What are the best sweeteners for people living with diabetes?

There is a lot of controversy regarding  sweeteners (sugar substitutes) and which is better for people living with diabetes. Retha Harmse simplifies the facts.

Sugar consumption

The dangers of excessive consumption of sugar is well-documented. Including how it negatively affects the health status of individuals but even more so for people living with diabetes.

The typical South African consumes 24 teaspoons of sugar daily. More than double of the World Health Organization guidelines for daily intake. Added to that, 7% of the South African population has diabetes (3,85 million people, aged between 21 – 79 years old).

In 1985, 30 million people had diabetes. Its prevalence has increased six-fold and today  425 million people worldwide are currently. If nothing is done now to prevent this, this number will continue to increase to 629 million people by 2045.

Sugars that increase blood glucose levels

Some foods will be labelled “no added sugar” but will still be high in natural sugar (e.g. fruit sugars). These natural sugars also raise blood glucose levels and should be monitored for people with insulin resistance and diabetes.

Sugar Forms & uses Other things you should know
  • Brown sugar
  • Maltodextrins
  • Icing sugar
  • Agave syrup
  • Invert sugar
  • Brown rice syrup
  • White sugar
  • Corn syrup
  • Dextrose
  • High fructose corn syrup
  • Fructose
  • Maple syrup
  • Glucose
  • Fruit juice concentrates
  • Lactose
  • Honey
  •  Maltose
  • Molasses
  • Sucrose
  • Barley malt
  • Used to sweeten foods and beverages.
  • May be found in certain medications.
  • There is no advantage to those with diabetes in using one type of sugar over another (in other words, one teaspoon of sugar has the equal effect of one teaspoon of honey).
  • Sugars may be eaten in moderation. Up to 5% of the daily caloric requirement can come from added sugar.
  • High-sugar diets are not recommended, since such foods could replace more nutritious foods and lead to deficiencies.

Sugars that don’t affect blood glucose levels

Non-nutritive sweeteners, such as aspartame, sucralose, saccharine, stevia, xylitol, and neotame, are so popular due to it being approximately 300 to 13 000 times sweeter than sugar. Though, they don’t have any nutritional value (meaning no or low kilojoules).

Although artificial sweeteners may help to reduce total energy intake, the effectiveness in weight loss or diabetes management has not yet been established. We think fewer calories consumed equals less weight gained or more weight lost, right?

However, according to a recent review, regular consumption of non-nutritive sweeteners is related to an increase in BMI. This might be explained by sweeteners being associated with an amplifying of general cravings and appetite.

Despite this, and this is imperative: sweeteners are not all the same. They have different biochemical structures, with different routes of metabolisation and absorption. Certain sweeteners metabolise differently and are therefore better than others in maintaining blood glucose and weight management. Let’s look at a few different sweeteners and how they weigh up.


Sucralose (sold as Splenda) is 600 times sweeter than normal sugar. It’s mostly secreted which means it does not get absorbed in the body.

Although this might sound great, don’t be so quick to jump on the bandwagon. Sucralose has been associated with inflammation, and there is still ongoing research on whether it increases blood glucose level. The data is leaning towards a ‘no’ for people living with diabetes, as long-term use can cause insulin resistance.

It’s also worth mentioning that added table sugar, if consumed in excess, also causes inflammation and has also been associated with insulin resistance.

Conclusion: Consuming sucralose (or normal sugar) in excess over a long period of time has been linked to inflammation. Sucralose should rather be avoided if you’re diagnosed with any inflammatory diseases such, as rheumatoid arthritis or Crohn’s disease, as it can worsen the inflammatory state.


Aspartame is mostly used in sugar-free or low-sugar drinks and Iced Tea lite.

After the big media frenzy of aspartame causing cancer, recent human studies proved aspartame had no carcinogenic effect. However, it’s worthwhile to note that it’s still not beneficial for your health. More specifically gut health, as aspartame increases certain bacteria in your gut that are directly associated with weight gain.

Furthermore, the long-term (more than 10 years) use of aspartame has been negatively associated with cardiac health. Lastly, aspartame also leads to an increase in carbohydrate cravings, which can lead to increased appetite.

Conclusion: Although aspartame was set-free from being cancer causing, it still increases carbohydrate cravings and the effect it has on gut- and cardiac health shouldn’t be neglected.

Remember that moderation is key. Try to replace diet drinks with infused water or homemade iced teas (rooibos is such a good option). But if you still plan to consume aspartame, be sure to include extra fibrous vegetables, or even a probiotic, to keep the microbiota in balance.

Stevia, erythritol and xylitol

These three sweeteners have been categorised as natural sweeteners. The benefits of these sweeteners are that they don’t need insulin to be metabolised. Therefore, improves glucose tolerance and reduces insulin levels.

Stevia does have an undesirable bitter aftertaste, and erythritol and xylitol are quite expensive (roughly R150-160p/kg). But it seems worth it, because when consuming these natural sweeteners, the rewards system is activated leaving you feeling satisfied. And, in contrast to the previous mentioned sweeteners, they do not increase cravings.

Conclusion: Stevia, erythritol, and xylitol are superior. They can improve glucose levels and aid in weight management, in comparison to the other artificial sweeteners.

Still, moderation remains a key factor in any healthy diet. Therefore, using it sparingly will benefit your health as well as your wallet.

Retha Harmse is a Registered Dietitian and the ADSA Public relations portfolio holder. She has a passion for informing and equipping the in the field of nutrition. She is currently in private practice in Saxonwold, Houghton and believes that everyone deserves happiness and health and to achieve this she gives practical and individual-specific advice, guidelines and diets.


Retha Harmse (née Booyens) is a registered dietitian and the ADSA public relations portfolio holder. She has a passion for informing and equipping in the field of nutrition. She is currently in private practice in Saxonwold, Houghton and believes that everyone deserves happiness and health and to achieve this she gives practical and individual-specific advice, guidelines and diets.

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The keto diet – what you need to know

Recently, the ketogenic diet (keto for short) has been in the spotlight as the new diet to try. With that dietitian, Retha Harmse, educates us on the ‘latest craze’ diet.

The keto diet is everywhere; it’s difficult to avoid seeing it on influencers’ Instagram stories; keto options in supermarkets and on restaurant menus; and even friends or relatives speaking about their wonderful results. But, let’s take a closer look at the ketogenic diet.

What it the keto diet?

The ketogenic diet is a high fat, low carbohydrate and low to moderate protein diet that changes the body’s metabolism into ketosis. Any diet where fat is metabolised instead of carbohydrate is essentially a ketogenic diet.

Understanding ketosis

During a ‘normal’ or well-balanced diet, the body’s main source of energy is carbohydrates. More specifically, glucose which is the end-product of carbohydrate metabolism/digestion.

But the body is also able to burn fat for energy, and this is utilised in the form of ketones. Ketones are molecules produced by our liver when fat is metabolised; this metabolic switch is called ketosis.

However, the body doesn’t go into ketosis if there is enough carbohydrates available. Consequently, carbohydrates need to be drastically reduced or eliminated to move towards ketones as the primary energy source.

What does it involve?

Generally, on the ketogenic diet, the macronutrient ratio varies within the following ranges:

  • 65 – 80% of calories from fat.
    • Fat-intake is often over 150 grams (double the usual intake of fat).
  • 20 – 25% of calories from protein.
  • 5 – 10% of calories from net carbohydrate.
    • Roughly 20 – 50 grams a day (compared to the recommended daily amount of 200 – 300 grams per day).

What does this mean in non-dietitian language?

The keto diet prescribes high amounts of fat (both animal and plant sources), low-carbohydrate vegetables, nuts, seeds, and modest protein in the form of meat, fish and eggs. It excludes grains, dairy, legumes, soy, most fruits and starchy vegetables.

Meticulous planning

Ketogenic diets require meticulous planning to ensure the liver continues producing a constant supply of ketones to supply the body with energy.

To maintain ketosis, an individual’s diet needs to be precisely planned and tracked daily, as limiting carbohydrates and increasing fat is not the only focus of the ketogenic diet.

It’s also imperative not to consume protein in excess, as proteins can also be broken down to glucose (through a process called gluconeogenesis). This will in turn inhibit the ability for the body to move into ketosis. Also, if carbohydrates are not restricted enough, it might result in ketonuria (ketones in the urine and not used as energy). This is detectable by urinary dipstick analysis.

The history of keto diets

Although ketogenic diets might seem like the new ‘craze’; they are nothing new. Ketogenic diets have been around from the early 1900s, when they were discovered to have an efficacy in the treatment and management of epilepsy in children.

It is still used for this purpose; although more recently these diets have gained popularity for the management of obesity and Type 2 diabetes.

However, it’s important to note that the macronutrient ratios and recommendations for the ketogenic diet in the management of paediatric epilepsy are substantially different than those advocated for the management of obesity and Type 2 diabetes.

What are the benefits?

In terms of weight loss, evidence suggests quicker initial weight loss. This might be due to the initial use of glycogen stores (glucose stored in the muscle and liver), or reduced energy intake due to increased satiety from eating a large amount of fat and protein.

But long-term differences in weight lost showed no significant difference in comparison to other diets.

As mentioned previously, ketogenic diets have been used for decades to treat epilepsy. But, more recently, research has suggested that they might have a role in treating Type 2 diabetes and inflammatory conditions, such as chronic pain. That been said, there isn’t sufficient evidence just yet to support ketogenic diets for these conditions in terms of its long-term safety and efficacy.

Lastly, research has found that people consuming fewer calories from carbohydrate tend to eat fewer foods high in added sugars, such as soft drinks, doughnuts, etc. Yet, other research has found that the more carbohydrate consumption is restricted, the greater risk there is for poor nutrient intake. 

Potential side effects

  • High fat diets, especially when it’s high in saturated fat, increases total cholesterol. More specifically LDL cholesterol which is the “bad” cholesterol.
    • Both total and LDL cholesterol are both biomarkers for poor cardiovascular health.
  • Reduced energy and decrease in performance in activities that use short bursts of power, because ketogenic diets depletes the energy stores in your muscles (glycogen as mentioned previously).
  • Fatigue, general weakness, headaches and sluggishness, or brain fog.
  • Due to the very low fibre intake of ketogenic diets, you may experience constipation, increased risk of digestive problems and microbiota imbalances.
  • Limited fruit, vegetables and grains consumption – thereby limiting nutrient intake that might lead to deficiencies.
    • Nutrients (lack of) of particular concern on the ketogenic diet are calcium, vitamin D, selenium, magnesium, zinc and phosphorus.
  • Increased oxidation and inflammation in the body.
    • Recent evidence has shown that high fat diets, especially saturated fat, may promote inflammation and lead to the progression of inflammatory diseases, such as Alzheimer’s disease.
  • Possible loss of lean muscle mass.
  • Dry mouth, frequent urination, halitosis (bad breath = acidic, fruity odour).

Take-home message

Currently, there is a lack of strong evidence for ketogenic diets, based on their health claims about longevity, gut microbiome and heart health. Diets that are higher in carbohydrates and lower in protein, in fact, have the strongest links to longer lives and happy guts.

There are various probable side effects when following a ketogenic diet, which is why there is a need for ongoing monitoring and consistent assessment by a qualified dietitian.

Overall, unless medically indicated, I do not recommend following a ketogenic diet. Considering fat and carbohydrates, it’s all about balance.

  • The types of fat you include and the quantities you consume does matter.
  • Carbohydrates does form part of a healthy balanced diet.

My tactic is always to look at sustainable changes you can make that doesn’t include elimination of entire food groups.

Retha Harmse is a Registered Dietitian and the ADSA Public relations portfolio holder. She has a passion for informing and equipping the in the field of nutrition. She is currently in private practice in Saxonwold, Houghton and believes that everyone deserves happiness and health and to achieve this she gives practical and individual-specific advice, guidelines and diets.


Retha Harmse (née Booyens) is a registered dietitian and the ADSA public relations portfolio holder. She has a passion for informing and equipping the field of nutrition. She is currently in private practice in Saxonwold, Houghton, and believes that everyone deserves happiness and health. To achieve this, she gives practical and individual-specific advice, guidelines and diets.

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What fruit is best for you?

Dietitian, Donna Van Zyl, explains the considerations for diabetes patients when eating fruit.

There is often concern as to eating ‘sweet fruit’ if you have diabetes. However, this does not mean that you should avoid eating fruit completely.

Fruit can be classified under the macronutrient, known as carbohydrates. Carbohydrates, or fruit, are digested and converted by the body into glucose and therefore should be counted as part of a carb-counting regimen.

What needs to be considered when eating fruit is: the type of fruit and the quantity consumed as both these influence blood glucose control.

If we look at the type, fruits are classified according to their glycaemic index, which will further have an impact on the spike of the blood glucose level.

Type of fruit: The glycaemic index

What is the glycaemic index (GI)?

It is a numerical measure of the rate i.e. how fast and to what extent the intake of carbohydrate rich foods may affect your blood glucose levels. An item of food with a high GI raises blood glucose levels more than an item of food with a medium or low GI.

Glucose has been given a numerical value of 100, because it is absorbed immediately into the bloodstream. All carbohydrate-containing food, such as fruit, are compared to the reference of glucose.

The low-GI index food items fall below the reference range of 40 (<40) and are given the green to go. Whereas intermediate-GI food items falls within the reference range of 56 – 69; the orange for slow down and proceed with caution. The high-GI food items, with a reference range of above 70 (70+), gets the red for halt.

Though, high-GI fruits can be consumed with exercise, depending on blood glucose levels, and in combination with other foods products, especially protein or fat, or even to correct a hypoglycaemic event.

The GI Foundation uses the following icons to indicate the GI of foods:

Absorption and digestion factors

Factors affecting the absorption and digestion of fruit, which in turn may influence the GI of foods include:

  • The amount of cooking (cooked apple versus raw apple).
  • Processing (fruit versus fruit juice).
  • Ripeness and storage time: the riper a fruit, the higher the GI.
  • The type of fibre (soluble – citrus fruits).
  • The more acidic a food is, the lower the GI value. e.g. lemon juice lowers the GI of the food or meal.
  • The presence of fat, protein or low-GI foods consumed with the GI carbohydrate.

When eating a higher GI fruit, you can combine it with other low GI foods, or protein and fat to balance out the effect on blood glucose levels. For example, eating a fruit salad and yoghurt (plain).

The GI of fruit commonly eaten

Fruit GLYCEMIC INDEX (glucose=100)  Serving size in gram
Apple, average 39 120
Banana, ripe 62 120
Grapefruit 25 120
Grapes, average 59 120
Orange, average 40 120
Peach, average 42 120
Peach, canned in light syrup 40 120
Pear, average 38 120
Prunes, pitted 29 60
Raisins 64 60
Strawberries/Berries 40 120/125
Watermelon 72 120

When looking at the GI of specific fruits above, a variety of low GI fruit should form part of a balanced dietary intake. Fruits are not only delicious, but a good source of fibre which helps aid in regulating blood glucose levels. Fruits are also a good source vitamins, minerals or phytochemicals which aid bodily functions and help fight against disease.

Give preference to apples, berries, peaches or citrus throughout the day and consume with meals to ensure that the rise in blood glucose is covered by the insulin injected i.e. part of carb-counting.

Whereas your high-GI fruit, such as watermelon or grapes, can be used to prevent hypoglycaemia, especially after exercise, or to correct a hypoglycaemic event.


Be mindful of your portions too. You will see the above-mentioned GI of fruit is indicated per quantity. Remember, the more fruit you eat at once, the more fruit sugar is also consumed which will affect blood glucose control.

One small apple provides approximately 15g of glycaemic carbohydrates. So, eating two apples in one go will naturally provide you with up to 30g of glycaemic carbohydrates, which will lead to a spike in blood glucose levels due to quantity consumed.

Take home message

Fruits form part of a healthy balanced intake. A variety of low-GI fruit should ideally be consumed and distributed throughout the day. Be cautious with high-GI fruits, however. they can be useful especially in picking up blood glucose levels.


Donna van Zyl is a private practicing dietitian for Nutritional Solutions, Bloemfontein. She is growing in the field of paediatrics and plays a key role in individualising nutritional therapy for Type 1 diabetics. Her special interest is in optimising health, managing chronic lifestyle related diseases, and sports nutrition. She lectures part-time at the University of the Free State, which she enjoys thoroughly.

Coconut oil – is it what it is set out to be?

The claimed health benefits of coconut products are in abundance, but how much of this information is true? Dietitian, Jessica Oosthuizen, tells us.

Coconut products are abundant on the shelves of supermarkets and health stores. These products promise so many health benefits. Apart from coconut oil, you will find coconut milk, coconut water, coconut yoghurt and coconut snack bars just to name a few.

If you Google the health benefits of coconut oil, the websites and lists will be endless. Claims for coconut oil will vary from increasing fat burning; reducing hunger therefore help you to eat less; ability to raise your ‘good’ HDL cholesterol; protection of skin, hair and dental health; reducing inflammation; and stimulating organs, such as the thyroid and the brain, to assist in weight loss. Let’s take a further look at the health claims.

  1. Coconut oil lowers your risk for heart disease

There are claims stating that populations who eat a lot of coconut oil are healthy. Such as those in India, Sri Lanka and countries in the South Pacific area. However, when evaluating these claims, it’s important to remember that there are various factors other than cholesterol that contribute to one outcome, such as heart disease.

The overall diet will play a key role towards how nutrients influence health outcomes. The diet consumed by these populations will contribute to their minimal risk for developing heart disease, as their diet is mostly unprocessed, and rich in wholegrains, fish and fresh fruit and vegetables. This type of diet contrasts with the typical Western diet – high in refined carbohydrates, sugars and saturated fats.

Clinical trials comparing the direct effect on cardiovascular disease (CVD) of coconut oil have not been reported. Therefore, there is no scientific evidence stating that coconut oil can reduce your risk for CVD.

Many studies have evaluated the effect of consuming a variety of fats and oils on blood lipid profiles, including coconut oil, butter, coconut butter and unsaturated fats (olive oil, sunflower oil, safflower oil and corn oil). Coconut oil raised both HDL and LDL cholesterol.

Numerous studies have shown that you can lower your risk of heart disease by replacing saturated fats with unsaturated fats in the diet. Individuals who adopt the Mediterranean style of eating that includes nuts, olives and olive oil had a lower risk for developing heart disease, stroke and death compared to those who follow a low-fat diet.

  1. Coconut oil is healthy as it contains medium-chain triglycerides (MCT)

All dietary fats consist of a variety of fatty acids. Depending on the length of the fatty acid chain, fatty acids are classified as short-, medium- or long-chain fatty acids. MCTs are easily digested and absorbed by the body.

The truth lies in the fact that lauric acid, which is the predominant property in coconut oil, has a higher molecular weight and is metabolised differently to the lower-molecular-weight triglycerides, such as caprylic and capric acids.

Most MCT fats are made up of caprylic and capric acids and not the lauric acid found in coconut oil. Since the triglycerides that are present in coconut oil cannot biologically or functionally be classified as MCTs, it is incorrect to apply these health benefits of coconut oil as the research is not relevant.

  1. Coconut oil is better to use for cooking

It’s imperative to understand the smoke point of certain types of oil when determining if it is suitable for cooking. The smoke point refers to the temperature that the oil can be used in cooking. The higher the smoke point, the more cooking methods it can be used for. The smoking point of coconut oil is 177°C compared to healthier options, such as virgin olive oil which has a smoking point of 210°C; sunflower oil (227°C) and canola oil (204°C).

The conclusion on coconut oil

The evidence showing an association between coconut consumption and risk factors for heart disease is mostly of poor quality. However, it does show that coconut oil compared to unsaturated plant oils raises total cholesterol, HDL cholesterol and LDL cholesterol. There is no convincing evidence to support the benefits of consuming coconut oil. Research suggests that replacing coconut oil with unsaturated fats, such as olive oil, could reduce your CVD risk.

With this said, it does not mean that all coconut products need to be completely avoided. They can add flavour to the occasional Thai or Indian dish.

When selecting an oil to use every day, it would be best to choose an unsaturated fat, such as olive oil. The World Health Organisation (WHO) recommends reducing saturated fats to <10% of total energy intake. Practically speaking for a man following an 8400kJ (2000kcal) diet, 10% of this would be 22g of saturated fat per day. One tablespoon of coconut provides 12g of saturated fat. Therefore, you can get an idea of how easy it is to reach your saturated fat intake for the day if using coconut oil. As a comparison, 1 tablespoon of olive oil only has 2g of saturated fat and 10g of monounsaturated and polyunsaturated fatty acids.


  1. Sacks et al. (2017). Dietary fats and Cardiovascular Disease. A Presidential Advisory from the American Heart Association. Circulation. 135 : e00-23.
  2. Clifton, P.M. & Keogh, J.B. (2017). A systematic review of the effect of dietary saturated and polyunsaturated fat on heart disease. Nutrition, Metabolism & Cardiovascular Diseases. 27:1060-1080.
  3. Eyres, L., Eyres, M.F., Chisholm, A. & Brown, R. C. 2016. Coconut oil consumption and cardiovascular risk factors in humans. Nutrition Reviews. 74(4):267-280.
  4. World Health Organisation. Practical advice on maintaining a health diet : Fats. 2018.


Jessica Oosthuizen RD (SA) is a Type 1 diabetic herself (since the age of 13). She has a special interest in the nutritional management of children and adults with diabetes. She also has a key interest in weight management and eating disorders. Her experience includes working in the clinical hospital setting as well as experience with a variety of chronic diseases of lifestyle, such as obesity, hypertension and Type 2 diabetes.

What have you gained this year through your diabetes?

As you reflect on the management of your diabetes in the year 2017, what are the first thoughts that come to mind? Has it been a difficult year where things have gone wrong? Has it been a better year than last year? Have you benefitted from your diabetes in any way?

Hopefully there have not been too many difficulties for you, but if there were, why not try to reframe those difficulties. What have you gained from them? If you don’t believe that you could gain from having diabetes, let me share some ideas of what you probably did gain, over and above all the knowledge you learned as you managed your diabetes.

What you might have gained

  • You developed a greater appreciation of life itself. Diabetes is one chronic condition where you can continue living a healthy life if you follow your treatment well.
  • Your sense of self-worth increased as you realised you really want to live and will do what you have to do to keep living.
  • You developed more resilience – the courage to come back – as you tackled your diabetes each day, even if you did not always succeed.
  • You strengthened your resistance to the tough times and that allowed you to cope better when the tough times came.
  • You learned more perseverance because diabetes is ongoing and requires your input daily.
  • You gained confidence as you coped with the ups and downs and gained experience of what was happening.
  • You developed the capacity to be adaptable and flexible since diabetes is never an exact science and often does the unexpected.
  • You developed the ability to learn from your experiences.
  • You increased your level of tolerance of negative emotions and failures.
  • You have greater compassion and empathy for others who have struggles, especially those who have diabetes.
  • You have developed the ability to maintain courage, hope and informed optimism in the face of diabetes.

Personal growth

So, although negative consequences are usually associated with diabetes, there is positive personal growth too. How many of these qualities do you think you have gained? I am sure if you think about it, there will be at least a little of each. If it is just a little, keep working at your diabetes in the best way you can and you will come to the end of next year with more days of adjustment, inner peace and positive self-worth. At best you will be a stronger person, who is well able to continue managing your diabetes effectively for now and in the future. May 2018 be a year like that for you.


Rosemary Flynn
Rosemary Flynn is a clinical psychologist at the Centre for Diabetes in Johannesburg. She has worked with children, families and adults with diabetes for 24 years, enabling them to overcome their anxieties about their condition and to deal with the difficult events in their lives.

What jobs can’t diabetes patients do?

There are certain types of jobs that diabetes patients are not allowed to do, especially if they are on insulin. Dr Louise Johnson explains the jobs that fall in this category and further discusses other concerns that diabetes patients could have while in the workplace.


A Type 1 diabetes patient can’t be a pilot, however, a Type 2 diabetes patient, only treated with metformin tablets, can. The reasoning behind this is other oral medications and especially insulin could cause a sudden drop in blood glucose. This is dangerous for not only the pilot but passengers and public on the ground.

Mining industry

As soon as diabetes patients who work in the mining industry go on insulin, it becomes dangerous to go underground due to the risk of hypoglycaemia.

Public transport drivers

Since the driver controls the vehicle (taxi, bus, train) that carries passengers from point A to point B, it can be risky if the driver experiences hypoglycaemia. It can also be dangerous, if the driver has high blood sugar as it may lead to drowsiness and possible accidents.

Other concerns

Safety shoes

Diabetes patients working in industries where safety shoes are a requirement, need to ask their doctor to write a motivation to wear special safety shoes, suitable for diabetic patients. This is of importance to prevent their feet from injuries, such as scratches, pressure points and ulcers. Since injuries on the foot of a diabetes patient can lead to deeper ulcers and infection.

If it is not treated correctly and the patient has impaired sensation (peripheral neuropathy), it can contribute to the development of an amputation should the wounds not heal. Diabetes patients with impaired sensation often complain of burning feet, especially at night. They are the high-risk group for feet problems.

Writing exams

Diabetes patients that are on the go with studies should discuss their condition with the lecturers or invigilators. They need to inform them that their blood glucose can go incredibly high due to stress, and can cause severe drowsiness and a diabetic ketoacidosis (high sugar coma).

Diabetic ketoacidosis is a condition where the sugar rises exceptionally high due to insufficient insulin in the body. The body’s metabolism changes from using glucose as substrate for energy to using muscle breakdown products, called free fatty acids. The result is difficulty breathing, abdominal pain, nausea, vomiting, and confusion. This is a medical emergency, and can lead to death if not treated urgently.

Hence, why the lecturer/invigilator should also allow the diabetic student to take a sugar snack, glucose test machine, and insulin into the examination room. This is necessary to correct low or high blood sugar immediately to prevent any acute complications. Additional time should also be allocated to the student during exams, should the student have a low blood sugar event as it takes up to 30 minutes for the brain function to return to normal.


For many South Africans, driving forms part of their work – either by driving long distances to get to work or driving being one of their duties. Diabetes can affect driving due to hypoglycaemia. The low blood sugar may result in transient cognitive dysfunction or even loss of consciousness.

In a simulator, it was shown that cognitive functions critical to driving, such as reaction times and hand-eye coordination are impaired during hypoglycaemia. People experiencing hypoglycaemia ignored road signs and did not keep to lanes3.

Diabetes can also affect driving due to chronic complications associated with diabetes. The bleeding diabetic eye with decreased vision and the patient with an amputated limb has more difficulty to drive. The same can be said of the diabetic patient that had a stroke.

Type 2 diabetes is often associated with sleep apnea (stop breathing intermittently). This is a condition where a person has excessive daytime sleepiness due to snoring and a severe interrupted sleep pattern at night, which can be dangerous if the person is driving. Sleep apnea can be associated with obesity. It is effectively managed with a continuous positive airway pressure (CPAP) machine that increases the pressures in the airways at night and prevents the sleep apnea.

Any diabetic that had a severe hypoglycaemic event should not drive for at least six weeks thereafter. A severe low blood sugar event is where a person needs the help of a third party or is hospitalised due to hypoglycaemia. They can start driving again after six weeks or only after their awareness of hypoglycaemia has returned4.

Type 2 diabetes

People with Type 2 diabetes can do most occupations, if they follow a rigorous healthy lifestyle and diet to prevent going onto insulin.

Insulin is currently still needed after about 10 years of Type 2 diabetes but there are a variety of new drugs on the horizon that may help stretch this period even longer. Always take your HbA1c (average blood glucose value) into consideration to prevent complications and stay on target.

Managing your diabetes and workday

In the normal course of a workday, diabetes should be taken into consideration. Midday meals should not be skipped. If a person works at a company with a canteen, it would be reasonable to expect the company to cater for people with diabetes. Scholars and students attending academic institutions have the same requirements for special low-glycaemic index (GI) meals. Ideally, these institutions should cater for these scholars and students and their special needs.

The 2015 International Diabetes Federation (IDF) stats show that one in eleven people have diabetes, while the number of people suffering from diabetes in Africa was 14,2 million. This means that there are many diabetes patients at any company or academic institution.

One should take into consideration that obesity has epidemic proportions and healthy food consumption can help curb the diabetes epidemic. The South African National Health and Nutrition Examination Survey (SAHANES) data show that one third of men and two thirds of women are currently obese in South Africa1.

The data shows accordingly in Type 2 diabetes – an unhealthy lifestyle plays a major role in developing Type 2 diabetes and 80-90% of Type 2 diabetes patients are overweight. Data also showed that if obese people loose 5% to 10% of their weight, diabetes could be prevented2.

Any company should screen employees for diabetes at least once a year, since early detection of Type 2 diabetes can be excellently managed with lifestyle management such as moderate exercise and weight loss.


  1. Shisana O, Labadarios D, Rehle T et. al. (2014) ‘The South African National Health and Nutrition Examination Survey. ( SANHANES-1)
  2. Wing RR, Lang W, Wadden TA et. al. (2011) ‘ Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes.’ Diabetes Care, 34(7) p1481-1486
  3. Cox DJ, Gonder-Frederick L, Kovatchev B et. al. (1993) ‘Driving decrements in type 1 diabetes during moderate hypoglycaemia.’ Diabetes, 42 p239-43
  4. SEMDSA Type 2 diabetes guideline expert committee. (2017) ‘The 2017 SEMDSA Guideline for the management of type 2 Diabetes.’ JEMDSA,22 (1)Supplement 1 (S1-S196)

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Johnson
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.

What it takes to have that ‘perfect’ smile…for you

There is something rather special about a big bright smile. There is a certain warmth that we feel when greeted by someone who is smiling broadly. What is it about a full smile that makes it so attractive? Is there such a thing as a perfect smile? Marc Sher touches on some of the fundamentals of aesthetics in dentistry.

When the human eye sees things in proportion, we immediately find this attractive. This concept is known as the golden proportion or golden ratio, and is mentioned countless times in literature pertaining to cosmetic surgery and dental aesthetics. The golden proportion is an ancient concept, dating back to the times of the ancient Greeks. It has helped us understand why the relationship of adjacent shapes/objects makes it appeal to the human eye. The golden ratio is 1:0.618 or Pi, and is consistent in nature. The ratio between the front eight teeth, when looking directly at the central incisors, is one of these natural concepts that follows the golden proportion.

When the eight front teeth (smile line) of the top jaw follow the golden proportion, they will immediately look attractive; this is what we aim to achieve in dental aesthetics. It will always be a dentist and dental specialist’s greatest challenge when trying to recreate a smile.

The concept of the golden ratio is also seen in the relationship between the lips and teeth, the smile and teeth, and even the eyes and teeth. For any dentist to achieve that perfect smile for their patient, they must understand the golden ratio.

Just to clarify, the perfect smile does not exist in isolation and cannot be copied from person to person. To have a perfect smile is to have the right smile for you. Yes, we follow the principles that can help create that perfect ratio which may lead to a more attractive smile, but to try and achieve ‘perfection’ is only in the eye of the beholder.

Many dentists who specialise in aesthetic dentistry will understand the concept of a smile design. This is a process that we use to analyse a specific patient’s smile that helps guide the dental team in achieving their desired result; it involves using digital photography and videography to evaluate a patient’s smile line, lip line and central line, amongst other important features. We can use this information to digitally design a smile. It allows us (the dentist/specialist) to communicate the needs to the dental laboratory, in order, to create the ceramic/porcelain crowns or veneers which are to be bonded onto the front six to eight teeth (sometimes more) in the smile line. We then communicate this back to the patient. The use of a specialised dental laboratory is essential in this process as the dental technician is the one creating the ceramic/porcelain teeth.

The process of crowning/veneering teeth can be incredibly invasive as the tooth is usually irreversibly cut down to allow the ceramic prosthesis to fit. I, personally, do not advocate the cutting of healthy teeth to change their appearance. Once a tooth is cut/drilled on, there is no turning back. In cases where all other non-invasive options have been investigated and a tooth is already compromised, filled, broken, or missing, only then should the use of ceramics/porcelains be used.

I usually urge a patient to follow a less invasive route if they’re looking at changing their smile line. Orthodontics is my preferred method of moving teeth into their ideal proportion/relationship as orthodontists are incredibly skilled in creating the correct relationship between teeth. I always encourage my patients seeking an ‘aesthetic makeover’ to investigate the orthodontic process. This specific process does involve a sacrifice of sorts; wearing braces or retainers to move the teeth can be uncomfortable, cumbersome and obviously less attractive. However, it is important to understand that it is only a short-term sacrifice in the grand scheme of things, and the benefit is that you do not land up cutting healthy tooth structure.

“We shall never know all the good that a simple smile can do” – Mother Teresa

Tooth whitening

Tooth whitening plays a massive roll in the realm of aesthetic dentistry. I am often bombarded with requests to make my patients teeth whiter. What is important to understand, is the concept of tooth colour and staining. A natural tooth can have a variety of different levels of whites, yellows, blues and, even, greys. Therefore, we classify tooth colour in shades. This can be seen quite easily if you look at your canines; the neck of a canine has more of a yellow shade then the adjacent incisor.

Tooth whitening or bleaching changes the intrinsic (natural) shade of a tooth by penetrating the enamel layer and ‘bleaching’ the layer below, the dentine. The process involves the use of a peroxide-based bleaching agent, and a heated exchange reaction takes place. Tooth sensitivity is a very common side effect. However, it is not long-lasting.

Staining of teeth involves the extrinsic surface of the tooth. This is the after-effect caused by many of the wonderful things we love to eat and drink, such as coffee, tea, red wine, fruits, some vegetables and more. Smoking is also a major factor in extrinsic tooth staining. Fortunately, extrinsic stains can be quite easily removed by an oral hygienist or a dentist with specialised cleaning instruments. I always recommend a professional cleaning before any bleaching procedure is commenced.

All the concepts I have mentioned play a pivotal role in aesthetic dentistry. In today’s times, we can easily become obsessed with our appearance and be incredibly self-conscious of our smile. We may feel pressured to achieve perfection in our smile, and that obsession can alter the very essence of why we smile in first place. The act of smiling is far more important than the way it looks!

It is vital to protect what nature has given you by following a strict protocol of maintenance and prevention. You must also never compromise your dental health and function to achieve an aesthetic outcome. It is however comforting to know that with the help of modern technology in dentistry and with the skilled hands of a dentist, specialist and dental technician, we’re able to create beautiful bespoke smiles if needed.  


Dr Marc Sher (B.Ch.D) practices at The Dental Practice in Sea Point, Cape Town, and can be reached via email: [email protected]