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frequently asked questions

Frequently asked questions when diagnosed with diabetes

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When diagnosed with diabetes, you will have a plethora of questions. Diabetic Nurse Educator, Christine Manga, shares the top 10 frequently asked questions.

A whirlwind of emotions is dealt with when receiving a diabetes diagnosis. Because of this, the first consultation post diagnosis barely touches on treatment per se. This is due to the fact that patients have an overwhelming need to get answers that are pertinent to them. There is definitely a trend to the questions that are asked regularly. I consider the following questions to be frequently asked questions (FAQs).

1. Is my diagnosis correct?

For a diabetes diagnosis to be made, a minimum of two blood glucose tests need to be done. It is recommended that the same test is used, but on two separate days. A fasting blood glucose reading of ≥7 mmol/l, a random blood glucose level of ≥11 mmol/l, or a two hour post glucose ingestion reading of ≥ 11 mmol/l is required for diabetes to be confirmed. One HbA1c level of ≥6,5% would also be sufficient to make the diagnosis of diabetes. If these tests have been done, then the diagnosis is most likely correct.

2. Is Type 2 diabetes reversible or is there a cure?

No and no. It can, however, be managed that it goes into ‘remission’ or gets significantly better. This is more likely to happen in the early stages of the disease. This can be achieved by being physically active and losing excessive amounts of weight by dietary means or bariatric surgery. Even with this weight loss, some people will not go into remission. Unfortunately, aging, the natural progression of Type 2 diabetes, and weight regain will cause the diabetes to return in most people.

3. Did I get diabetes from eating too much sugar?

No. However, a high consumption of fatty and sugary foods can cause weight gain. This extra weight could lead to insulin resistance which usually precedes Type 2 diabetes.

There are some people who do not carry extra weight and yet go on to develop diabetes. In these individuals, genetics may play a significant role. If you have a parent or sibling with Type 2 diabetes, you have an increased risk of developing diabetes yourself.

4. What do I do now that I have been diagnosed with diabetes?

It is important to make positive lifestyle changes. Being active is important. The World Health Organisation recommends 150 minutes of activity a week. Following a balanced, nutritional eating plan is imperative in managing your diabetes. A dietitian can assist you with this, as it is best if it is individualised.

Adhering to the medication regimen, prescribed by your medical practitioner, will also form part of the lifestyle changes. An annual screening by a podiatrist and ophthalmologist are also advised.

5. What should my glucose readings be?

There are international guidelines set out for glucose targets. These targets may need to be adjusted according to your individual needs. Your practitioner would assist you with deciding on a target. By achieving these targets, it may delay the onset of diabetes complications.

The targets set out for the general population with diabetes are:

  • fasting blood glucose 4,0-7,0mmol/l
  • post prandial (MEAL) blood glucose of <10,0mmol/l

Avoiding hypoglycaemia whilst reaching these targets may be challenging.

6. I don’t want to inject, but do I need to take insulin?

Some patients may live for many years using only oral medication to manage their condition. Research indicates that the earlier diabetes is diagnosed and treated, it may delay the need to use insulin.

On the other hand, some patients experience a much quicker progression of their diabetes. This could result in the need to use insulin early on in the condition. Most people living in excess of fifteen years with diabetes will require insulin.

An indication that you may need insulin is when your glucose readings and HbA1c start to increase. Your medical practitioner will discuss with you – if and when it is necessary to commence insulin.

Once on insulin, you will usually use it for the rest of your life. If the correct injection technique, site rotation and needle replacement is practised, injecting of insulin will not be too uncomfortable.

7. Now that I take insulin, do I have Type 1 diabetes?

No. Type 2 diabetes can’t turn into Type 1 diabetes. They have different causes. Type 1 diabetes is an autoimmune disease – the body completely destroys the insulin producing cells so that no insulin can be produced. People with Type 1 diabetes need to start taking insulin at diagnosis. Type 1 usually occurs in childhood and is much less common than Type 2 diabetes.

With Type 2 diabetes, the body does still produce insulin, however, the body can be resistant to it. Over time the body will produce less insulin, at this stage you will need to start to replace insulin by means of injections. You will still have Type 2 diabetes.

8. Will I gain weight with insulin?

Possibly yes. When you are not using insulin, your levels of glucose in the blood stream are high. Some of this glucose is lost in the urine. Once you commence insulin, the cells in the body absorb this glucose from the blood, to be used as energy. If you are consuming extra glucose, the body will now store it as fat. Portion control and being active are important ways to combat the potential weight gain.

9. Can I share a glucometer with my family/partner?

Preferably not. Firstly, for infection control, it is important that each person who is pricking their finger should use their own needle. This will prevent blood borne diseases spreading.

Secondly, when your practitioner downloads the glucometer to evaluate your control, it will not be a true reflection. Your averages will be skewed and the profile of your readings will be inaccurate. This could lead to incorrect management choices. If you do have to share a meter with someone, let your practitioner know.

10. Can I drink alcohol?

Yes. Taken in moderation it is okay to consume alcohol. One drink a day for women and two drinks a day for men. Taking alcohol with certain medication and/or insulin can increase your risk of hypoglycaemia. Discuss this with your diabetes practitioner.

No doubt, there will be many other questions; direct them to your healthcare provider who will give you the correct information.

MEET OUR EXPERT

Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.
Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.
jogging safety tips

Jogging safety tips

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Jogging provides the perfect opportunity to keep fit and enjoy the outdoors, however, it is important for runners to keep road safety top of mind while heading out on foot. Imperial Road Safety share five jogging safety tips.

Road safety should not only be a priority for motorists; it is of even more importance for runners, who are exposed to all kind of risks – one of which are unaware and/or reckless drivers. So, before you head out for your next jog, here are jogging safety tips to keep top of mind.

Leave a message

Before you head out for your jog, make sure that there is always someone who knows where you are going. We live in a digitally connected world that has made it easy to inform someone of your whereabouts. Let your family, friends or even your next-door neighbour know you have stepped out for a jog, and give them details on your planned route.

Run on the same side as oncoming traffic

While out on the road, run facing the oncoming traffic; this assists motorists, approaching your direction, in being able to see you better. Also, if anything happens in front of you, you can react quicker and possibly avoid accidents as opposed to having your back against traffic.

Wear visible clothes

The importance of being highly visible while running cannot be stressed enough. Always ensure that you wear high-visibility, brightly coloured clothing, irrespective of what time of day you are taking a jog.

For those who prefer jogging in the evenings, invest in a headlamp or handheld jogging torch so you can see where you’re going. The other road users will see you, and more importantly, avoid knocking you over.

Obey the rules of the road

While jogging, it’s often easy to forget the normal rules of the road. Therefore, it is important to be more alert while on the road. Obey the rules of the road. Remember motorists have the right of way in South Africa, unless you are running in an estate or complex that has a specific running track. More importantly, don’t forget to look right, look left, and right again before running across a road.   

Avoid wearing earphones

Most joggers prefer to play their favourite tunes to keep them motivated. However, this can have dangerous consequences. How are you able to hear anything around you, including approaching vehicles and hooters, if you have music playing full blast in your ears?

If you can’t do without your headphones, lower the volume instead. Keep it at a level that still allows you to hear what is going on around you. Another consideration is to only wear your earphones in one ear, leaving the other ear free of sound and able to identify any alerts.

jogging safety tips

The IMPERIAL Road Safety programme aims to create a sustainable and viable way of changing the perceptions and behaviours of road users, to encourage responsible road usage in South Africa from grass root level upwards.

When food stands still

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Dr Angela Murphy shares one of her patient’s stories to explain the connection between diabetes and gastroparesis.

Ms DL is a 28-year-old lady, who was diagnosed with Type 1 diabetes at the age of 15. She had poor control from the start due to not being able to accept the diagnosis. She was admitted regularly with diabetic ketoacidosis, with extreme dehydration. During these episodes, she would go into renal failure. Closer questioning revealed that symptoms would begin with nausea and vomiting. She had been experiencing bloating after meals for over a year.   A gastric emptying study was done, which showed significant gastroparesis.

What is gastroparesis?

It is a condition where the stomach does not empty properly, resulting in food not moving into the small intestine. Normally, the muscles of the entire gastrointestinal tract contract and release rhythmically to move food along, which is necessary for the digestive process. This muscle action is controlled by the vagus nerve. However, damage to the vagus nerve results in weaker, poorly contracting muscles and slows the movement of food out of the stomach.

Causes

Unfortunately, there are many causes – it can occur as a complication of surgery to the gastrointestinal tract; as part of neurological disorders; infective and inflammatory conditions; or in underactive thyroid disease. Over a third of cases are due to diabetes, and in some cases no specific cause can be found.

Poorly controlled diabetes can result in damage to the vagus nerve, and is the most common known cause of gastroparesis. Patients classically present with stomach pain, bloating, indigestion, nausea and vomiting. In an insulin-dependent diabetic patient, vomiting will lead to ketones, and the presentation may look like an episode of ketoacidosis. In addition, patients may have documented reflux disease or irritable bowel syndrome (IBS), and the symptoms may be attributed to these conditions. A careful examination and history is needed to work out the sequence of events.

Diagnostic tests

Ms DL had a variety of tests to diagnose her problem, such as:

  • Upper gastrointestinal gastroscopy is performed by either a gastroenterologist or a surgeon, and can be carried out as an outpatient. The patient fasts for six hours, then a flexible camera is used to look inside the oesophagus, stomach and the duodenum (the first part of the small intestine).
  • Barium meal and follow-through is when a patient must fast for eight hours and then drinks barium – a chalky type liquid – that is used as the contrast agent. A series of X-rays are then taken. Barium lines the gastrointestinal tract so will show any obstruction, such as food in the stomach, quite clearly on the X-ray.
  • Ultrasound allows the radiologist to exclude any disease of the gallbladder or pancreas.
  • Gastric emptying scintigraphy is usually the gold standard for diagnosis. The patient fasts from the night before and is then required to eat a bland meal which is radiolabelled with technetium. A camera then scans the abdomen to follow the progress of the radiolabelled food hourly for four hours after a meal. If more than 10% of the meal is in the stomach after four hours, the diagnosis of gastroparesis is made.

Treatment

Ms DL was started on domperidone (prokinetics) and erythromycin (antibiotic). After 10 months, the episodes returned despite medical treatment. She then had a gastric pacemaker inserted, which only seemed to give benefit for six months. Ms DL recently spent weeks in hospital being treated with anti-nausea medication and intravenous fluids. Unfortunately, there was no way to improve the result with the pacemaker so she was given the option of Botox injections; however, the relief in symptoms after this was very short. After almost two years of suffering, Ms DL underwent a sleeve gastrectomy. (See medical explanations below).

  • Prokinetics are drugs that improve the contraction of the stomach muscles, and move food through to the small intestine more effectively.
    • Metoclopromide is the active ingredient in Maxalon and Clopamom. This should be taken 20-30 minutes before meals. It helps reduce nausea and vomiting. Although it is approved for gastroparesis, it may have side effects, such as tardive dyskinesia – a movement disorder which causes shaking.
    • Domperidone
  • Erythromycin is an antibiotic. When it is prescribed chronically at low doses, it improves stomach muscle contractions. Unfortunately, it can also cause nausea and stomach cramps which limits its use in the gastroparesis patient.
  • Anti-emetics are anti-nausea drugs.
    • Prochlorperazine (Stemetil) is useful when the patient is acutely ill, however, it has even more side effects with chronic use than metoclopramide.
  • Antipsychotic drugs
    • Chlorpromazine (Largactil) has frequently been used in patients with severe, persistent hiccups. Its actions on muscle have also worked in the patient with gastroparesis with some degree of success.
  • Botulinum toxin is used when a gastroenterologist injects Botox directly into the pylorus (the valve between the stomach and duodenum involved in the rate of gastric emptying) using an endoscope. This relaxes the valve, keeping it open for longer periods allowing food to pass through. The results of Botox are quite variable; some patients have relief of their symptoms for months, while others find no improvement.
  • Gastric pacemaker is a neurostimulator device which can be surgically implanted. This is normally done in patients with symptoms not responding to medication and diet changes. The battery-operated device has electrodes that are inserted into the stomach muscle wall. This then sends signals at regular intervals to stimulate the stomach muscle.   Studies have found that sending pulses that have a higher frequency than normal gastric contraction improves nausea and vomiting more effectively. However, more work needs to be done to refine this treatment for patients.
  • Jejenostomy is a feeding tube which is placed through the abdominal wall directly into the jejunum (the second section of the small intestine). Special, balanced liquid food can then be given to the patient. It is commonly used in a malnourished, dehydrated patient.
  • Surgery
    • Sleeve gastrectomy is a near total gastrectomy performed via keyhole surgery.
    • Roux-en-Y gastric bypass is when a small pouch is made from the top of the stomach and is attached to a loop of jejunum.

In both these surgeries, by removing most of the functional stomach it is possible to relieve symptoms of nausea and vomiting. Patients must be well-prepared, even though the dietary changes required are essentially the same as they should be following: small regular meals (see info on diet below).

Surgery is the treatment of last resort, but in my patient, this was life-changing. In the months post-surgery, she has had fewer and fewer episodes of vomiting. Generally, her symptoms have declined and her quality of life has improved incredibly.

Diet

There are several useful measures patients can take to improve symptoms:

  • Eat six small meals a day; this gives the stomach a chance to empty.
  • Limit the amount of fatty foods.
  • Limit fibre as it also takes longer to digest.
  • Eat in an upright position.
  • Avoid late evening meals.
  • Avoid carbonated drinks.
  • If the patient is very symptomatic then a liquid diet is the best choice until improvement.

Gastroparesis and diabetes

There is no doubt a vicious cycle exists when diabetes and gastroparesis occur together; high blood glucose directly slows down gastric emptying. Poor diabetes control for more than 10 years increases the risk of damage to the autonomic nervous system. The autonomic nerves control the automatic functions of the body, such as heart beat, blood pressure and gastric emptying.   The erratic emptying of food into the small intestine makes timing of insulin doses very difficult, and patients often swing from high to low blood glucose levels. It may be necessary to change the insulin regimen to get better control, and frequent blood glucose testing is vital.

Gastroparesis severely impacts a patient’s quality of life. Most patients with gastroparesis will respond to dietary changes, prokinetics and erythromycin.   However, for those that don’t, it is important to pursue more invasive treatment until relief of symptoms is achieved.

MEET OUR EXPERT - Dr Angela Murphy

Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence and has a busy diabetes practice.