hear just how unique each one is, how differently we respond to a common theme.

When I share these written stories with my sister and brother we are often shocked by the difference our experience was of the times and events we shared.

Life-threatening condition

During the past year, I was diagnosed with a life-threatening condition. The doctors give a catalogue of symptoms, treatments and lifestyle modifications. It’s all so overwhelming. You can be pulled this way and that by the experts who have different opinions on how the condition should be managed. It’s rather like going to buy a coat. We know that the coat has a certain design. Yet each of us needs to find out what suits our unique body; the texture, colour and cost. Just so when faced with a diagnosis, like diabetes for example, how does one tailor-make the avalanche of information to accommodate individual needs?

Looking back to the schooling course in England, I found one of the exercises was helpful, in coming to terms with my condition. We were asked to recall someone, whether it be a teacher, parent, bully at school, sibling or employer, who made life miserable.

Even though we might have hated or feared them at the time, when looking back at this person all of us, without exception, found that the difficulties made us stronger. Perhaps more courageous, more tolerant, enabling us to grow. Let’s face it, we don’t grow when we’re sitting in our comfort zones, lazing about in the sun, visiting with friends. That’s where we recharge our energy.

Recall this person in the greatest detail; replay the experiences exactly as possible, but with the eyes of a stranger. Look at the consequences of the encounters. You’ll find you developed in some way. Looking at this person with hindsight, you can only think of them with gratitude for the lesson learnt. You’ll be surprised at what you discover if you think of this person objectively without bitterness. What has this to do with a life-threatening condition?

Making peace

The theme of this issue of Diabetes Focus is Making peace with my diabetes. Making peace implies that a war had been going on. Fear, pain, dread and an enemy. What started the war? Who is the enemy? What are they fighting about? What does the winner get?

Having learnt so much from my so-called enemies of the past, I tried this same exercise on my new situation on the battleground of health. There was no escape. I was wounded and scared. I needed an arsenal of ammunition to fight this monster. Perhaps you can look at these questions and write down your own experience on what your war is with diabetes. What are you afraid of? What do you dread? Who is the enemy, what the fight is about, who is the winner? And is there a loser? You may be surprised by what you discover about you and your diabetes. You may get to know each other better.

Are you ready to die?

Then I met with a priest who had had the same diagnosis as I had been given. Her first question was “Are you ready to die?” This was not what I wanted to hear. She said that this was a wake-up call for me to face my own mortality and then to embrace life fully.

As I went through the dreadful first stages of physical medical aspects of my condition, I realised that what she said could free me. I got my will and the list of all my personal papers in order. Quite an ordeal considering one of the items was my elaborating my funeral arrangements! I placed them all in a drawer and felt totally liberated as I had conquered a fear and could get on with living.

I may or may not have a long time. None of us knows how long, yet we can choose how to live these years our best way under the circumstances. This included listening to my own inner voice for clues. My life has led me to this point, living the only way I knew how until I got the wake-up call. The battle had begun. Now many options opened-up. What do I need to do differently so that I can change the trajectory of my life path which has led me to this situation?

Choosing the path where peace reigns

I chose a medical path that I trust and agree to follow. Not being told what to do, but choosing what to do. I embraced singing lessons, writing and drawing to widen my horizons.

Many people I had not seen for a long time contacted me. My family started a family chat group which has connected us all over the world; each member has said it is a true gift.

Is it easy living with a chronic condition? No, but in this battle, we are both the victor; it has changed me for the better. I am grateful; my opponent has become my teacher. My eating habits have benefited my body. The lifestyle changes have been brought joy and pleasure, despite the health challenges. There is a new bond between my community and me. Suddenly it does not feel necessary to sweat the petty stuff. The war is over; peace reigns in the newly acquired self-knowledge and gratitude for what has happened to me and why.

Enjoy your own voyage of self-discovery and appreciation for who you can become.


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

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Management of diabetes in hot weather

Dr Louise Johnson educates us on how to manage glucose levels during hot weather.


Thermal stress in cold and hot weather

Having diabetes tends to place individuals at greater risk for heat-related illness during heat waves and extreme hot weather.

Diabetes has been linked to impairment in temperature regulation during extreme hot or cold weather. These circumstances are referred to as thermal stress. This can be challenging on the body: both on the heart and glucose control.

During intense hot weather, the blood vessels of the skin open-up (vasodilation) to help the body expel extra heat this way.

In cold weather, the opposite happens and the skin blood vessels close-up (vasoconstriction), thus sending all the blood to the core of the body. Warmth is preserved in this way.

Impaired temperature regulations

In people with Type 1 or Type 2 diabetes these mechanisms may be impaired. This can be due to:

  1. Long-standing diabetes with complications of peripheral neuropathy (loss of sensation in feet or lower sensation or burning feet).
  2. Complication of peripheral vascular disease (illness of blood vessels of legs that cause muscle cramps when walking a distance). These abnormalities affect the blood vessels and nerves of the legs more than the arms and cause an abnormal reduction in sweating.
  3. It is now thought that abnormal sweat glands and sweat response can also in itself be a complication of diabetes. It is proven that people with diabetes have less nerve density at the site of the sweat glands. The sweat glands also produce less sweat than healthy individuals.1
  4. Poorer glucose control with HbA1c above 8,5%.
  5. Longer duration of diabetes.

How the body regulates temperature

The body regulates a tight temperature control of 37 degree Celsius. Life-threatening complications can arise with a core temperature increase as small as three degrees (40 degrees).

To maintain this body temperature, the body must be able to sweat to cool down. This is particularly important during exercise in the heat. Sweat dripping promotes no heat loss but instead dehydration. To cool down, sweat must be able to evaporate.

High-risk of hospitalisation in hot weather

Epidemiological data shows that Type 2 diabetes patients have up to 56% greater risk for hospitalisation and mortality during a heat wave. This is because Type 2 diabetes presents a lot earlier with macro vascular (big blood vessels) disease, hypertension, obesity and abnormal blood lipids.2

It was also shown that young overweight individuals with a BMI above 27 (normal is 18 to 24) are 3,5 times more likely to experience a heat-related fatality compared to their lean counterparts. This is worse once diabetes is added to the equation.

It is well-established that glucose levels decrease in those with diabetes during an exercise bout. Hot conditions can also independently change glucose by increasing insulin absorption and cause lowering of blood glucose.

Local heating of the insulin injection site can lower glucose levels through faster insulin absorption.

Consistent with these findings, seasonal variations in glucoses control have been reported. It shows that HbA1c levels are clinically lower in spring and summer relative to autumn and winter. This is independent of exercise levels.

Severe hypoglycaemia (low blood glucose) is almost twice as frequent in the summer months. The difference in glycaemic control in the winter may be related to the stress hormone cortisol that causes a degree of insulin resistance.

How to manage glucose levels during warmer months

  1. Drink plenty of water even if you’re not thirsty. This will prevent dehydration. Dehydration can raise blood glucose and can cause excessive urination that can aggravate the dehydration.
  2. Avoid alcohol and drinks with caffeine (coffee and sports drinks). Drinking them can lead to water loss and spike blood glucose levels.
  3. Check blood glucose regularly before and after you are active.
  4. Don’t store insulin or oral diabetes medication in direct sunlight or in a hot car. If you’re travelling, keep insulin and other medication in a cooler bag. Remember not to put insulin directly on ice or a gel pack.
  5. Heat can damage your blood glucose monitor, insulin pump, sensor, and test strips. Don’t leave them in a hot car, by a pool, in direct sunlight or on the beach.
  6. Remember hot temperatures can change how your body uses insulin. You may need to test your blood glucose more often and adjust your insulin dose and what you eat or drink.
  7. Uses sunscreen to prevent sunburn. Sunburn is an inflammation of your skin and causes a rise in blood glucose. The same as what happens when you develop an infection.
  8. Keep items at hand to treat low blood glucose. This can be glucose tablets or gel. If you have frequent low blood glucose levels or aren’t aware of it, a glucagon injection kit should be taken with for an emergency. This should be administered by a friend when you’re unable to swallow glucose or in a coma.
  9. Keep snacks with you. This is important since it can serve as a meal replacement in emergency circumstances or if glucose is low.
  10. Limit how much time you spend outside in extreme temperatures. Remember it’s harder to stay cool when the humidity is high. Humidity above 40% in hot weather can be dangerous. It’s better to stay in the shade or inside.
  11. Remember your feet. Diabetes patients have a higher risk for feet problems (damaged nerves, abnormal blood flow, burning feet.) The summer is a great temptation to go bare feet on the beach or next to the pool. Be aware and check your feet daily at the end of a day for any trouble.

Enjoy summer

Summer is a wonderful time of year with lots of sunshine, long hot days and nice sundowners on the beach or next to the pool. Enjoy this time but remember to drink enough water and check your glucose.


References:

  1. Kenny GP, Sigal RJ et. al. “Body temperature regulation in diabetes.” Temperatue Vol 3 ,1 p119-145; 2016
  2. Semenza JC, McCullough JE et. al. (1999) ‘Excess hospital admissions during July 1995 heat wave in Chicago.’ Am J Prev. Med. 16:269-77
Dr Louise Loot

MEET THE 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.


Hunger vs thirst: know the difference

You have a gnawing feeling in your stomach, a headache and you’re feeling a little dizzy. You go to the fridge to find something to make you feel better. Do you take a bottle of water or take the last slice of leftover milk tart? Are you thirsty or are you hungry?


The signals our bodies send us when we are hungry are like those of thirst. All too often the two are confused. With food and drinks always being available we tend to eat and drink without feeling hungry or thirsty, and many of us have forgotten how it feels and how to distinguish one from the other.

Hunger vs thirst

What is hunger?

Hunger is the demand for energy. It is a feeling we get when our energy levels are running low and need to be topped up.

What are the signs of hunger?

  • An empty feeling in your stomach
  • Tiredness
  • Feeling light-headed
  • Shakiness
  • Difficulty concentrating
  • Dizziness
  • Headache

What drives hunger?

Our hunger, and therefore need to eat, is influenced by many factors, from within the body and external influences. The hypothalamus in the brain decodes signals that it receives from:

  • Contractions in an empty stomach.
  • The absence of nutrients in the small intestine’
  • Hormones, such as leptin and ghrelin.

If we have not eaten for a while, the signals received by the hypothalamus will tell us that we are hungry and need to eat.

Physiological factors are not the only ones that influence whether we eat. We are often driven to eat, even when we are not hungry. It may be a social situation that requires you to eat, or maybe you derive comfort from eating and will then eat when you feel stressed.

It’s important to recognise what drives you to eat. Are you eating in response to genuine hunger, or are your eating in response to your emotional state?

Thirst

What is thirst?

Thirst is a conscious sensation of the need to obtain and drink fluids high in water content. It’s a sensation we get when our hydration levels are starting to drop.

What are the signs of thirst?

  • Dry mouth
  • Dry skin
  • Dark-coloured urine
  • Tiredness
  • Feeling light-headed
  • Dizziness
  • Headaches

What drives thirst?

As with hunger, the sensation of thirst is triggered by both internal and external factors. Physiological factors that tell the brain that we need to drink include:

  • Less saliva is being produced
  • Decrease in blood volume
  • Increased concentration of salt

Other factors that drive the thirst mechanism are social, cultural and psychological. We don’t only drink fluids because we are dehydrated, we also drink to be sociable, when we engage in cultural ceremonies and, as with hunger, we may drink because we derive pleasure from drinking.

Can hunger and thirst be confused?

While the main signals for hunger (empty feeling in your stomach) and thirst (a dry mouth) are quite distinct, if you are focusing on something else and ignoring these signals, the signs that come a little later are alike and may result in you eating a toasted sandwich instead of drinking a glass of water.

It’s quite common for someone to think they are hungry when they are actually thirsty. This means that you will go through your day eating often and drinking very little.

Considering that we need to eat just the right amount of food and drink just the right amount of water to remain healthy, consuming food and drinks in such a manner means that we are causing an imbalance in energy, nutrients and water.

When it comes to health, and in particular, weight loss and blood glucose control, it’s important to identify hunger and thirst correctly to prevent overeating or dehydration.

Eating too much has obvious consequences, especially if we choose unhealthy foods. If we habitually eat when we are actually thirsty, there is a good chance that our food intake will be too high resulting in weight gain and raised blood glucose levels.

Water is involved in almost all bodily processes including digestion, the absorption and utilisation of nutrients, elimination of waste and brain function. None of these processes will work at an optimal level if we are in a state of dehydration.

Mild dehydration causes thirst and other symptoms mentioned above, leaving us feeling tired and lethargic. The symptoms worsen as the state of dehydration increases, effecting heart rate, breathing and mental state.

Stop and ask yourself

Next time you are feeling hungry, stop and ask yourself:

  • When last did I have something to eat?
  • What did I eat? Was it enough?
  • When last did I have something to drink?
  • Is it hot today?
  • Have I done any exercise today?

We need to eat every three to six hours to maintain our blood glucose and energy levels. Our meals should be balanced and provide us with the energy and nutrients to make it comfortably to our next meal without having to eat another big meal or snack.

Water is not stored in the body and constantly needs to be replaced. Our water requirements are roughly two litres per day. More if it’s very hot or if you have lost a lot of water through sweating on your morning run.

Unlike eating, it is a good idea to drink consistently throughout the day to avoid dehydration and to keep your energy levels high and your brain sharp.

Tips to drink more water

  1. Keep a bottle of water with you.
  2. Keep a jug of water on your desk.
  3. Add sliced lemon, mint, strawberries or any other fruit or herb to the water to make it more interesting.
  4. Add ice to make it more refreshing.
  5. Try sparkling water to make it more exciting.
  6. Set a goal and set reminders to help you reach your goal.

So, next time you are standing in front of the open fridge, looking for something to make you feel better, reach for the ice-cold water first.  If you are still hungry 15 minutes later, go back for something to eat, but choose a fruit instead of the milk tart!

MEET THE EXPERT


Wendy Lord is a registered dietitian, based in Sandton. She has been guiding people towards a healthier lifestyle with practical advice and gentle encouragement for more than 20 years. Her main area of interest is conditions of lifestyle including weight loss, diabetes and heart disease. She strives to make her advice family-friendly so that everyone enjoys the same meals.  

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The truth about sugar-free drinks

Dietitian, Jessica Pieterse, details the advantages and disadvantages of drinking sugar-free drinks


Sugar-free drinks initially sounded like a gift to all the people wanting to lose weight and to people living with diabetes needing to control glucose levels. However, there has been talk that sweeteners may be causing harm. So, what should you believe now?

What does sugar-free mean?

For a drink, sweets or food to be sugar-free, normally a form of sugar alternative has been used. Let us clarify first what sweeteners are out there.

Possible benefits

Sugar-free drinks normally contain a type of non-nutritive sweetener, like sucralose, as the manufactures want to lower sugar and kilojoule content. This could be helpful in dropping a person’s overall kilojoule intake for the day and so aiding weight loss.

Having a lower sugar content means the food item should cause less of a rise in blood glucose levels after consuming the drink. This is advantageous for people living with diabetes and anyone needing to stabilise blood glucose levels.

A word of caution

Some sugar-free drinks don’t substitute sugar with a no-kilojoule alternative but rather a ‘healthier natural’ version of sugar. Examples are honey, palm sugar, agave nectar, etc.

Often these alternatives are misleading. They generally have very similar sugar contents to regular sugar and the glycaemic index may be lower but often by a small fraction that it’s almost not noteworthy enough.

Some of these sugar substitutes are marketed as a healthier option due to more vitamins, minerals or food components, like flavonoids, in them compared to sugar. This benefit is levered off too much by marketers as you would often need to eat buckets of the sugar alternative to consume enough of a specific food component to reap the health benefit of it. Simply, it’s impractical volumes for health claims to be attached to the sugar alternatives.

The genetic factor

Sugar-free drinks may reduce sugar intake, but this is not enough according to genetics. One gene, called TAS1R2, can indicate the genetic predisposition of having a sweet tooth. There are three variations of the TAS1R2 gene. People with one of the variations will crave more and seek out sweet foods, based on how these people taste sweetness.

What may surprise people is that simply avoiding sugar is not the complete solution here. People with the TAS1R2 higher-risk variation continue ‘feeding’ their sweet tooth when they consume drinks with sweeteners as the food item is still sweet.

Scientific research

Some journal articles have found possible negative effects of artificial sweeteners. Unfortunately, most studies are not good quality. Either the study is done on animals and not humans; has a small population group tested; or poor research procedures.

Some articles mention that artificial sweeteners may alter the gut bacteria or microbiome in a way that leads to glucose intolerance, but evidence was not strong enough for confirmation of this theory.

Some studies suggest some artificial sweeteners can be linked to increased cancer risk. Again, studies were not robust enough.

There tends to be large numbers of anecdotal or self-reported negative experiences of consuming artificial sweeteners. Unfortunately, clear conclusions can’t be made from such person-to-person encounters.

There are not enough published, good quality scientific reports documenting harm from intake of artificial sweeteners in doses that doesn’t exceed acceptable daily intake. Regulatory associations, such as Canadian Food and Drug Regulations, therefore, allow artificial sweeteners in food items under certain regulations.

What should I do?

So, as the jury may still be out regarding sugar-free drinks, it is best to follow these tips for a healthier you:

  • Drink water as your main source of hydration. Aim for about six to eight glasses a day. Ways to help you drink more water can be:
    • Find a water bottle with marks on it to remind you to drink water at certain intervals during the day.
    • Take a bottle with you in your car and aim to finish one bottle on the way to work as well as another bottle on the way home.
    • Set regular goals for yourself during the day to drink water. For example, drink another glass by lunch or by the end of a meeting.
    • Download an app that notifies you at regular intervals throughout the day to drink water.
    • Always have water available on your desk.
    • Add lemon slices, mint or fruit to the water to make it more desirable if needed.
    • Pour yourself water as you arrive in meeting rooms and order water as you arrive at a restaurant.
    • During winter, you can count a black herbal tea with no honey or sugar as a glass of water. Herbal teas that count are rooibos, camomile, peppermint and other herbal teas. Teas that contain caffeine, such as normal tea or green tea, won’t count as a water.
  • Teach yourself to enjoy drinks that are less sweet to reduce sugar cravings.
    • Dilute fruit juice, iced tea and fizzy cold drinks with water.
    • Reduce your sugar intake in hot beverages by half a teaspoon every two weeks.
  • Try have sugar-free drinks only on the odd occasion to reduce intake.
  • Read labels on drinks so you are aware of what you are drinking.

References
  1. Alternative sweeteners factsheet. The National Diabetes Services Scheme by Australian Government and Diabetes Australia. com.au https://www.ndss.com.au/wp-content/uploads/fact-sheets/fact-sheet-alternative-sweeteners.pdf
  2. Suez J, Korem T, Zeevi D, Ziberman-Schapira G, Thaiss CA, Maza O, et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014 Sept; doi: 10.1038/nature13793
  3. Carmel E. Smart. ISPAD Clinical Practice Consensus Guidelines 2018: Nutritional management in children and adolescents with diabetes
  4. Health Canada. Saccharin artificial sweeteners. https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-additives/sugar-substitutes/questions-answers-saccharin-artificial-sweeteners.html
  5. Health Canada. Sugar-substitutes. https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-additives/sugar-substitutes.html
  6. Health Canada. Sugar-alcohols-polyols-polydextrose-used-sweeteners-foods-food-safety. https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-additives/sugar-substitutes/ sugar-alcohols-polyols-polydextrose-used-sweeteners-foods-food-safety.html
  7. Health Canada. Aspartame. https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-additives/sugar-substitutes/aspartame-artificial-sweeteners.html
  8. Mahan Escott Stump. Krauses Food and Nutrition Care Process
  9. Omotayo O. Erejuwa, Siti A. Sulaiman and Mohd S. Ab Wahab. Fructose Might Contribute to the Hypoglycemic Effect of Honey. Molecules 2012, 17, 1900-1915; doi:10.3390/molecules17021900
  10. Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners. J Acad Nutr Diet. 2012;112:739-758
  11. Chamoun E, Mutch DM, Allen-Vercoe E, Buchholz AC, Duncan AM, Spriet LL et al. A review of the associations between single nucleotide polymorphisms in taste receptors, eating behaviors, and health. Critical Reviews in Food Science and Nutrition. 2018; 58(2): 194–207.

MEET THE EXPERT


Jessica Pieterse is a registered dietitian and owner of Dish Up Dietitians. She practices in Edenvale, Johannesburg and has a special interest in women’s health and gut health.


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