Kate Bristow, a diabetes nurse educator, shares easy and practical tips to nourish and care for your skin during the colder months.

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Skin 101

Did you know that your skin is an organ? In fact, it’s the largest organ of the body, packed with blood vessels and nerves and is the centre for your senses (touch and pressure, pain and temperature).

The skin sheds about 40 000 skin cells every day and is a protective barrier that is capable of continually replenishing itself. Its primary role is temperature regulation, but it’s also a shield from disease, infection and the sun.

When we talk about the effects of diabetes on all organs in the body, this includes our skin. Your skin is a very good indicator of general health. If you notice skin changes have them checked out. Early diagnosis and treatment are essential in preventing complications from skin problems caused by diabetes.

How does winter affect your skin?

As we go into winter, the changes in temperature and humidity may change your skin’s texture and it will need a bit more care. Winter can make your skin drier and more irritated, and heaters will further dry out your skin.

If you suffer from eczema, rosacea or psoriasis, these conditions can flare in the winter. Note, these conditions are common conditions of the skin, not isolated to persons with diabetes.

Tips to take good care of your skin in the cold weather

1. Go easy on cleansing of the skin – A daily wash/cleanse is important, but don’t wash multiple times in a day. Moisturising cleansers instead of foaming face wash will strip less of the natural oil off the skin. Also using a thicker moisturiser may help prevent dryness.
2. Don’t forget the sunscreen – Shorter days and a weaker sun may make you slacker with using sunscreen. Although the UV rays are less, they are still there, and sunscreen remains an essential part of skincare management. Remember to re-apply it every two hours and pick shade where possible.

Did you know that sunscreen loses its properties of protection when it is expired? So, check the expiry date. A sun protection factor (SPF) of 30 or higher is recommended.

3. Use a humidifier with heaters – If you are using a heating device, such as a gas heater or an air conditioner on heat, have a humidifier going in the same room to keep the skin more comfortable. Remember this rule applies for an open fire too.
4. Avoid soaking in the tub – Long hot showers and baths which are so divine in winter can actually dry the skin out. So, try keep soaking in the tub to a minimum and keep the water lukewarm and not piping hot. Try to use your moisturiser while your skin is still damp to seal the hydration in. If you have a dry skin, this is important all year round.
5. Switch to fragrance-free products – Certain products may be more irritable to your skin. Know how you react and if you have an irritable skin, avoid products, such as laundry detergent with fragrances.
6. Take care of your nails – Often, we don’t look at our nails until it’s time to wear sandals but things like fungal infections can start developing in winter. Foot care and nail care is important; if you notice brittle, yellowing or nails lifting check in with a doctor.
7. Wear gloves and keep your skin warm – It’s also a good idea to wear gloves for doing dishes or with use of any cleaning products.
8. Remember your lips – Use a gentle lip balm on a regular basis. Try not to use products that sting or make your lips tingle.  Suggested ingredients include glycerine, shea butter, beeswax, olive oil, castor oil and coconut oil.
9. Be patient with dry, cracked skin – If your skin is already irritated, please be patient; badly cracked and dry skin or broken skin barrier may take months to heal properly. If you suffer from any diagnosed skin conditions (rosacea, eczema, or psoriasis), it’s important to get specialised treatment from a dermatologist.
10. Stop smoking – Smoking makes you look older and contributes to wrinkles. It also narrows the tiny blood vessels in the skin, decreasing blood flow and increases the risk of squamous cell skin cancer. In the words of the Mayo clinic, “The best way to protect your skin is to quit!”
11. Manage your stress levels – This may be the hardest one, but stress can increase your skin’s sensitivity and trigger acne and other skin conditions. Try to get a balance: enough sleep, exercise and time to do the things you enjoy.
12. Follow a healthy eating plan – Plenty of vegetables, whole grains, lean protein and some fruit. Drink enough water to keep your skin hydrated.

References:

• https://www.today.com/health/skin-beauty/winter-skin-care-tips
• Skin Care: Dermatologist Recommended Tips (clevelandclinic.org)
• Skin care: 5 tips for healthy skin – Mayo Clinic

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Gynaecologist, Sumayya Ebrahim, educates us on vaginal candidiasis, also known as vaginal yeast infections, and its link to diabetes.

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Research has consistently shown that vaginal yeast infections are common in patients with both Type 1 and Type 2 diabetes. This is especially so if glucose control is not optimised.

Candida 101

Candida (or yeast) is a type of fungus that lives naturally in the body. We find it usually in the mouth, throat, gut and vagina. It also lives on the skin surfaces. Occasionally, when certain conditions exist in the body, this organism will multiply and cause an infection. This infection goes by the common name of thrush or candida.

What conditions favour the development of vaginal candida?

• Pregnancy – due to the hormonal changes
• Users of hormonal contraceptives
• Diabetes – especially if control is poor
• Recent antibiotic usage
• Weak immune system – from HIV, chemotherapy or any immune-related illness

Lifestyle factors

Candida loves a warm moist environment. Below are some lifestyle factors to get candida:

• Staying in a wet swimming costume
• Not changing sweaty gym clothes like lycra
• Using scented tampons
• Using a vaginal deodorant
• Unhealthy diet that consists of refined and processed foods and deficient in fresh fruits and vegetables

What are the symptoms?

Please note, vaginal candidiasis is not a sexually transmitted disease.

Symptoms can range from very mild to severe. In some instances, if the underlying problem is ongoing, the infection can recur frequently.

• Vaginal or vulva itching and irritation
• Sensation of burning during urination or intercourse
• Vaginal rash, tiny blisters or even cuts
• Redness and swelling of the vulva
• Vaginal or vulva pain
• Thick white vaginal discharge that resembles cottage cheese; this often has no odour

How is vaginal candida treated?

Treatment of vaginal candida involves either topical antifungal treatment like a cream to the skin or an ovule into the vagina. These are available over the counter.

Treatment usually lasts up to five days and resolves the problem. Oral antifungals are also available on script from your doctor. These can be used as an alternative for an early infection or be reserved for when candida recurs.

Prevention of vaginal candida

The best way to prevent vaginal candida infection is to avoid all the lifestyle factors that can act as triggers. In sufferers with ongoing diabetic challenges, the key strategy is good glucose control. Without good glucose control, candida overgrowth and symptomatic infection are never really kept in check.

Oral probiotics in the form of capsules or regular dietary unsweetened yoghurt with lactobacillus also prevents candida overgrowth.

Gynaecologists may also recommend vaginal probiotics inserted as a pessary directly into the vagina once or twice per week. This restores the good bacteria in the vagina called lactobacilli and allows the vagina to regulate its own pH. Thus, keeping it healthy. This in turn, helps to prevent ongoing or recurrent infection. A recurrent infection is said to occur if it happens more than four times per year.

Special considerations with diabetes

1. New research shows that a new group of drugs to treat Type 2 diabetes, called sodium glucose cotransporter 2 (SGLT2) inhibitors, makes users more prone to develop recurrent candida infections. These include dapagliflozin and empagliflozin.
2. Recent studies show that people with diabetes are more prone to having candida caused by strains different to the general population. In the general population, candida albicans is the most common yeast identified. In people with diabetes, the most common strain is candida glabrata; this strain has also been shown to be more resistant to successful treatment.

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Dr Paula Diab shares valuable tips for keeping blood glucose spikes in-check to avoid the post-meal rollercoaster.

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Over nearly 20 years of assisting people managing their diabetes, I’m always humbled by how much there is to know about the disease. Not too long ago, I thought that if you could master the art of counting carbohydrates, then dosing insulin would be simple. 1 unit of insulin for every 15g of carbohydrates. 1 slice of toast = 15g of carbohydrates. What could be easier?

But if practicing medicine has taught me nothing else, it is that medicine is an art as much as it is a science. Seemingly simple maths does not always add up.

In listening to patients, I began to realise that they too were finding that this simple maths didn’t always work and that eating a burger with a side salad as a starter would sometimes work out better than eating just the burger alone. And then I had the opportunity to attend an international conference where I attended a lecture on macro-sequencing and the puzzle pieces slowly started to fit together.

One of the latest buzzwords or phrases in diabetes management is Time in Range (TIR). This refers to the overall time during the day that you spend within a particular target range. This range can depend upon your circumstances but is generally between 3.9 – 10.0mmol/L (70-180mg/dL).

If you are able to spend 70% or more of your time within this range, your risk of complications and overall prognosis in diabetes will be greatly improved. Studies have shown that kidney and eye disease are accelerated with greater post-meal peaks as well as these rises being an independent risk factor for developing cardiovascular disease.

Matching the action of insulin

Short-term glucose control is also negatively affected by these post-meal peaks which manifests in a decrease of energy, cognition (thinking) difficulties, mood swings and other physical and emotional abilities are affected.

As we then struggle to get the readings back into range, a common problem is that of overcompensating and causing what clinicians refer to as a rebound-low. A key component of remaining in range is therefore being able to manage your glucose levels after meal times and not just monitoring your fasting glucose levels early in the morning.

Keeping your glucose levels to remain in the target range with as little fluctuation as possible. In fact, if you are trying to get your glucose levels closer to that magic number of an HbA1c of 7%, managing your after-meal peaks is going to be all the more important.

It is normal to have fluctuations in glucose levels throughout the day even for people who don’t have diabetes. However, if the peak of the rise is too high or lasts too long, this may have adverse effects on your health. The idea in diabetes is to match the action of insulin with the consumption and digestion of carbohydrates.

Measuring and targets

Medicine is an art as well as a science. So, whilst most people will experience a peak about 60 – 90 minutes after starting their meal, this may vary from person to person and depending upon the meal eaten.

The next conundrum occurs when looking at what your targets should be. General guidelines suggest a post-meal peak of <10mmol/L (180mg/dL); however, this may also vary. Elderly patients or those with multiple co-morbidities may be encouraged to set their targets slightly higher to avoid the disastrous consequences of hypoglycaemia whilst pregnant women will be encouraged to have a much tighter range and not allow their post-meal peak to rise above 7.8mmol/L (140mg/dL) in order to prevent unnecessary damage to the foetus.

Peak management

1. Selecting the correct insulin

Very often people think that all rapid-acting insulins are the same. The reality is that whilst most people (particularly with Type 2 diabetes) don’t notice a significant difference between insulin aspart or glulisine, for example, other people do react very differently.

There are also newer ultra-rapid insulins that will act even quicker as well as different formulations of insulin (inhaled insulin, not yet available in South Africa) that also work much quicker.

2. Injection technique

The manner in which you inject insulin can also affect the way it’s absorbed and how quickly and efficiently it acts. Injected insulin works much faster when the injection site is warmed. This can be done by rubbing the site before injecting, exercising the muscle near the site or immersing the site in warm water.

In practical terms, your insulin may be absorbed quicker after a warm bath, after a run or on a warm summer’s day. Injecting directly into the muscle (anterior thigh or arm) is not usually indicated but if you are wanting insulin to work very quickly in the case of diabetic ketoacidosis (DKA) or treating a very high glucose level, this will certainly make a difference.

Remember that working quicker or faster doesn’t mean working for a longer time which will be discussed later.

3. Pre-bolusing

Some people may have heard about the concept of pre-bolusing or injecting insulin prior to a meal. This can have a significant impact on squashing the peak that occurs after a meal, but you do need to be careful.

The aim is to get the insulin into your body and working at its maximum at the same time as your meal peaks. The exact timing of this will depend on multiple factors as medicine is an art, as well as a science.

High glycaemic index (GI) foods will peak quicker and therefore may require a bolus 15 – 30 minutes before the meal whilst lower GI foods may digest better when the insulin is given at the start of the meal. Higher pre-meal glucose values may respond better when mealtime boluses are more pronounced whereas lower glucose levels may benefit from insulin taken during or even after the meal.

4. Other medications

The effect of insulin may be enhanced by other hormones, such as GLP-1 receptor agonists. These delay gastric emptying and keep carbohydrates from raising the blood glucose levels too quickly after meals.

Another drug, pramlintide (not available in South Africa) also helps to reduce appetite and squash the post-meal secretion of anti-insulin hormones in the body. Both of these medications will result in much more stable glucose levels and smaller peaks.

These are the pharmaceutical ways in which you can squash that post-meal peak but there are also quite smart manoeuvres you can try with simple lifestyle adjustments that will also have a significant impact.

Lifestyle adjustments

1. Glycaemic index

As mentioned previously, lower-GI foods (pasta, beans, legumes) will digest slower and therefore have a flatter peak if you measure the glucose response.

Higher-GI foods (bread, cereal, potatoes, rice) are converted into glucose more quickly and therefore will tend to give a higher and more pronounced peak.

In addition to balancing the timing of your insulin, try to balance your meals with a combination of carbohydrates so that you do not only get a quick peak and then feel hungry again soon afterwards.

2. Acidity

The addition of acidity to food has also been shown to reduce the post-meal spike. In practical terms, this can be in the form of sourdough bread as opposed to regular flour bread; adding vinegar or even tomato sauce as a condiment.

3. Food sequencing

The order in which you eat your food has also been shown to be important in maintaining stable glucose levels. Having a salad or vegetables prior to your main meal will allow time for your digestive enzymes to be secreted so that when you eat your carbohydrates, your body is optimally-primed to digest these foods.

Fats will slow down the absorption of carbohydrates in the body. The most typical example is that of a cheesy pizza – very often insulin is given in split doses in this case to match the peak of the carbohydrate as well as the delayed peak of the fat in the cheese.

Proteins will also slow down the absorption of food in the body and contribute to satiety (fullness) therefore reducing the overall glucose load.

As always, a healthy balanced meal is recommended so experiment with your favourite meals and see what the impact can be on your post-meal peaks.

4. Splitting meals

Other suggestions are to split the meal and have a portion of the meal 30 – 60 minutes after the initial meal. This is particularly useful if you are to embark on a large gourmet feast. The longer you take to eat the food, the more time your body has to digest it.

Even smaller meals can be broken down in this way by having a cup of coffee prior to breakfast and then eating the bowl of cereal and milk a while later.

Those who like to have a mid-morning or mid-afternoon snack may consider removing a serving of fruit from breakfast or lunch and having it between meals. In this way, the body is presented with smaller loads of carbohydrates more consistently which will certainly assist in more regular blood glucose levels. Please speak to your clinician about how to dose insulin if you are going to split your meals in this way.

5. Exercise

If ever there was a solution to almost all problems, it is that of physical activity. Being active after eating will reduce post-meal peaks by slowing down absorption of glucose into the bloodstream. The body also uses the glucose consumed and actually becomes more sensitive to insulin as well. Ten to twenty minutes of mild activity (walk, household chores, etc.) is usually adequate.  

4. Prevent hypoglycaemia

We’ve spoken often about the dangers of hypoglycaemia but one of the most overlooked problems is the vicious cycle that it creates. The body responds to low glucose levels by doing everything it can to counteract this potentially lethal situation. It empties the stomach quicker, food is digested quicker and blood glucose levels rise more rapidly. In addition, counter-regulatory hormones are released that stimulate glucose production in the liver. The end result – blood glucose levels peak and it becomes difficult to lower them again.

Take-home lessons

Its highly possible that by now your blood glucose levels have dropped, due to all the mental agility, or sky-rocketed, due to the stress response elicited by the body by reading all this information. Perhaps, they’re perfectly stable with no change at all.

If you take away one thing, remember that medicine is an art as well as a science. Sometimes, what looks like simple maths is actually a complex interplay of numerous different factors with even more unexpected outcomes.

Another good point to remember is to be alert to new ideas and thinking and constantly try to improve your knowledge and understanding of diabetes. What worked for the last 20 years, may not be the most ideal way to manage your diabetes and sometimes change is necessary and even helpful.

Experiment with your medication and food and find out what works best for you. Read through this article slowly and carefully and try one strategy at a time and get a good idea of the impact it has on your diabetes.

Obviously, all these strategies are much easier when using a continuous glucose monitor but you can get a very good idea by testing before and two hours after each meal and then discussing your findings with your diabetes educator or diabetologist.

Treat it as an interesting puzzle and try to solve the conundrums. Even experienced clinicians are sometimes forced to go back to the drawing board and ask for assistance. Managing the post-meal rollercoaster very often requires time, lots of trials and testing and a great team-effort.

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Dr Angela Murphy expands on time in range and why it may become the most important of all glucose measurements in the future.

Listen to this article below or wherever you get your podcasts or visit our playlist.

It’s estimated that about a half a billion people are living with diabetes worldwide. Most of them will have Type 2 diabetes, with about 10% living with Type 1 diabetes.

Large scale studies have proven that good glucose control reduces the complications associated with diabetes: cardiovascular disease, such as heart attack and stroke, kidney disease, vision loss and amputations.

At the heart of this statement are the words ‘good glucose control’. Until now, two main parameters have been used to determine diabetes control:

1. Home glucose levels
2. HbA1c

Blood glucose measurement

Initial testing of blood glucose levels in the 20^th century was done using urine test kits. These were difficult to interpret and had no real correlation with complications of diabetes. The introduction of the Ames dextrostix, in the 1960s, paved the way for home glucose testing as we know it today.

We now have a choice of efficient, accurate glucometers. It’s possible to get a glucose reading from capillary blood in mere seconds, allowing the person living with diabetes (PWD) to act timeously.

In 1999, the first continuous glucose monitoring (CGM) device was approved. For the first time, blood glucose levels were measured continuously over a 24-hour period. A sensor is worn by the PWD which transmits readings to a reader, insulin pump or a smartphone. The real time sensors will alarm if the glucose level becomes too high or drops too low. This can assist the PWD to take more accurate and frequent actions to improve glucose control. 

Figure 1:  CGM device showing current blood glucose level, arrow with direction of blood glucose rise and graph of previous 8 hour readings. (https://www.freestylelibre.com.au/getting-started-with-freestyle-libre-2)

HbA1c (glycated haemoglobin)

Researchers, Samuel Rahbar and Helen Rannay, found that haemoglobin (Hb) from blood samples of PWD had a specific pattern and this was named HbA1c.

HbA1c is formed when excess glucose in the blood attaches to the haemoglobin molecule, a process called glycation. Red blood cells are renewed on average every three months, so HbA1c is regarded as an average of blood glucose control over a three-month period.

Every PWD should be aware of their most recent HbA1c reading. Two landmark trials have proven that HbA1c correlates with complications.

1. The Diabetes Control and Complications Trial (DCCT), which involved people living with Type 1 diabetes released its results in 1990. It conclusively showed that improved glucose control, defined as a HbA1c < 6.5%, reduced the risk of microvascular (small blood vessel) complications of the eyes, kidneys, and nerves.
2. The United Kingdom Prospective Diabetes Study (UKPDS) confirmed these reductions in microvascular complications with good diabetes control in people living with Type 2 diabetes. Longer follow-up studies eventually showed the benefit in cardiovascular disease too.

Without HbA1c, this would have been nearly impossible to demonstrate.

Figure 2: Demonstrates the concept of a lower HbA1c: <7.0% being good, so it is green, whereas a higher HbA1c is dangerous and thus, is in red. HbA1c can be affected by several conditions that may make it less reliable, such as kidney failure, pregnancy, smoking and ethnicity (Quora.com).

Time to understand measuring glucose readings

Testing blood glucose regularly is an onerous task. It’s important therefore, to test with purpose.

Guidelines suggest that PWD treated with oral medications can measure blood glucose levels two to three times weekly. The timing of the test can vary from a fasting blood glucose to two-hour post-meal.

PWD using insulin will have to check their glucose readings more frequently. As a rule, the minimum tests should equal the number of injections per day. For PWD on four to five injections daily, this is taxing. However, we know that more frequent glucose testing does improve diabetes control.

How to understand continuous glucose monitoring

CGM devices are the machines of many a PWD’s dreams: a way of always seeing the blood glucose without having to open a conventional glucometer and prick a finger.

As the CGM devices became more advanced, they not only showed the current glucose reading, and of course the tracing of where the glucose had been but could predict where the glucose would go. In this way, PWD can be forewarned of hypoglycaemia or hyperglycaemia and take appropriate action to avoid these.

When this type of CGM technology works in tandem with insulin pumps, we see the makings of an artificial pancreas.

A CGM tracing can look like a rollercoaster. So where do we start to assess what the overall picture means?

Figure 3: CGM download showing blood glucose readings over a 24-hour period (Supplied by author).

Time in range

What data from CGM shows is that we cannot always rely on average blood glucose levels, even HbA1c, to fully assess overall diabetic control.  Averages do not show the extent of the high and low glucose readings.

Let me explain: if there are three blood glucose values of 6.0mmol/L, then obviously the average blood glucose is 6.0mmol/L. However, three readings of 12mmol/L, 2mmol/L and 5mmol/L will also give an average of 6.0mmol/L and yet only one reading is in the target range. This variation in glucose levels is called glucose variability.

CGM demonstrates patterns of glucose over a 24-hour period in detail so the swings in blood glucose levels are easily seen. The more frequently the blood glucose levels swing from highs to lows, the higher the glucose variability. There is concern that this variability can damage blood vessels and thus, may be implicated in diabetic complications.

Glucose targets

Based on data from all the large diabetes trials over the years, you can set targets for good diabetes control. This is not a one-size-fits-all range. Age, duration of diabetes, presence of complications, risk of hypoglycaemia and pregnancy all affect the target blood glucose levels.

In older PWD who have diabetic complications, particularly of the heart and kidneys, glucose levels are slightly higher than a young, newly diagnosed PWD.

Table 1: Glucose Targets set out by SEMDSA 2017 (Society of Endocrinology, Metabolism and Diabetes of South Africa).

In 2019, the International Consensus in Time in Range (TIR) defined the desired targets for CGM readings.  If blood glucose levels remain between the values of 4.0mmol/L and 10mmol/L 70% of the time (Time in Range – TIR), the corresponding HbA1c is around 6.5%. That equates to excellent diabetes control. Time below range (TBR) refers to readings < 4mmol/L and time above range (TAR) gives the percentage of time glucose readings are above 10mmol/L.

Figure 4: International Consensus of Time in Range (Battelino T et al., Diabetes Care 2019; https://doi.org/10.2337/dci19-0028)

Figure 4 illustrates the ideal range for patients with Type 1 and Type 2 diabetes and in pregnancy. Several medical aids will now consider reimbursement (with various levels of co-payment) for people living Type 1 diabetes who wish to use CGM devices.

Summary

To achieve good diabetes control, you try to get as close to physiological glucose levels as is safe. This has been proven to decrease both microvascular and macrovascular complications. Good control is not only a good average glucose, but also stability of glucose levels over time.  Time in range gives us insight into glucose stability and may become the most important of all glucose measurements in the future.

References

1. ParkinG, Zhihong Jelsovsky, Bettina Petersen, Matthias Schweitzer, Robin S. Wagner. Structured Self-Monitoring of Blood Glucose Significantly Reduces A1C Levels in Poorly Controlled, Noninsulin-Treated Type 2 Diabetes. Diabetes Care Feb 2011, 34 (2) 262-267; DOI:2337/dc10-1732
2. Battelino T, Danne T, Bergenstal RM, Amiel SA, Beck R, Biester T, Bosi E, Buckingham BA, Cefalu WT, Close KL, Cobelli C. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diab Care. 2019;1(42):1593–603.
3. Gabbay, M.A.L., Rodacki, M., Calliari, L.E. et al.Time in range: a new parameter to evaluate blood glucose control in patients with diabetes. Diabetol Metab Syndr 12, 22 (2020)
4. Hirsch IB, Welsh JB, Calhoun P, Puhr S, Walker TC, Price DA. Associations between HbA1c and continuous glucose monitoring-derived glycaemic variables. Diabet Med. 2019;36:1637–42.

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