DIABETES Lifestyle Real People, Real Stories, Real Answers
The Narrative Issue • Positive Power
• The write way to heal • Cover story Fighting fit Greg Rusznyak
Wanna hike the Himalayas? Eating Green Support Groups How they can help
School and diabetes Sweeteners
The pros and cons Issue 3: 2010
The Official Community Journal of the Centre for Diabetes and Endocrinology Distributed free via selected pharmacies and medical aid schemes
R30.00 incl. VAT
INSIDE REGULARS Editor’s Note
• CONTENTS Surviving the diagnosis
32
Climbing with diabetes
34
PARENTING School & diabetes
In the Beginning...the history of the CDE
6
CDE Service provider classifieds
48
DIABETES MANAGEMENT Why it’s important to see a nurse educator
14
How a diabetes support group can help you
20
Caring for your kidneys
22
The lowdown on insulin pumps
24
Real men don’t use moisturiser
44
28
Trekking in the Himalayas
2
FOCUS ON THE CDE
37
EAT RIGHT The humble bean is king
16
Eating Green
40
Sweeteners - the pros and cons
45
LIVING WITH DIABETES
DISCLAIMER
The Power of Positive Narrative
8
The write way to heal
10
Alec & Eric
11
Fighting Fit - a lesson in hope reborn
12
Views expressed in editorial are not necessarily those of the CDE , the Publishers, or Editors. While every effort is made to ensure the accuracy of the content of this magazine, the CDE, the Publishers, and Editors do not accept responsibility for omissions or errors or their consequences. Any general advice contained within cannot and is not intended to be a substitute for professional medical advice, diagnosis or treatment and is not purporting to be the practice of medicine. Never disregard professional medical advice, or delay in seeking it, because of something you have read here, or rely on this information in place of seeking professional medical advice. Always discuss any new information with your Diabetes Team before acting on any aspect of it. Use of the information contained within this publication is thus with the understanding that it is at the readers own risk. Acceptance of advertising does not imply that these products and services are recommended by the CDE, the Publishers, or Editors.
Diabetes Lifestyle... Real People,Real Stories, Real Answers
Published for the Centre for Diabetes and Endocrinology by DevAd Publishing cc P O Box 377, Strubens Valley, 1735 Telephone - 011 475-1536 devad@polka.co.za Editor Michael Brown - CDE Houghton Managing Editor / Editorial Sharon Dale Wiggill devad@polka.co.za Advertising Executive Angela Bell 011 787-9366 / 0824510193 angbell@mweb.co.za Editorial Advisors Dr Larry Distiller Dr David Segal Dr Stan Landau Vanessa Brown Mandy Marcus Andrew Heilbrunn Tracey Johnson Paul Baker Design and layout Ian Wiggill Project Manager Peter Black - CEO, CDE Diabetes Management Programme Repro & Print CTP Web Printers Centre For Diabetes And Endocrinology 011 712-6000 www.cdecentre.co.za Copyright Material published in Diabetes Lifestyle, including all artwork, may not be copied reproduced or published without the permission of the publishers.
It is nearly the end of the year as we send our third issue of Diabetes Lifestyle to print. We trust that it will provide you our readers with some inspiring reading over the holiday period and a spark to some lasting New Years resolutions. I would like to thank all our contributors and our design and publishing team (Sharon and Ian) for their hard work, often late into the night! Personally, I thank God for helping me with this awesome responsibility. You might notice a new look and feel to our cover and contents – we are striving to make Diabetes Lifestyle the premier community journal on diabetes, by focussing on “Real People, Real Stories and Real Answers”. Please let us know if we are giving you what you need. In keeping with our focus on ‘Real People’, our cover story and picture this month highlight the journey of Greg Rusznyak who used to hate exercise and his diabetes. Greg tells a wonderful story of finding his ‘muse’ for diabetes and for life with it - truly hope reborn. Everyone has different needs, interests and motivations – the key is finding yours. We hope that his experience will be as helpful to you as it has been for him. Do you and diabetes have an interesting and extraordinary relationship? We would love to feature your ‘Real Story’ and your picture on our cover… Greg also experienced an added benefit of writing about his journey. He found it immensely therapeutic, so leading on to our theme for this issue, which is the power of the ‘personal narrative’. Everyone has a story - Rosemary Flynn, Paul Baker and Greg show us the importance of making your story positive, writing it down to help crystallise, process and own it and then going out and living a healthy, productive and fulfilling life as possible. In addition, we give ‘Real Answers’ on the crucial topics of sustainable eating on a severely wounded planet, schooling and diabetes, the importance of community support groups for diabetes, moisturising your feet and on caring for your kidneys. As always, that is not all…so you wanna hike the Himalayas? Congratulations to Elke Guy (who has lived with diabetes for 44 years) and Sharnay Ferreira, the first and second persons respectively to provide the correct answers (4 units and approximately 3 crackers) to our Readers Competition Number 2 (page 48 of Issue 2). Well done Elke and Sharnay – you have no problems with your numerical literacy! Your prize of a pair of Polaroid sunglasses valued at R550 / hamper of natural vitamins from Nutrifruit labs valued at R250 is on its way to you. We wish you love and rest with your family and friends…
Michael Brown Editor
Michael@cdecentre.co.za
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www.cdecentre.co.za
• FOCUS ON THE CDE
In the Beginning... the history of the CDE Dr. Larry Distiller Specialist Physician / Endocrinologist CDE. Houghton
In the 1980’s three things happened which completely changed not only our perception of diabetes management, but also our ability to improve diabetes control and outcomes for our patients - the first Home Glucose Monitoring meters were launched, insulin pen injectors became available and at the same time the importance of patient self-empowerment, though patient education, was realised. From the latter need, the concept of the Diabetes Nurse Educator was developed. It also became obvious that even patients with type 2 diabetes not on insulin would benefit enormously by a better understanding of their condition and a comprehensive team care approach. By the early 1990’s it was clear to us that in order to promote better diabetes care using these principles, we needed a multidisciplinary clinic. Therefore, in 1992 we opened the first “Centre for Diabetes and Endocrinology” in Parktown, Johannesburg. At that time, we had two doctors (Dr Brian Kramer and I), one educator, one podiatrist, one biokineticist, one dietician, and a small pharmacy with a qualified Pharmacist. Out of these seven individuals, the CDE as it currently exists was born. However, in those days the Medical Aids did not fund diabetes education, did not understand the role of Podiatry, and did not accept dietary intervention by a dietician as necessary. They paid a pittance, if at all, for these services. We therefore found ourselves in the unenviable situation of being unable to fund our staff salaries from our consultation fees. It rapidly became apparent that our dream of a Diabetes Clinic offering the best evidence-based care available was about to die. We knew our patients were getting comprehensive world-class care of their condition and were getting fewer complications, less hospitalizations and achieving a far better quality of life. It struck us that it would be ideal if we could partner with the Medical Aids. Our proposal asked them to “carve out” diabetes and pay us a set monthly (capitation) fee to take care of all aspects of the diabetes for their patients with this condition. By doing this, we could create a situation where we could continue providing the necessary high quality care that our mutual patients / members deserved and guarantee the Medical Schemes better outcomes for their patients and lower costs.
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Finally, we would be able to survive financially. This was a real win-win-win situation for the patients, the Medical Aids and us. In those days, Managed Care programmes and Disease Management as such was unheard of. It was with some difficulty that we finally persuaded the first Medical Aid Schemes to try out our capitation based Programme. Early in 1994, two Schemes, agreed to “give it a try”. Within 6 months, they contacted us to report that they were thrilled with the outcomes. So thrilled were they in fact that they wanted to open our “Diabetes Management Programme” to their members countrywide and not only at our clinic. That prompted us to approach the other Endocrinologists in the country (there were eight of us in the Private sector in those days) to ask them to provide the same service under the same financial arrangement. The CDE network was thus extended to include Durban, Cape Town and Bloemfontein. By the following year, our Programme had grown to include partnerships with a further three Medical Schemes. We were put under pressure to expand our network further to include other cities and towns across the country. No Endocrinologists were available, so we set about identifying Specialist Physicians and General Practitioners with an interest in diabetes. We offered to train them to run Centres under the CDE banner. Our network continued to expand to places like Port Elizabeth, East London, Polokwane and Nelspruit, to name just few areas. This also was the start of our Education Courses for doctors and Nurses. Understandably, many patients did not want to leave their current doctors to switch care to a CDE Centre and many doctors felt they would like to run a CDE Centre. We therefore opened the CDE up to any doctor who wanted to take on the responsibility, provided they attended our training courses and agreed contractually that they would provide the minimum care that we had guaranteed the Medical Aids. We also instituted the first Peer review and Audit process for a managed care Programme, with a medical doctor going from Centre to Centre to confirm adequacy of care and good clinical practice. From these beginnings, the CDE now encompasses over 270 Centres across South Africa. We have contracts with 30 Medical Aid partners and provide state-of-the art managed diabetes care to 20,000 patients with diabetes. We have also trained over 1000 doctors and 1500 nurses in our courses and in addition have trained health care providers in Lesotho and Botswana. The CDE Diabetes Management Programme has been accepted and lauded internationally as an “ideal” diabetes management programme. It is our hope the CDE will continue to grow and expand in order to provide ongoing quality care to many more patients with diabetes, to reduce hospitalization rates, to reduce long-term complications and improve their quality of life. All this must be done in a cost-effective manner for the Medical Aids. As we grow and evolve, we continually strive to meet the needs of people with diabetes and to remain relevant in our changing health care system. Watch this space! That ends the brief overview of our history to date, but the CDE story has only just begun…
• LIVING WITH DIABETES
The Power of Positive Narrative Rosemary Flynn Clinical Psychologist, CDE, Houghton
A narrative is a story that is created. Humans in all cultures develop their identities in some sort of narrative form. We have a conscious say in selecting the story we will use to make sense of the world we live in. Your life with diabetes is a narrative... You can choose to make the story very negative – a disease, difficult treatment, it is never-ending, it requires daily lifestyle management, there are complications... Focusing on these negatives in your story will tempt you to adopt a pessimistic view of your diabetes. Is there in fact anything positive about having diabetes? Can the story be a positive one? I believe there are positive stories to be told, not only to inspire hope, but also resilience. For a start, the condition is treatable. Even though the treatment is invasive and variable, it allows the individual to have a quality life in spite of the condition. With good management, the individual can pursue most interests. People with diabetes have studied doctorates, climbed Kilimanjaro, had successful relationships, run the Comrades marathon, cycled in races, been successful business men and women, and travelled all over the world. With good management, people with diabetes can live without complications for a very long time.
You can change the story of your life… Crafting your own story with your eyes on the positive, helps you to make sense of your adversity - diabetes. Start at the beginning – Know your diabetes. Be straight about the challenges you face. Talk about the things you have done right and where you might have done better. Use the support systems available to you – to gain skills, to make necessary adjustments, to find new ways of doing things. Highlight the good things that people are doing despite the tough times. Address the conflicts – Be certain to talk about how the dramas you experience are affecting your ability to cope, positively or negatively. Be specific and realistic. Address what you did and how you could have done something differently for better effect What is happening now! Adversity can bring about positive change. It may be an opportunity to lose the weight you always wanted to, to exercise again or even for the first time, to eat healthily, or to take responsibility instead of meandering through your life without a sense of meaning. Never make assumptions about the ending. We all want a happy ending to our story, but life often takes a different course to the one we planned. Learn to adapt the story to whatever life puts in your way. This will enable you to look at the different experiences as challenges to be dealt with and from which to grow, rather than to let them take over your life. This also provides you with a way to look at possibilities rather than to reach forgone conclusions. Dave Brooks, a New York Times columnist, put it this way; “If you craft a narrative that includes a context of the way things were, as well as the way things can be, you provide a road map to make sense of the world in ways that inspire hope”. Developing a positive story about your diabetes is the first and the last step in living at peace with it. Being at peace will enable you to cope with whatever comes your way.
If you listen to the positive stories people have told about how they coped with diabetes, it seems much less of a threat than it appears to be on the surface. The truth is that there are many success stories if you look for them. And, positive stories reinforce our belief that it is worth making an effort to manage diabetes effectively.
may be thinking, “what qualifies her to talk about ‘diabetes’ and ‘positive’ in the same sentence?”
Rob Geis said: “When you change your thinking, you change your beliefs; when you change your beliefs, you change your expectations; when you change your expectations, you change your attitude; when you change your attitude, you change your behaviour; when you change your behaviour, you change your performance; when you change your performance, you change your life”.
Apart from her Masters Degree in Clinical Psychology and her many years of clinical experience in diabetes, Rosemary’s best qualification to write this article is that she has had type 1 diabetes for 29 years. In spite of multiple daily doses of insulin and endless finger-pricks, she is a role model for the power of the positive narrative. Still not convinced? Read the next two real stories from real people with diabetes...
10 DIABETES Lifestyle
Editor’s Note - You have just read Rosemary’s article and you
• LIVING WITH DIABETES
The write way to heal the restaurant. It’s quite stressful if you are not used to it. The coffee seems to be working and I start to think about when I first realised that there was more to this process of writing.
Blogging for diabetes By Paul Baker
It’s twelve o’clock at night and all is quiet. Well all is quiet except for the fan of my PC that seems to be working in overdrive. I am writing an article for Diabetes Lifestyle. A thought: ‘Why?’ I try to erase the thought quickly with a ‘because you said you would’. This didn’t work so well because my next thought was ‘I could be sleeping. Everyone else is’. Yet I don’t go to bed. Something is keeping me here. Writing has become important to me. I started writing a blog about my diabetes almost a year ago. I had never written anything like this before, and the reasons I gave myself were: I wanted to help others who were in a similar situ-
ation. The thought of other people not coping with type 1 diabetes was overwhelming to me. I was coping. I felt this need to share some of the wisdom that I had gained in the hope that it would help others;
Certain experiences that I had had were worth dis-
cussing. I wanted to vent;
I always wanted to write but never seemed to have
a reason. I had one now;
My once creative job was not so creative anymore.
I needed another creative outlet.
My eyes suddenly feel heavy so I get up and turn on the kettle to make a cup of coffee. It has been quite a busy day that ended with my wife being called to the hospital in the middle of my son’s birthday dinner - my father-inlaw is not well. On top of that, my responsibility suddenly changed from finishing my beer lite to looking after four kids who seemed to only want to play on different sides of
After my third blog post, it occurred to me that I might not be the first person to think of writing a blog on my experiences as a person with diabetes. I investigated a bit deeper and discovered that there were over two million blogs like mine. I must confess to feeling a bit hurt at not being original, but then it dawned on me. Writing is about healing too. Being diagnosed with diabetes is traumatic. It is also likely that other traumatic times will follow. Yet we don’t go for trauma counselling, or at least I didn’t. I did some reading about dealing with trauma and there are similarities with how I sometimes feel. The denial: “I feel fine”, “I know I am different”, “This will pass”; the anger: “Why me?”, “It’s not fair”; the depression “I cannot get this under control. What is the point in trying? Pass me that slice of cake ….” You are supposed to go through all of these phases before you come to acceptance. I seem to go through any one of these phases at random times. Lucky for me, I spend most of my time in acceptance, or is it luck? Perhaps it’s the writing... There was a bonus too. When searching some of these two million blogs, I found a community that is incredibly supportive and accepting. I also discovered some very inspiring stories. Like the woman who has had type 1 diabetes for 63 years and has not yet had any complications; or the long list of successful sportsmen and celebrities who are living with diabetes; or the mother who has turned her sons type 1 diabetes into a story of hope and success. Living with diabetes can be isolating - this is perhaps the last reason why I and two million other people with diabetes around the world have chosen to write … and to heal.
Readers Competition Number 3 Continuing with our important theme of numerical literacy, try out our Competition Number 3. We have a pair of Polaroid sunglasses (either a ladies or gents pair, valued at R550) as well as a hamper of natural vitamins from Vitabiotics valued at R200 for the first two respondents to send in the correct answers to Michael@cdecentre.co.za 1. You test your blood glucose 4 times a day. How many strips do you need to take with you on a 2-week holiday? 2. You test your blood glucose 3 times a day and 6 times on Saturday, when you play 18 holes of golf. You start a new bottle of 50 strips on December 2nd 2010 (your last). Of the dates below, by when will you need to buy new strips to avoid running out of strips? Your pharmacy is not open on Sunday or on Public Holidays. Dec.15th
Dec. 16th
Dec. 17th
Jan. 2nd
Don’t forget to get your holiday diabetes supplies in good time!
• LIVING WITH DIABETES
& Eric
Dr Mac Robertson, Specialist physician, Centre for Diabetes and Endocrinology, Durban
Sunday 14 November was World Diabetes Day - I was reminded of a day in November 16 years ago, when on entering my rooms a few days after World Diabetes Day 1994, I saw what appeared to be twin males. Named Alec and Eric, they were, however, unrelated, but neighbours in Durban North. Their regular Saturday morning programme involved a short stroll to the Pick & Pay Hypermarket-By-The Sea where the local Lions Club sold hot-dogs and boerewors rolls. Before collecting their “boeries”, they ventured across to where three nursing sisters were conducting bloodglucose tests as their contribution to Diabetes Day. To their astonishment, both their levels were so high as to place them firmly in the “confirmed with diabetes” category. Just to add to my confusion, their initial HbA1c levels were identical. I made appointments for joint visits for both to our Nurse educator, Dietician and Ophthalmologist. I asked them to start a simple exercise programme by walking three times a week and to consult me again in three months to assess whether pharmacological treatment was indicated. They came separately this time. Eric suggested that his pal Alec suffered from an obsessive-compulsive disorder in that he went walking with his dog every morning at 04h30. The lights from Alec’s bedroom disturbed Eric and his family. As Eric (the “psychiatrically sane” one) showed no evidence of control, I started tablets for his diabetes and indicated a repeat session with the dietician.
Alec said he actually enjoyed the exercise but as a busy executive, he had no time during the day, hence the early start. His blood glucose levels were those of someone without diabetes so there was no call for tablets.
This pattern for both continued through the years. Alec graduated from walking to running. By 2006, he had completed 10 Comrades runs and earned his “green number”, all the while with superb blood glucose control and without pills. Eric, on the other hand, needed insulin when optimal doses of oral agents failed to work. His poor control led to a host of complications like erectile dysfunction (and a subsequent acrimonious divorce) and three sessions of pan-retinalphotocoagulation (laser therapy) for diabetic retinopathy. He also has chronic diabetes-related ulcers on both feet and has had four toes amputated. At present, Eric is on a dialysis programme awaiting a kidney transplant. Alec (still not on any pharma-therapy) is fit and well and his wife has just had another baby. This unfortunate fellow continues to display truly obsessive-compulsive behaviour, and runs almost every day. And, this poor, confused doctor is left wondering if there is a lesson hidden somewhere here… DIABETES
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• LIVING WITH DIABETES
Fighting fit
By Greg Rusznyak
A lesson in hope reborn Two things struck me about my youngest son Matthew’s remark: firstly, that the six year-old was able to project his voice clear across the Standard Bank Arena … and secondly, the marked tone of surprise. Brat! Definitely cutting his pocket money in half … I had just moved to the next round in the Kata section of the 2010 JKA Karate Tournament. Sounds impressive, doesn’t it? What’s more, I went on to win the gold medal in my category: the hotly contested 35-45 year-old male, novice, white-to-orange-belt category. OK, so there were only three of us, and I was always going to finish in the medals. I still count it as a victory. Let me tell you why. Growing up, I was always the biggest kid in my class, and I don’t just mean the tallest. I thought that the potato crisp was the pinnacle of innovation, and chip dip was just taking a good idea and making it better. I wasn’t the sportiest chap either. Even during the Basic Training phase of my National Service, I could not get serious about exercise, especially push-ups (Nog tien vir Raiseneck!). My heart just wasn’t in it. It wasn’t that I didn’t like exercise … it was that I hated it. After National Service, I decided to study. While at university, I joined a gym. Gotta get in shape, you know? I got a great deal on a 10-year, Supergold, all-singing, all-dancing membership to one of the popular gyms at the time. I went 3 times a week ... Religiously ... For about 6 months. After that, I carried around the laminated membership card in my wallet … Religiously … For about nine years and six months.
Moving ahead Fast-forward a bit: My eldest son, Timothy was born about 8 years ago during a particularly cold July. Just before the birth, I was feeling run down and full of ‘flu. I had always been the guy who never got sick. Yet now I was getting a bad cold every year – sometimes twice a year. I had also noticed that I was thirsty, all the time. Once on a 5-day business trip, I worked out that I had drunk nearly 70 litres of fluid during the 5 days. My wife, Lee, fetched
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me from the airport and the first thing that she said to me was “Wow! You’ve lost weight!” Something wasn’t right. I went to my doctor for a physical, and I asked him to check my blood pressure, cholesterol … oh, and my blood sugar. When the lab results came back, I learned that my blood glucose had been over 17 mmol/l. That was before breakfast. Not the ideal fasting blood glucose level. Well that’s no good. How do we fix that? My doctor’s advice was to attempt to control my blood glucose through ‘diet’, at first. After a few months however, it was time to add medication to the mix. I recall him mentioning that ‘diet and medication’ would take me part of the way, but that exercise was also crucial. I also recall nodding sagely. I now refer you to the last sentence in paragraph three.
Getting busy I bought a gym machine from a colleague at work. In fact, it is looking over my shoulder right now as I write this. The most exercise I got from it was disassembling, transporting and reassembling it every time we moved house. I also discovered that if you hang your wet jeans from the lat pull down bar, they would be dry by morning. Then I discovered squash. A great game. In fact, it was the very first form of exercise from which I ever experienced an endorphin rush. Surely, I’m on to something now? Alas, it was not to be. As a ‘diabetic’ with early signs of neuropathy, squash is a little too high-impact on the feet. Also with my one hundred and <deleted> kilograms hurtling around in a confined space, I found that I ran into walls a lot. The proverbial bull in a china shop. So, one cracked rib, one split forehead and
• LIVING WITH DIABETES two trips to the emergency room later, my squash days were over. True story … Cycling! Why didn’t I think of that before? Your feet are on pedals. They go round and round. Virtually zero impact. That’s the ticket. So, I shelled out a few thousand bucks on the all-singing, all-dancing … sigh. Does anyone want to buy a mountain bike? Hardly used. The brakes still squeak … What does this have to do with karate? Well, I did karate when I was a kid. Back then, I did it because my friends were doing it and because it was very Bruce Lee (younger people: think Jackie Chan, and don’t say a word!). When my parents divorced and we moved away, I had to give it up. However, I had enjoyed it. When the opportunity arose for our sons to do karate, Lee and I thought it was a good idea. It would teach them discipline and self-confidence. It would teach them to stand up for themselves and take a knock or two. It would also wrench them away from the TV for a while. Our boys had been doing a basic introduction to karate at their nursery school with Sensei Mark Wainman of Grove Karate. When they left nursery school, they joined Sensei Mark’s karate dojo. They took part in a karate competition at the beginning of 2010. Watching them compete, I was surprised to find that it tugged a very deep heartstring. I wanted to get back into it. I didn’t know it then, but Lee was also thinking about doing karate. We told our friends. They thought it was hilarious. We did it anyway.
Eight months later It is now eight months later, and I have noticed a few things. There are about 640 to 850 muscles in the human body, depending on whom you ask. I was using very few of them. Well I’m using lots of them now. My energy levels are up. My exercise recovery time is down. Endorphin rush? Absolutely! What is it about karate that means more to me than any other exercise I have tried? I think it is because it is not mindless exercise for its own sake. It is a martial art, and there is a strong mental component too. It is something that our family does together. In fact, I have noticed that there are several families at Grove Karate – parents
and children, who do karate together. Our kids think it is cool. So do I. I have also found that increasing my fitness through karate has changed how I feel about my diabetes. For years, ‘diet and medication’ have been the primary tools I have used in my diabetes management. Medication is determined by my doctor, and I ‘comply’. My responsibility has been to watch what I eat. If my ‘diet’ slipped, well then my diabetes control slipped as well. Karate has given me another tool, which I own. Through karate, I am discovering what it feels like to be stronger, fitter and healthier. I have a new exercise regimen, mental discipline, a family pursuit and a shiny gold medal! Editor’s note: Thank you so much for your story Greg. We wish you the very best in your future journey as you work to control your diabetes. You have won far more than a gold medal - as an observer, I can see a new man! A careful reading of what you have written will reveal some pure, golden nuggets of wisdom of which health care practitioners working in diabetes will do well to note. Your diabetes team cannot externally ‘motivate’, prescribe or ‘order’ you to do anything if you do not want to do it. Greg found something that tugged at his heart - he just did it - he owns this tool and wants to use it. The resultant spin-offs into all areas of Greg’s life have been huge – His smile is now as real as you can get!
• DIABETES MANAGEMENT
WHY it is important to see a nurse educator Laurie van der Merwe Specialist nurse educator, CDE, Empangeni
A diagnosis of diabetes can be overwhelming for many people; the management of a chronic condition such as diabetes is based on responsible self-care These two statements have huge implications for the care of the person with diabetes. This is where the Diabetes Educator plays an integral part in facilitating the dayto-day self-management of diabetes. The International Diabetes Federation, recognising this role, states “every person with diabetes, no matter where they live, has the right to learn about their condition”.
What is a diabetes educator? Diabetes educators are highly trained registered health professionals (e.g. registered nurse / dietician) with an extensive experience in diabetes. They help people with diabetes learn the skills needed to live a healthy lifestyle, to take charge of their own health needs, carry out responsible self-care and make informed decisions. The goals of self-management education are an increase in diabetes knowledge and skills, changes in attitude and motivation, concordance (agreement) with treatment and improved care. One of the main tasks is listening to the patient’s way of experiencing their condition and its treatment, and promoting the patient’s understanding of it. This ongoing process requires passion, time and dedication. Sessions may be on a one-to-one or group
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basis and may take 1 to 1 ½ hours each session. Diabetes education should be individualised to fit the person’s lifestyle taking into account treatment choices, meal choices and times, food likes and dislikes, cultural and religious choices, physical activity options and preferences and work / school issues. The person should feel the need to know what is being taught. This is more likely to happen when the process is personally relevant and enhances what that person already knows.
Case Study Mr K had been diagnosed with Type 1 diabetes and been prescribed a basal-bolus regimen, which involved an insulin injection before each meal and before bed. According to studies, this is the best regimen for good diabetes control. However, the doctor had not taken into consideration Mr K’s personal circumstances. Because of some severe episodes of hypoglycaemia (low blood glucose) at work, Mr K was now afraid of the insulin and had stopped taking it! When referred to the diabetes educator from his work clinic, he was very defensive. After discussions and history taking, it turned out that this young man worked in a very hot environment as a shift worker. If he did not work in this area of the factory for a required period, he would be unable to progress in his career. The severe hypos he had experienced were now putting his career in jeopardy. His blood glucose levels at this stage ranged between 18 and 28 mmol/l. His HbA1c was 13.7 %, indicating severe insulin deficiency and very poor diabetes control. After further discussions, he agreed as a short-term measure that he would be prepared to take one
• DIABETES MANAGEMENT injection a day of a long-acting insulin analogue to stabilise his blood glucose levels at a manageable if not ideal level. His doses of insulin were started at low levels due to his fear of hypos and then titrated up as he gained confidence. After two months, his HbA1c was down to 7.5 %. He was now confident enough to see for himself from pre- and post-meal blood glucose testing, that his main meal raised his blood glucose level too much. He was then taught exactly how the different insulin regimens worked, and when the different peaks of actions and periods of action were before making a decision of which regimen he could manage. This discussion took into account meal times and choices, shift times and risks of hypos. A rapid-acting insulin was then added before his main meal. Based on success with this stepped approach, he has since started taking a pre-meal dose before most meals when he is not going to work in the physically stressful environment. This approach did not immediately reflect the ideal “medical” management of diabetes. However, by finding
a regimen that suited him and with which he felt he could cope at the time, Mr K really started to manage his own diabetes. As he has lost fear and gained confidence, his blood glucose control has improved dramatically. Once he was lost, but now he is found… A diabetes educator is a great resource for people with diabetes. If you are newly diagnosed or have trouble controlling your blood glucose, a diabetes educator can help you take charge of your condition and implement the medical advice of your doctor. Your doctor can refer you to a diabetes educator in your area. You may meet oneon-one with an educator or in a group setting. The cost of seeing a diabetes educator may be covered by your medical aid. Editors Note: All members of the CDE Diabetes Management Programme are expected to have at least two consultations with a diabetes educator annually (CDE funds these consultations). Are you receiving this vital service? It is your right and your responsibility.
• EAT RIGHT
The humble bean is King ...or how to incorporate pulses into your meal plan
growth of “friendly bacteria” in the large intestine. They produce substances called short chain fatty acids, which promote bowel health and improve our overall immunity;
Ria Catsicas RD (SA) in Private Practice Legumes (Leguminosea), also called pulses, are a group of plants that grow worldwide and form a staple highquality dietary protein supplement. Legumes are generally cultivated for their seeds, and come in the form of lentils, peas and all types of beans including green, butter, kidney, black eye and haricot and sugar beans. Oily seeds such as soya beans are grown for their high protein and oil content. What are the health benefits of legumes? 1. All legumes contain Sterols that reduce cholesterol absorption; 2.
Soya beans contain isoflavones that make LDL (bad) cholesterol less atherogenic and contribute to preserving bone mineral density and maintaining the body’s calcium balance; 3. Their high fibre content give legumes a low GI (glycaemic index) which may contribute to slower absorption of dietary carbohydrates and improved glycaemic control; 4. The fibre in legumes promotes the
5. Legumes contain an average of 0.5g fat per 100 g (they are LOW in fat), they contain no cholesterol and they are low in salt. Replacing chicken and meat with legumes, contributes to a significantly lower overall intake of saturated fats. It is not surprising that most of the authoritative health organizations such as the International Diabetes Federation, American Heart and Diabetes and American Cancer Society strongly encourage us to consider the following steps for better health: TEN easy, innovative and practical ideas to incorporate more legumes and plant foods into your eating plan: 1. Using canned legumes can save you time and effort. Alternatively, you can buy legumes dry. However, it is important that you soak the legumes in cold water overnight and drain them before cooking. This procedure removes their bloating potential. It makes sense to cook legume dishes in bulk, as they can be refrigerated or frozen. Legumes are indispensable items to add to stews, salads and soups; 2. Replacing half of the meat with lentils in mince dishes and half of the meat with beans contributes to healthier and more economical dishes. Butter beans can be added to chicken dishes and kidney beans to meat dishes; 3. For those following a traditional African diet, adding lentils to tomato-onion relish (chakalaka) and then serving this with samp and beans, makes a far more nutritious meal than straight ‘pap ‘n meat’; 4. Use baked beans with grilled tomatoes and stir-fry onion and mushrooms to replace the sausage and bacon in the traditional English breakfast;
• EAT RIGHT 5. Serving a slice of health bread with a salad or soup makes a healthy light meal. Replace the servings of egg, cold meat and chicken in a salad with butter or kidney beans or chickpeas. In soups, replace the chicken and meat in the soups with lentils;
choice than potato crisps or fatty crackers (such as bacon kips) and commercial dips. Liquidize 1 can of chick peas or butter beans with 1 dessert spoon of olive or canola oil, 2 dessert spoons of lemon juice and 1 teaspoon of crushed garlic. Add black pepper and spices to taste;
6. Replace mash potato and oven baked chips with a spicy lentil rice. Stir-fry onion and garlic in a teaspoon of oil. Add ½ portions of brown rice and brown lentils in the boiling water into the pot. Add a reduced-salt vegetable stock powder for taste and cook until done;
9. Replace chicken and meat twice a week with a vegetarian dish such as a bean butternut curry or a vegetable soya bean casserole;
7. Replace the ‘pap’ and garlic bread at a braai with a lentil bake. Another good choice is corn on the cob, which is first boiled and then brushed with olive oil and roasted on the coals a few minutes. Also, consider the “three bean salad” as an essential item on the braai menu;
10. Make your own burgers on a weekend night by replacing the beef burgers with ones made from commercial soya - grill and serve with a tomatoonion sauce. Check the label for the total fat, which should be below 10g per 100 g of food.
NOTE: Legumes do not have a definite taste and easily take on the flavours of any foods with which they are cooked. Add flavour to the dishes by 8. A vegetable platter with a dip made from chick- liberal use of all types of herbs and spices, curry, peas (hummus) or butter beans is a much healthier cumin, garlic, peppers, chillies, tomato and onion.
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How a diabetes support group can help you
Sharing diabetes recipes;
Sharing your emotions without fear of being judged;
Lightening the stress of living with or caring for someone with diabetes;
Learning about the latest diabetes treatments, benefits and side effects;
Staying on top of the newest diabetes research;
Many people conjure up ideas about ‘support groups’ from what they see on the television and in the movies… the likes of Brad Pitt attend an AA meeting and say - “Hi, my name is Brad and I’ve been sober for …”. Diabetes support groups are however very different from that scenario. Depending what the age demographic of the group is and what area the members are from, meetings can vary widely. They can be held either during the week or like many, on Saturday afternoons.
Getting information on diabetes specialist doctors and treatment centres;
Finding support for diabetes-related complications such as amputation, addictions or death;
Gaining insight on how to be a better caregiver or advocate for your child with diabetes;
Having a support network during times of crisis such as surgery or bereavement;
One thing that all support groups have in common is that they are for people with diabetes and their families and friends who want more information and who want to help to understand and cope with the condition. They are also for people who want to meet and interact with other people that are in the same position as themselves.
Hearing new information or the same information in new ways from guest speakers.
Louise Pywell Co-ordinator, Centurion Diabetes support group
More and more people are turning to diabetes support groups to cope with some of the difficulties associated with the condition
The Non-Governmental Organisation, Diabetes SA, encourages participation in diabetes support groups and has a number of these groups countrywide. The benefits of being in a support group are many, but the main one is that meeting other people with the same condition as you can be very comforting. You know that you are not alone and that others have the same concerns, questions and fears as you do. Other benefits of diabetes support groups include: Getting practical tips for coping with problems and daily life;
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Gaining knowledge Gaining accurate knowledge about diabetes from qualified professionals in all fields, for example, doctors, diabetes nurse educators, dieticians, podiatrists, biokineticists and psychologists is vital. All these sources should provide a congruent flow of correct information and not half-truths or conflicting views. What is so empowering about a support group, is that you can access all the information you need in a non-threatening environment and ask questions without feeling ‘stupid‘. The facilitators of these support groups can empathise with the group as they themselves have a connection to diabetes in one form or another. Either they themselves have it or their loved ones do.
• DIABETES MANAGEMENT
The requirements of a support group leader Any support group needs a good leader preferably someone with a strong outgoing personality. He/she must have a sympathetic ear and care for the well-being of other people (that is what a support group is all about after all). It is very important that he/she have an extremely good knowledge of diabetes. They need to work in association with doctors or clinics who can refer people with diabetes to the group. In some cases, the diabetes nurse educator working at a doctor’s practice runs the support group with Diabetes SA’s assistance. A diabetes educator is a good choice for a support group leader since people with diabetes in the community already know him or her. Important also is a circulation of members within the group as “new members bring new ideas”. It has been found that some patients attend a support group only when they are going through a rough time. Once they are coping again, they don’t attend
group meetings. When they go through a rough time again in the future, they will start attending again. On the other hand, one finds the regulars. These patients don’t miss a single meeting. It is not a bad sign to have these different types of people within a group as this diversity often makes the group a success. People need other people to interact and socialise with and to CARE for each other. What better way is there than in a diabetes support group?
For information on Diabetes SA support groups, contact 011 886-3765 or e-mail info@diabetessa.co.za DIABETES
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• DIABETES MANAGEMENT
Dr Ray Moore Specialist Endocrinologist CDE, Umhlanga
The kidneys are one of the most important organs in the body, controlling your salt and fluid status and ridding your body of soluble waste products They are also the only site of production of a hormone called erythropoietin, which maintains the normal level of the oxygen-carrying pigment called haemoglobin in your red blood cells. Unfortunately diabetic kidney disease, affecting about one third of all patients with diabetes, is the commonest single cause of end-stage renal (kidney) disease in most countries of the world. Fortunately, we have an early warning marker to detect which patients are likely to develop nephropathy (kidney disease) during the course of their diabetes. It is called urine microalbumin. This test looks for minute quantities of protein leaking from the kidneys into the urine. The test has to be performed in the pathology laboratories because the normal dipstick testing we do in our rooms is not sensitive enough to pick up these tiny amounts. Good diabetes care involves the measurement for microalbumin on a yearly basis along with your HbA1c, lipids and blood tests of renal function as well as clinical checks on your blood pressure, your eyes and your feet. Recent studies have shown that the onset and subsequent time course of diabetic nephropathy can be ameliorated by several interventions. All of these have the greatest impact if instituted early in the course of the development of this microvascular (small blood vessel / capillary) complication. Many studies
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have demonstrated that good control of the blood glucose levels early on (the first ten years) has great benefits in reducing the subsequent development of several complications of diabetes including nephropathy. The presence of hypertension (high blood pressure) increases the risk of nephropathy. That is why doctors who have a special interest in diabetes look for and treat hypertension earlier and more aggressively. The current guidelines say that a person with diabetes should be treated down to a blood pressure of 130/80 mmHg. In the presence of microalbumin, it should be brought down further to 120/70 mmHg. This often necessitates the use of up to 3 to 5 or more anti-hypertension medications. We always start treatment with an “ACE-inhibitor”. If this drug is not tolerated, usually because of a persistent dry cough, then a more expensive “ARB” group of drugs is used. These two classes of drugs often reverse a positive urine microalbumin test and greatly slow down the early progression of diabetic nephropathy. This is in addition to the beneficial effect they have on the blood pressure. Continued smoking has disastrous effects on the progression of all complications of diabetes, especially retinopathy and the cardiovascular ones. Any person with diabetes who continues to smoke is in effect going against everything his medical team is trying to do for him. One vital aim specialists in diabetes have in treating our patients is to prevent or reduce the potentially disastrous long-term complications of poorly controlled diabetes. If you are not receiving the regular investigative check-ups mentioned in this article on a yearly basis, please ask your doctor to do these tests and to discuss the results with you. Editors Note: Dr Moore has given us some great advice. Do you have microalbumin in your urine? What is your blood pressure? … and your HbA1c?
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The lowdown on insulin pumps to those who use them not to those who wear them.” Almost all evidence to date suggests that more highly motivated and better-educated operators achieve the best results. Dr David Segal Paediatric Endocrinologist CDE Parktown
As knowledge about diabetes has increased, so too have the tools of the trade
What you need to know… If you are considering managing diabetes with an insulin pump there are a few preliminary considerations: The most common indications for an insulin pump are to: • Improve quality of life;
Diabetes is a daunting condition to manage. It requires its master (that’s you) to balance life (exercise, multiple, • Achieve improved blood glucose control; varied meal challenges, other medications, stress etc) and insulin delivery to achieve blood glucose values • Reduce the frequency of severe and recurrent as close to normal as possible – all without significant low blood glucose episodes; highs and lows. As knowledge has increased, so too • Manage diabetes pre-conception and during have the tools of the trade. These include insulin pens, pregnancy. quick-acting insulin analogues to improve blood glucose values after-meals and long-acting insulin analogues that reduce the risk of nocturnal hypoglycaemia. The Remember that an insulin pump is attached 24-hours a scene has also changed with the addition of insulin day and this should be considered for those who may pumps to the armamentarium in the 1970’s. However, have an “attachment” issue. it is only within the last decade that they have really reached “useable and functional” status.
Knowledge is power Insulin pumps provide for the most “physiological” replacement of insulin - they can deliver minute doses as often as the operator desires to deliver them and the background or “basal” insulin delivery can be tailored to achieve more stable blood glucose trends. Unfortunately, the pump cannot measure ones blood glucose level and automatically inject the appropriate dose of insulin. These “closed-loop” pumps are still a few years away. Until then we will have to acknowledge that the major shortcoming of a pump is that it is an operator driven device. “Insulin pumps provide benefit
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Pumps and technology A new discreet pump has been launched that allows the pump to remain concealed while operating the pump via Bluetooth from a paired blood glucose meter / remote control. Pumps are also available that communicate with a continuous glucose monitoring device (CGMS), a small device that measures blood glucose values almost continuously and relays them to the screen on the pump. This pump also has the ability to suspend insulin delivery when a prolonged period of low blood glucose has been detected and alarms have not been heeded. This feature is only available while the CGMS is in use.
â&#x20AC;˘ DIABETES MANAGEMENT What an insulin pump can do for you
Insulin Pump Centres
Insulin pumps are expensive and monthly running costs are significantly higher than on injection therapy. Therefore, medical funders have endorsed the Insulin Pump Centre concept - Pump Centres are located nationwide and have the necessary expertise to initiate you on a pump. They provide the best knowledge and expertise to help ensure that you achieve the desired outcome from pump therapy. Funders typically need a motivation from the Pump Centre to assist in making It is vital that the pump initiation process is smooth and the funding decision. Ongoing pump costs may not be orderly as it is an incredibly labour and time intensive covered if your care is not delivered by one of the process. It involves a good working relationship Accredited Centres. between the patient and their medical team (doctor and educator) who are initiating the pump. Insulin pumps Accredited Pump Centres undergo additional training to offer a better service to pump patients. They are should not be started by industry representatives. also subjected to a peer review process. Improving For this reason, it is important that you contact an the lives and outcomes of people with diabetes is the primary goal. Secondly, every effort to document Accredited Insulin Pump Centre with experience in improved outcomes with insulin pumps must be made. pump use. They can advise you on which pump is most The will help to ensure the survival of pump therapy appropriate for your needs and train you not only on as a viable and expanding management option for how the pump works but also how to USE your pump to people with diabetes within our current economically achieve your desired outcomes. They will also train you challenged medical environment. on diabetes management skills including carbohydrate counting, adjustments to exercise, how to test your Your medical aid can assist you in finding your nearest blood glucose and to perform pattern recognition and Accredited Pump Centre should you want a suitability assessment. insulin dose adjustments.
Have realistic expectations of what a pump can do. An insulin pump is not an easier way to manage diabetes; it is a different way to manage diabetes that may well circumvent some of the onerous lifestyle issues related to injection therapy, but it still requires dedication, commitment and hard work. There are no age limits for pumps and we have experience in managing babies to octogenarians.
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• LIVING WITH DIABETES
Surviving the diagnosis Peter Black CEO, CDE Diabetes Management Programme
A modern day private healthcare horror story Having previously worked in the healthcare sector, and more specifically, in diabetes management, it was easy for me to identify that my son, Sean, had diabetes. Sean (nearly 16 years old at the time) and I were in the car, on our way back from a tennis tournament at Ellis Park. Sean had just won a match 6-0, 6-0 (yes, he is still very good): Sean: “Hey Dad, I’ve been weeing a lot” Me: “Have you also been thirsty?” Sean: “Yup” I remembered Sean complaining a few weeks previously about his eyesight and wanting his eyes tested. My wife Robyn and I assumed that it was “too much computer” at the time. Me: “Sounds like you got diabetes...” and then, which I regret to this day, because I should have known better... “If you do, then you are in for a lot of Sh%&*. You can get kidney failure and go blind if you don’t control it.” This was his first “education” about diabetes. I cringe when I think back to that car trip. I should have known better... We went straight to our local pharmacy, where a finger prick test showed “HI”, indicating that Sean’s blood glucose level was too high for the meter to read. It was then that I saw Sean cry (not a lot) for the first time since he was 6. I should have known better... I then took him to a local private hospital casualty, where his reading was measured at 32 mmol/l. Diabetes confirmed.
Then the horror began... Sean was admitted into ICU immediately. It was not clear then, but now I know that this was unnecessary. He had
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no ketones, and he was not unwell. He had just spent 90 minutes playing hard tennis. His only issue was a finger prick reading of 32. My best guess is that the hospital regarded his admission to be important to their revenue stream. The doctor that saw Sean wasn’t bad… Not a diabetes specialist, but competent nonetheless. However, the ICU nursing care was diabolical. We were fortunate to be around when the lack of care and attention by the ICU nurses could have led to two very serious consequences for Sean. I believe that the second incident could have led to his death, had we not intervened. Incident 1: Drip inserted, insulin injected via drip, nurses disappear. Sean went into an immediate state of shock: pale, sweating, heart palpitations. No nurses to be seen anywhere. We shout for help. Nothing. We find a nurse looking after another patient. She tells us that she will get there when she is finished. We run out the ICU to the hospital cafe, buy a coke, and feed it to him. He glugs it down like a starving crazed prisoner. When the nurse eventually strolls over, she immediately stops the drip in a panic. His blood glucose had dropped down to 2.5 mmol/l. Incident 2: Two days later. It was now time for the ICU nurse to “educate” Sean and show him how to inject his own insulin. My wife and I watched with interest, since we needed to know this too. Thank the Lord that we were there. Sean’s dose was 6 units. Out came an old-fashioned insulin syringe – and a vial of insulin. ICU Nurse: “Here we go, draw up 6 units… there up to that point” Sean obliges and fills the syringe up to the point she has shown. ICU Nurse: “Now inject yourself like you have seen us do it...” I jump in. “Hang on”, I say. “Is that the right syringe?” The nurse looks disdainfully at me… “Isn’t that syringe graduated in 10’s?” I ask. “You are going to give him 60 units, not 6” To her credit, the nurse did apologise. I just thank our lucky stars that the injection did not happen. I still shudder about what might have been…
So how are things now? It is now just over 2 years later. As I write this, Sean is busy writing Matric and thankfully, this is our main cause of stress and not his diabetes. He is a very pragmatic young man, and takes his diabetes in his stride. His HbA1c runs around 7.5 to 8 % (which isn’t bad for a teenager!). He
• LIVING WITH DIABETES eats normally, and enjoys a beer with me now and then. He has received the best of care and advice from his local CDE and this has enabled him to take control of his diabetes. He makes it look relatively easy. He plans to go to Rhodes University next year to study Journalism and Drama. Watching him gear up to leave the nest, is both gratifying and enormously stressful at the same time. As parents, we will always worry about his health, probably a lot more than he does. So what does this modern day horror story teach us?
The impact of a diabetes diagnosis can be devas-
tating, especially if the diagnosis involves your child. It seems harder to accept diabetes in your child, than having it yourself.
Finally, things
do get better. I promise…
I suppose one could summarise as follows: The level of understanding and knowledge about
diabetes is generally poor amongst healthcare givers, especially our nurses. One would expect better from a private hospital ICU;
Knowledge can be both good and bad. My first
comments to Sean about diabetes were factually correct (in the context of poor diabetes care and control), but given to him in the most insensitive and stupid manner possible. On the good side, my knowledge of diabetes syringes prevented what could have been a tragedy;
Dr. Everard S Polakow and Sr. Lynne Kruger have CDE Centres at: • Linksfield and Edenvale - 34 Meyer Street, Linksfield • Kempton Park - Unit 1, 40 Monument Road • Boksburg - 8 Albrecht Street (behind Sunward Park Hospital)
Contact: Sr. Lynne Kruger on 082 330-2031
Editors note: Thank you Peter, for sharing the journey your family has had with diabetes this far. One thing we have realised is that diabetes is a condition that can and should be treated in the community wherever possible. From a psychosocial, medical and cost point of view, hospitalisation in Sean’s case was unnecessary and possibly even harmful. We wish Sean and your family well next year as Sean starts a new chapter in his life.
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Trekking in the Himalayas By Ralph Spies
Taking diabetes control to new heights It is almost 40 years since I was diagnosed with diabetes. Over this time, I have seen numerous changes on how to manage my ‘diet’, the development of equipment, changes in insulin and the perception of diabetes. I am now on the Accu-Chek Spirit Combo insulin pump (Paired via bluetooth to a dedicated Accu-Chek Blood glucose meter). The advancement in technology and information at the disposal of the diabetes team and people with diabetes is for the betterment of all. Being able to be totally transparent with my doctor lets me be far healthier with my diabetes. At 53 years of age, I have always kept myself reasonably fit. I visit the gym regularly and have been a keen cyclist for around eight years completing numerous races in very respectable times. Having diabetes for this amount of time has affected other aspects of my health. I am on a beta-blocker for my heart. This does restrict my performance but it is not a hindrance to me ‘just doing it’.
Manaslu trek Earlier this year, a close friend invited me to join him and nine other like-minded people of all ages to do a threeweek trek in the Himalayas during October into November. The Himalayas are vast, spread across the entire northern
border of Nepal and then to Pakistan and India to the west and Bhutan in the east. Our trek was in the Trans-Himalayan region that is in the opposite direction to Mount Everest.
Getting the all clear I purposefully visited my CDE branch beforehand to discuss how I would manage my insulin doses whilst trekking. In conjunction with Biokineticist Andrew Heilbrunn and Educator Vanessa Brown, we opted to set two additional basal profiles on my pump - one at 30% and another at 50% of my normal basal rate. This was to provide me with two additional options to cope with the (usually lowering) effects of prolonged exercise on blood glucose levels. However as the altitude increased, I would become more insulin resistant and might require more insulin. I knew I had to balance these two opposing effects. The first obstacle I faced as a person with diabetes was the flight from Jo’burg to Doha and onto Kathmandu. We spent fourteen hours in transit in Doha and that was probably as bad as the toughest day trekking. Although I ate correctly, my blood glucose levels never really stayed at a satisfactory level. On previous occasions when flying this has also proven to be the case. Perhaps it is anxiety or unbeknown to me, I am more stressed than I like to admit. Nepal is the second poorest country in the world and it is evident the further out of Kathmandu you travel. The country
• LIVING WITH DIABETES has an abundance of water flowing from the vast mountain ranges, however sanitation and sewerage is virtually nonexistent on the trekking routes. Trekking is tightly controlled and a permit is required, probably to protect the reserves where all the treks take place. Kathmandu is also the second most air-polluted city in the world. The traffic is chaotic. Our SA taxi drivers would be in their element. There are no road signs and the one traffic light flashes on amber continually, yet there were no serious accidents. Nepal, with a population of 26 million, has one hundred and three ethnic groups speaking more than ninety different languages. The climate ranges from sub-tropical in the lowlands to arctic in the high altitudes.
Getting started Our trek started in a town called Arughat (560 m), after an eight-hour, white-knuckle, un-roadworthy, third-class bus trip on narrow roads over the highest mountain passes in axle thick mud. We trekked up and along the Buri Gandaki River to Manaslu (8163 m). The route measures about 160 km on a map. The vertical distance covered however probably doubles the kilometres walked. Over the twelve days, we slowly gained altitude. The last four days before going over the pass were extremely tough with relentless steep rocky paths. Some of this route included inclines of over 50 % for longer than an hour. We were blessed with the most amazing vistas of snow-capped peaks, endless waterfalls cascading down mountain faces and numerous treacherous suspension bridges spanning up to 93 m in length over roaring rivers (like something out of ‘Raiders of the Lost Ark’). Our trek did not entail summiting Manaslu. Manaslu is more difficult to summit than Everest. This is borne out by Reinhold Messner (the first mountaineer to summit all of the ten highest peaks successfully), who in a thirty-year climbing career, lost only three climbing companions. Two of these were on Manaslu, including his brother-in-law.
Instead we trekked along the valleys and eventually behind Manaslu to then climb over the Larkya Pass (5 160 m). Every day we were greeted with friendly, inquisitive and smiling young children.
Managing my diabetes Despite the diligent and much thought out plan to increase my insulin doses as I gained altitude, my blood glucose readings did tend to run high. I handled this by testing frequently and giving corrective doses through the pump as needed. The high-carbohydrate meals prepared for us were exceptional and we had sufficient to drink. Twelve days and 210 km later, in temperatures ranging from 35 to minus 20 degrees and trekking through an elevation of nearly 5 km, we completed this once in a lifetime experience. Upon returning to Kathmandu and reminiscing on our trek, the group all concurred that rather than being a basket case, it was their opinion that with Bruce Fordyce (the same one who has done a ‘couple’ of ultra-marathons) I was one of the most consistent members of the group. I undoubtedly encourage anyone with diabetes who has any intention to participate in an event such as this to consider doing it with the due preparation required.
Editor’s note: Well done Ralph! Fellow ‘trekker’ Bruce
Fordyce provided us with the following inspirational comment: “Ralph managed his diabetes so well and so discreetly that if I hadn’t been informed of it I would never have known. He was one of the strongest walkers and on our toughest day (nearly 10 hours of walking at over 5000 m), he and I finished a good half an hour ahead of the rest of the group. He proved that anything is possible for people with diabetes as long as they monitor their condition as efficiently and meticulously as Ralph did.”
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Climbing with diabetes By Michael Cloete
Often one associates climbing a mountain with something recreational and relaxing. That’s one thing. Dealing with the Himalayas is another This famously iconic mountain range poses a challenge to people with and without diabetes. Our 16day journey took us through four totally different topographical zones: the highland areas close to the Tibetan border (dry, barren, austere and desert-like); the great Kali Gandaki river valley (lush and fertile, 80 km long, and said to be the deepest ‘ravine’ on earth with two 8 000m peaks flanking its sides); the southern foothills of the Himalayas which were ablaze with colour (the flowering rhododendron forests were at the height of their glory); and finally, the Annapurna Sanctuary (a remote enclave of snow and ice, dwarfed by soaring peaks rising 5 000 m above). Not only did this trek present me with mental and physical challenges, it posed a special challenge to my diabetes control and management.
Preparation In preparation for the undertaking of this adventure, my parents and I had to plan for the unknown. Nepal is not a country where you want to encounter a crisis regarding your health. This meant that extra careful measures needed to be taken to ensure my health and well-being throughout the trek. The biggest challenge that faced me was the possibility of my insulin becoming ineffective due to a lack of refrigeration. Included with this, was the problem of trying to calculate exactly how much glucose we needed to transport with us for hypoglycaemic events. Another, more concerning issue, was the lack of hygiene that we would experience throughout our trek. The route takes you on various mountain paths and roads, with
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pit stops at Tea Houses in small rural villages. Being on an Accu-Chek Spirit Pump, cannula changes are always done in as sterile environment as possible. This meant I would need to pay extra special attention to making sure the site of insertion was clean before proceeding. I therefore needed an ample supply of alcohol swabs, cannulae, infusion sets and cartridges. In addition to this, experience with my condition has taught me to always carry back up insulin pens in case of unforeseen circumstances. These short- and longacting insulin pens proved to be life saving during my trek, as I shall later divulge. Ketone strips, test strips, my glucose meter, needles, lancets etc. all made up my kit along with regular medication. No supplies are to be found in the Sanctuary or villages, so my preparation needed to be precise and calculated. Over a trekking period of 16 days, I packed supplies that would cover me for each day. Extra supplies were packed for situations that could arise such as kinked cannulae or inactive insulin. I also met with my diabetes educator to work out a basal rate that would suit the strenuous activity that each day would present us with. All of this proved to be invaluable during my trek.
The trek To experience the Annapurna Sanctuary is an encounter that can rarely be comprehended by people who have not visited this special place. On average, the trek consisted of 12–15 km of walks and climbs per day. With this came breathtaking views and enchanting experiences. Each village had its own unique flavour and surprises are encountered at every corner. Included in this fair share of memories, was a good deal of ‘Low Blood Sugars’. From the very first day of trekking, I was ravaged by excessive lows, which hampered my progress to our first stop, Kagbeni. Tucking into my large supply of Gluco-gel that I took with, my lows were appeased but not eliminated. To compensate, I immediately altered my basal rate to a quarter of my usual daily basal rate. Seeing my educator had made this process easy and aided me in ending this problem early on. Things were looking up and I was in high spirits leading into Kagbeni, the first ancient village stopover.
• LIVING WITH DIABETES A dreaded condition for any person with diabetes struck me on the very first night of our trek Suspected food poisoning! The condition hit me full force during the middle of the night. I awoke to an incredible nausea and I was soon knocking on my parents’ door, wanting to vomit and feeling violently ill. Many know that being ill on such a trip is hazardous, but for someone with diabetes this poses a very real threat. I was hundreds of kilometres from adequate medical assistance, in the middle of the deepest gorge in the world and I faced possible dehydration and Ketoacidosis. Lack of an appetite and repeatedly being ill severely weakened me. A well-packed First Aid Kit was a lifesaver over the next 2 -3 days. So too, was ‘the set of wheels’ I could take advantage of! I was forced to undertake part of the trek in a Mahindra Jeep and other vehicles. When one is feeling ill and has ketones, a bumpy and very dusty road is not an appealing prospect, but I had to keep moving along or my adventure would have been over. I also believe that it was by some sheer miracle that we were able to find Diet Coke (needed to replace potassium caused by the onset of ketones) in a small rural village. Strangely, my readings were not excessively high, but my ketones became persistently worse. This was probably due to my lack of willingness to eat, dreading the possibility of becoming ill soon afterwards. The diet of the Nepalese people on these treks is often very high in oils and carbohydrates, something that my body was not accustomed to. The possibility of having to return to Kathmandu, and thereafter, home, was
becoming ever more real as my condition failed to improve significantly. I was too weak to walk, and was surviving on a diet of water, tea and soup. This is where the insulin pens came to my salvation. One normally corrects ketones with an insulin pen and not the pump, so I immediately switched to injecting insulin, until my condition improved. After roughly three days of being ill and fighting ketones, my condition began to stabilise. It was fortunate that I could make use of the transport still available on the first part of the trek because after the fifth day, no roads exist and then walking is the only way ‘to move’ for the following 11 days. I slowly increased my walking distance, depending less and less on the Jeep, until I was well enough to walk the full distance each day. It was through the care of my concerned mother and father that I managed to make a recovery. Without their guidance and support, my trek would have been over before it had even really begun! On a lighter note, had this condition not arisen, I would not have experienced Nepal in the same way! I found myself in various ‘exotic’ and basic forms of transport while I was recovering. I met interesting people who had a completely different outlook on life to me - it was an enriching experience. I travelled alone, without my parents, as we could not all be transported by vehicle. They would walk the distance and we would meet up at the end of the day. It just goes to show that having diabetes can take you to places and give you experiences of which you never dreamed!
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• LIVING WITH DIABETES
Throughout the remainder of the trek, my focus was kept on maintaining constant and controlled blood glucose levels. Fluctuations made walking difficult, so I was testing on average once every half hour throughout my day. I changed my cannula every third day and my pump cartridge whenever necessary. The excessive amount of exercise forced me to adjust my insulin intake at mealtimes and increase my intake of carbohydrates to fuel my body. The small group of Sherpa’s who accompanied our party was keenly interested in learning about my condition. None of them had ever seen the technology that I wore on my belt or the equipment used to test my blood glucose. I was ‘like a walking hospital’ one of them remarked! They continually supported me and looked out for my well-being throughout the trek. These simple but touching gestures preserved timeless memories for me. The final challenge I faced was my climb to Annapurna Base Camp. I had been worried that the sub-zero temperatures would freeze my insulin, rendering it useless. My fears were heightened during the heavy snowstorm we encountered at our pit stop before base camp. Luckily for me, the rooms were well insulated and my insulin never froze. Reaching Annapurna Base Camp was a dream-come -true! Relieved, and feeling a sense of accomplishment, I sat back and reflected on my incredible journey. Despite the many challenges due to my diabetes, persistence and determination helped me to complete the journey. The memory will never fade from my mind.
Reflection In 2005, I attended the Children with Diabetes Conference in Orlando, Florida USA. At this
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conference, I met the famous person with diabetes, Will Cross, who has summited the seven highest peaks found on each of the seven continents. His inspirational talk led me to my own adventure in the Himalayas with my family. With a structured plan, a person with diabetes is no different from any other person. I had made a full recovery and had gone on to enjoy my trek through the Himalayas, unhindered by problems due to my condition. The experience brought a sense of worth to me as an individual. Prior to this, I had never dreamt of accomplishing feats such as this and I most definitely have plans to return. This trip to Nepal and the Himalayas not only gave me a hunger for adventure, but also taught me a great deal more about the nature of my condition. It has also forced me to reflect on helping others similar to myself in less fortunate situations, giving me a drive to raise awareness for diabetes around the world. Shadowed by AIDS and many other life-threatening conditions, lesser-known diabetes is on the increase globally. I believe that it is imperative that we bring awareness of this condition to countries such as Nepal and other places where children and adults, like me, do not have the knowledge and necessities to manage their health. It has been a personal journey, one that I encourage others, with diabetes or not, to undertake. There is no reason why a person with diabetes should deny him / herself the chance to live an enriching life. A whole wide and wonderful world exists out there.
• PARENTING
School & diabetes School Bill of Rights for Children with Diabetes David Segal Specialist physician, CDE Parktown
Sending your child to school is always an emotional and daunting task for parents. When your child has diabetes, however, the anxiety and fear is two-fold The greatest fear for parents with children with diabetes is “will the school, teachers or your child recognise a low blood glucose level and will they know how to handle this”? Most parents tend to send their children to school with higher blood glucose levels to prevent lows. While this is an understandable emotion, the consequences of high blood glucose at school in terms of short- and long-term complications and the negative impact of raised blood glucose on memory and concentration make this option a non-starter. Every effort should be made to reduce the number and severity of episodes of low blood glucose at school and this can be done with the newer insulins, appropriate testing and planning. There is mounting evidence that hyperglycaemia (high blood glucose levels) is detrimental to the cognitive development of children. High blood glucose levels lead to poor concentration and failure to retain or retrieve information. Teachers will often indicate that the child is difficult to manage in class. This gives them a major disadvantage compared to their non-diabetic peers due to high blood glucose control. Therefore, finding the balance between low and high blood glucose levels is vital.
Children with diabetes must be able to: 1. Do blood glucose checks when necessary; 2. Treat hypoglycaemia with emergency glucose or glucagon injection; 3. Inject insulin when necessary; 4. Eat snacks when necessary; 5. Eat lunch at an appropriate time and have enough time to finish the meal; 6. Have free and unrestricted access to water and the bathroom; 7. Miss school, without negative consequences, for doctor’s appointments to monitor diabetes appointment notes will be provided by the diabetes team if necessary; 8. Participate fully in physical education and other extracurricular activities, including field trips.
Special circumstances at school Children with diabetes should not be excluded from participation in any event due to their condition. Camps and outings are an important part of every child’s schooling experience. The child’s diabetes team should be contacted by the parents or caregivers prior to the planned activity to discuss insulin dose adjustments, emergency management of low or high blood glucose values and to provide a list of emergency supplies and contact numbers.
Educating and informing teachers, sport coaches as well as the child’s classmates on diabetes and the management thereof, can help to prevent many of the highs and lows that can occur at school. If everyone is well informed, fears are eliminated or reduced substantially and the child can have rewarding school experience.
Children with diabetes can safely participate in school sports and participation is encouraged as it promotes a healthy lifestyle and helps regulate blood glucose levels. Blood glucose levels should be checked before and after events and snacks may be required to prevent them dropping. Children with diabetes should not be left alone after sporting events.
Children with diabetes often face discrimination in the school setting ranging from teasing to exclusion. They also require medical care to remain healthy. The need for medical care does not end while the child is at school, especially since most of their days are spent there.
Examinations are a very stressful time for children with diabetes and this can have a negative effect on their blood glucose levels. Stress can cause an increase in blood glucose levels therefore affecting their concentration, which DIABETES
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• PARENTING ideal for an eam environment. A low blood glucose level is something that must be avoided as the child may take a number of minutes to recover, wasting precious exam time. They must also ensure that they are able to keep low blood glucose treatment with them at their desk if needed during the exam (The child’s doctor can provide them with a letter explaining the reasons for being able to eat during an exam if necessary). Academic documentation such as the Learners with Special Educational Needs (LSEN) forms can be completed along with the letter from your doctor that allows the child to have an extra 15 minutes per hour exam in case low blood glucose occurs during the examination.
Diabetes Management at School Roles & Responsibilities A key part of ensuring good diabetes care for children at school is a clear understanding of who will be responsible for each task. What are the Parent’s responsibilities? Advocate on behalf of your child; Provide basic diabetes education to the teachers and sports coaches as well as supply all diabetes equipment and snacks; A hypoglycaemia (low blood glucose) pack should be supplied by parents and re-stocked regularly. Glucagon should be demonstrated and clear advice on when to use this given;
Immediate availability of diabetes supplies at all times such as during field trips, extracurricular activities and transport by school; An adult and a backup adult trained to do blood glucose monitoring if required and to record the result and take appropriate action; An adult and a backup adult trained to do insulin administration. (School staff should not be expected to administer insulin injections unless willing to do so and adequate training has been provided); Where the school has offered to take responsibility, they will follow guidelines in terms of doses to be given (as per instructions by parents) and record the amounts given and time given; Provision of a location for private testing and injecting if required; An adequate number of staff trained to ensure at least one trained adult is available at the school or on field trips; A knowledge of the testing, injecting and eating schedule of the child with diabetes; Advance warning to the parents of any schedule changes.
Help the school to understand the diabetes care plan and provide necessary training or resources;
What the law says
Provide clear information on dosages to be given, times given and the need to record information;
South African law says that no school can refuse to admit your child because he or she has diabetes and that all schools must admit students without discrimination of any kind including the health status of a child. The child may also not be refused if a parent or guardian has refused to sign an indemnity contract.
Update the school on changes regularly; Education and emergency numbers should be provided to deal with any situation, especially to manage low blood glucose levels.
What are the responsibilities of the school? The responsibility for the school is to provide education in a safe and caring environment for the child with diabetes and this should include: Staff with enough knowledge to recognise the signs and symptoms of hypoglycaemia (low blood glucose levels) and hyperglycaemia (high blood glucose levels) as well as the basic knowledge of emergency procedures;
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Case histories Lauren Le Roux’s twelve-year-old daughter Shannon has type 1 diabetes. When Shannon was diagnosed in Grade 1, Lauren immediately requested a meeting with her child’s teachers. She prepared a diabetes management sheet for them along with a ‘low box’ containing glucose sweets and snacks. She educated the teachers on what to do if Shannon had a low or if they suspected that her blood glucose levels were running high. The teachers were so interested in diabetes management
• PARENTING and education that they set up a Diabetes Awareness day during which they did a talk on diabetes for the whole school. Shannon’s homeroom teacher kept in constant touch with Lauren to the point of writing down Shannon’s blood glucose levels in a logbook to enable them to work out what insulin dosages and break time snacks were the most beneficial.
• EAT RIGHT
Green d. Use organic ingredients. This ensures that food is grown without the added pesticides. Organic farming is more environmentally sustainable as it reduces pollution and conserves water and soil. Michelle Daniels, Registered Dietician, CDE, Houghton
…making sustainable food choices for the future Generally when shopping in a supermarket or eating in a restaurant most people base their food choices on the health aspects, as well as the taste enjoyment of the food. Seldom do we consider the impact on the food chain, global food supply and the environment. Sustainable consumption has been defined as ‘the use of goods and services that satisfy basic needs and improve quality of life while minimising the usage of irreplaceable resources and the by-products of toxic materials, waste and pollution’. Sustainable farmers see nature as a help rather than a hindrance, and therefore they are able to produce food that is more wholesome using less fossil fuel. Thus, they contribute less to climate change. Unlike industrial farming, sustainable farming does not use synthetic pesticides, routine antibiotics and artificial hormones. Industrial livestock production is at odds with the welfare of the animals it produces. Animals are often confined, given feed that their bodies are not designed to digest, supplemented by synthetic fillers, and growth hormones. Moreover, these animals cannot display natural basic behaviours such as lying down, turning around, foraging and socialising. Here are a few steps that you should take to ensure that you are buying food from a sustainable source, as well as warranting an eco-friendly meal: a. Eat the greatest variety of the least processed food and eat less of it. b. Buy as locally and directly as possible - this helps to minimise unnecessary ‘transportation pollution’. It also reduces the deterioration in nutritional value. c. Grow some of your own food, even if it is something small such as a few vegetables.
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e. Eat less meat! And, if you do, try to eat grass-fed, free range meat. f. Select your fish carefully - this very topical issue deserves some attention ... The old saying, “There is plenty of fish in the sea” is horribly out of date. A study published in the scientific journal Nature, in May this year, shows that we need to dispel the notion that the oceans are inexhaustible. Due to destructive fishing practices and poorly managed fisheries, global fish resources have become depleted - Stocks of big-fish like swordfish, marlin, cod and halibut, have fallen 90 percent since 1950. The result is an unstable and unbalanced marine ecosystem that is endangering the continued existence of many species. If we continue to eat fish the way we do now, many fish resources will be exhausted by 2048. A British journalist recently wrote ‘if we don’t change the way we eat, there will be no more fish by mid-century. Instead of kabeljou and prawns, we will be facing plates of jellyfish and worms.’ The aim is not to make people stop eating fish completely but to do it in a more responsible way. According to the World Wildlife Fund’s Southern African Sustainable Seafood Initiative (SASSI), seafood has been divided into 3 groups: GREEN - best ORANGE - think again! RED - avoid buying! Please consult the SASSI website for a more comprehensive breakdown of the different groups of fish - www.wwfsassi.co.za Note that certain supermarkets have colour coded their fish to help consumers make more informed choices and therefore support sustained fisheries. g. Choose plant sources of Omega 3 fatty acids. Omega 3 fatty acids are long chain polyunsaturated fatty acids that are essential to the function of your body
cells. We cannot make them and so it is essential to get them from our diet. They are made up of 3 types: eicosapentanoic acid (EPA), docosahexanoic acid (DHA) which are the long chain marine types. Then there is alpha-linolenic acid (ALA), which is the short chain plant type converted by the body into EPA and DHA. The benefits of these long chain fats were discovered in the 1970’s where the Greenland Inuit people consume large amounts of fat from seafood. It was found that these reduced triglyceride levels, heart rate, blood pressure and atherosclerosis. They are also important for the nerve development of the foetus and infant. At present, fish and fish oils (e.g. mackerel, kippers, pilchards, fresh tuna, trout and salmon) are the only significant sources of these fatty acids. The Western diet contains a large ratio of omega 6 compared to omega 3 fatty acids (about 14:1 when this should be 4:1). It is currently recommended that we eat 0.45 g per day of omega 3 fatty acids or the equivalent of 2 portions of fish per week. (Pregnant or breast-feeding women should limit consumption of oily fish to no more than 2 portions per week and the rest of the population should not exceed 4 portions per week. This is because low levels of pollutants can build up in these predatory fish). Being conscious of cutting back on certain fish species (as well as being vegetarian or allergic to fish) means that we may have to supplement our diets with non-marine plant sources of ALA, which would then need to be converted to DHA and EPA. The best plant sources of these are flaxseed / linseed, flaxseed / linseed oil, walnuts, and soybean oil. A typical intake would require ¼ of a teaspoon of flaxseed oil, 1 tablespoon of walnuts and 1½ tablespoons of soybean oil. You can also get omega 3 fortified foods, such as omega 3-enriched eggs, soya and linseed breads, certain margarines and of course linseed / flaxseed oil in capsule form. h. Eat like an omnivore. The greater the diversity of species you eat, the more likely you to take in a wide range of nutrition. Biodiversity in your meal plan means less monoculture (the practice of growing a single crop over a wide area). The large monocultures that now feed us need huge amounts of chemical fertilizers and pesticides to prevent them from collapsing. Diversifying those cultivated fields will mean fewer chemicals, healthier soils, healthier plants and animals and, in turn, healthier people. i. Look for ‘Fair Trade’ on the label. this ensures that you are helping to support a business that promises a fair price to the farmer, contributes to underprivileged communities, as well as promoting sustainable farming practices. j. Avoid the extra packaging. Try and choose foods that are minimally packaged , buy in bulk, or look for products that are packaged in environmentally sensitive materials such as recycled paper or bio-based plastic, which is able to biodegrade.
Just taking small steps like those mentioned above will help contribute to healthier people and a better environment to live in
Future Life
™
THE COMPLETE MEAL FOR PEOPLE WITH DIABETES Do you feel your energy levels peaking immediately after eating a meal, but then start feeling sluggish and tired soon thereafter? Our nutrition plays a vital part in maintaining consistent energy levels in order to participate in sports, studies, and getting you through a long day at the office. FUTURE LIFE ™Immune Boosting Energy Meal does just that. Our bodies require foods with a low glycaemic index (Low GI) containing carbohydrates that are digested and released at a much slower rate than high GI foods that cause an immediate peak of blood glucose and insulin in the body. Scientifically formulated FUTURE LIFE ™Immune Boosting Energy Meal is a maize and soya-based food which contains an ideal combination of slow-released (Low GI) carbohydrates, protein, calcium and iron. Fortified with 23 vitamins and minerals, 19 amino acids and omega-3 and 6, it delivers 100% of the RDA for adults on all vitamins and minerals. Its unique combination of highly effective ingredients makes it the most advanced food supplement available – it’s totally natural, and also free of preservatives, dairy, cholesterol, gluten and wheat and it is completely suitable for people with diabetes. Consuming FUTURE LIFE ™will assist in balancing blood glucose levels and returning the blood glucose levels to normal. This is wonderful news for people with diabetes, people who are challenged with their weight, and people who are continually hungry. This proven formula may also assist with all lifestyle diseases, such as obesity, high cholesterol, high blood pressure, infertility, depression, and acne. It also contains the right amount and the right kinds of fats, and more than 6% fibre to address gut problems and IBS. FUTURE LIFE ™is not only an outstanding energy source but also an immune booster. Our body’s immune system is designed to protect against bacteria, viruses and parasites. FUTURE LIFE ™helps you to do this. It contains prebiotics to clean the intestines and improve nutrient absorption, and clinically tested Moducare®, the only clinically tested plant sterol and sterolin product that has shown, through research, to balance and improve the immune system (under licence from Aspen Pharmacare Limited). FUTURE LIFE ™is quick, convenient and easy to use as a cereal or any-time energy shake. It mixes instantly with water or milk and tastes great. FUTURE LIFE ™Immune Boosting Energy Meal is available in a 500 g box or 10 x 50 g sachets in three delicious flavours – Original, Chocolate and Banana. Not suitable for children under 12 months.
• DIABETES MANAGEMENT
Real men don’t DO use moisturiser Tracey Johnson, Podiatrist, CDE, Houghton
Keeping your feet moisturised – it’s important for everybody with diabetes! The majority of South Africans love walking barefooted in the hot summer months. Slip slops and sandals are worn frequently. Without regular moisturisation, skin is exposed to the elements resulting in thick, dry, cracked skin particularly on the heel area. Walking barefoot and wearing “cool” shoes may look and feel great, but this isn’t always practical with diabetes. People with (uncontrolled) diabetes may be vulnerable to developing extremely dry, cracked skin. Uncontrolled diabetes is associated with skin thickening and a reduction in blood flow to the skin. Not only is this skin more susceptible to infection, it is generally slower to heal. A parallel loss in nerve function can mean that the sweat glands do not function as they should. Sweat is an important aspect of skin hydration. Amputations can be the result in diabetes patients who have developed infections through cracks or breaks in extremely dry skin. The first sign of compromised skin health is dry, scaly skin. The skin is less supple and can crack easily. Skin cracks open the door for bacteria, viruses and fungi to enter the body, often leading to open sores and infections. Maintaining good skin health is important. Here are some simple steps to achieve this:
Practice good diabetes management Poorly controlled blood glucose and too many fluctuations in blood glucose can affect overall health, including that of the skin. To prevent diabetes related complications, keep blood glucose levels consistently controlled.
Hydrate your body Drink plenty of water, especially on hot summer days. Many moisturisers on the market just coat the skin to trap
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moisture. Moisture-replenishing products that contain ingredients such as urea are better. Very good moisturisers are available that are formulated specifically for feet and heels. The ideal time to apply moisturisers is immediately after a bath or shower, preferably in the evening prior to getting into bed. If you are worried about the bedclothes becoming greasy – wear socks. Alternatively wait for the moisturiser to absorb before retiring for the night. Practice experience has shown that people have good intentions of applying moisturiser to their feet, but hardly ever get around to doing this on a regular basis. Be it laziness, or promises to do it the next day, the excuses are plentiful. There are however, so many benefits to applying moisturisation. Not only will it improve and maintain good skin health, but also it means that you will be examining your feet on a daily basis. This is especially important for those with diabetes who have lost the ability to feel with their feet. Another benefit of applying moisturisers on a regular basis is that the massaging action is beneficial to the circulation. Most patients report a temporary relief in nerve related symptoms after having their feet massaged. Never apply moisturisers between your toes – these areas already tend to trap heat and moisture, creating a breeding ground for fungal and bacterial infections.
Be aware of your footwear A closed properly fitting shoe offers more protection to the skin than open shoes. It is understandable in hot summer months that closed shoes can be too hot to wear. On cooler days, or if you are going to be in doors, rather opt for closed shoes. Offer your feet as much protection as often as you can. If you are insistent on wearing sandals all the time, it is vital that moisturisers be applied even more frequently. Healthy skin is supple, smooth and well hydrated. It not only looks and feels better, but most importantly, healthy skin is the best defence against infection. To help you remember to moisturise, apply moisturiser to your feet before your brush your hair. You need your feet more than you need your hair. If you are a man and are bald, well, you then will have a more difficult time remembering to apply moisturiser to your feet. On the topic of men, moisturisation is for everybody (especially if you have diabetes) and not just for the ladies. Skin is skin - it needs to be taken care of! Happy moisturising …
• EAT RIGHT
Sweeteners
- The pros and cons
Mandy Marcus Registered Dietician CDE, Houghton
Overall, when used properly, all types of sweeteners can be useful in diabetes management Whether stirred into coffee, sprinkled on cereal, spooned into yoghurt or used to bake a great tasting dessert, choose the sweetener that works best for you. Three types of sweeteners can be used: 1. NUTRITIVE SWEETENERS Nutritive sweeteners, such as fructose, glucose, lactose, maltose, maltodextrin, honey, molasses and corn syrup, have the same calorie value as table sugar (sucrose) and can increase blood glucose levels. High fructose corn syrup (HFCS), made from fermented corn, is a cheap sweetening agent used extensively in the food industry. Fructose produces a slower and more gradual increase in the blood glucose level when it replaces glucose, honey, sucrose or starch in the diet. This benefit is however tempered by concern that fructose may increase triglyceride levels (a type of fat in the blood). Therefore, the use of HFCS and fructose powder as a sweetening agent for people with diabetes is not recommended. There appears to be no significant advantage of using these alternative nutritive sweeteners over sucrose. The good news is that
sucrose and sucrose-containing foods do not have to be avoided completely by people with diabetes. Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, can be adequately covered with insulin.
Take note that the intake of other nutrients ingested with sucrose, such as fat, need to be taken into account. Care should be taken to avoid excess energy intake, which leads to weight gain. 2. SUGAR ALCOHOLS These reduced-calorie sweeteners, also known as polyols such as sorbitol, xylitol, mannitol, isomaltose, maltitol and lactitol, are ingredients that are used as bulking agents and sweeteners in many products marketed towards individuals with diabetes. Sugar alcohols are not commonly used in home food preparation, but are found in many processed foods. They add texture to foods, retain moisture better and prevent foods from browning when they are heated. Food products labelled “sugarfree,” including sweets, biscuits, chocolates, chewing gum, soft drinks and throat lozenges often contain sugar alcohols. They are frequently used in toothpaste and mouthwashes as they reduce the risk of dental caries. Because they are not fully absorbed by the gastro-intestinal tract, they produce a lower postprandial (aftermeal) blood glucose response and provide fewer calories (about a half to one-third less calories) than regular sugar. This makes them popular among individuals with diabetes. Moderate amounts of foods containing sugar alcohols are acceptable in your meal plan but beware not to eat them in excess! Eating uncontrolled amounts will increase your blood glucose levels because they are eventually converted into glucose in the liver. There is often the misconception that all products containing sugar alcohols are “free foods”. However, some may still contain DIABETES
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• EAT RIGHT significant amounts of carbohydrates. It is important to check the food label for the total carbohydrate contained in the product. They contain a significant number of calories and often they are combined with fat, further increasing the calorie content. This may result in weight gain. Some individuals report gastric discomfort (bloating and flatulence) after eating foods sweetened with these products and consuming large quantities may even cause diarrhoea.
health and the use of aspartame in the periods studied. However, studies to determine the long-term effects of using sweeteners are yet to be done.
3. NON-NUTRITIVE OR ARTIFICIAL SWEETENERS
Many people experience sweet cravings from time to time. These cravings may be: physiological - when you don’t eat for long periods of time and have a gnawing feeling in your stomach, at the onset of an exercise programme or any time that you restrict your food intake - often they signal a blood glucose crash, like when you feel irritable and light-headed; or Psychological - when seeing or smelling food, when you are fatigued, upset or bored or before a menstrual period. This is when you become certain that you’ll fall over dead if you don’t get some chocolate now! Eating in response to a psychological craving almost always ensures overeating - this can cause weight gain, affect your blood glucose levels and may become a threat to your health and wellbeing. The ability to distinguish the difference between psychological cravings and physiological hunger is the first step in learning how to conquer your sweet cravings.
Non-nutritive sweeteners offer the sweetness of sugar without the calories. In fact, artificial sweeteners by themselves are considered “free foods” because they contain very few calories and do not affect blood glucose levels. However, they do not necessarily offer a free pass for sweetened foods. Many products made with artificial sweeteners, such as baked goods and artificially sweetened yoghurt, still contain calories and carbohydrates that can affect your blood glucose level and waistline. Non-nutritive sweeteners alone will not cause weight loss but may contribute to weight loss if used in conjunction with a calorie-restricted meal plan. Examples of artificial sweeteners include Aspartame, Saccharin, Acesulfame K or Sucralose. Some people’s taste buds are very sensitive to these products, and they describe a lingering bitter or metallic aftertaste. Using a different sweetener or using less of the product may help one to overcome this. Acesulfame K and sucralose are stable when heated and so are ideal as sugar substitutes for baking. Aspartame, however loses its sweetness if heated to high temperatures and is not recommended for baking. Before being allowed on the market, all underwent rigorous scrutiny. They were shown to be safe when consumed by the general public, including children, people with diabetes, and women during pregnancy. They are however classified as food additives and should thus be eaten in moderation. Over the years, various allegations have been made that artificial sweeteners can cause health problems like cancer, epileptic fits, multiple sclerosis, headaches and brain tumours. These fears are unfounded as virtually all of the information is anecdotal, from anonymous sources and is scientifically implausible. The fact that these things sometimes happen to coincide does not establish a cause and effect relationship between the symptoms and the use of aspartame for example. Short-term scientific studies confirm that there is no connection whatsoever between ill
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Whether your goal is cutting calories or eating healthier, options for sugar substitutes abound. It pays, however, to be a savvy consumer… get informed and look beyond the hype! THE REAL PROBLEM - SWEET CRAVINGS …
Your “psychological” sugar cravings are there for a reason and it’s usually a symptom of something larger. So, you’re much better off fixing the source of the problem than just covering it up by eating artificially sweetened foods. Artificial sweeteners, precisely because they are sweet, encourage sugar cravings and dependence and perpetuate the innate desire for sweetness. In order to overcome sugar cravings, the goal is to reduce your desire for sugary foods slowly instead of simply substituting with artificial sweeteners. By cutting down on refined sugars your body will slowly regain its natural homeostasis and balance out your hormonal signals. Your overwhelming cravings for sugar and your insatiable appetite will slowly dissipate. Essentially, artificial sweeteners fool your brain into thinking it is having sugar! So, when your brain is tricked, it never actually receives any feedback from your body that it got sugar. The hormones that normally trigger the sugar cravings to stop actually increase the signals, because it senses that your body is being deprived of it. The enhanced sugar cravings ultimately become too strong and you eventually end up consuming more sugar than you intended to consume. This means you consume more calories and
• EAT RIGHT produce an even higher insulin spike, which equals more fat deposition and greater weight gain. Researchers say artificial sweeteners may also interfere with the body’s natural ability to count calories based on a food’s sweetness and make people prone to overindulging in other sweet foods and beverages. For example, drinking a diet soft drink rather than a sugary one at lunch may reduce the calorie count of the meal, but it may trick the body into thinking that other sweet items do not have as many calories either. Researchers say that losing the ability to judge a food’s calorie content based on its sweetness may be contributing to the dramatic rise in overweight and obesity rates. Based on the research, it has been suggested to pay more attention to overall calorie intake and regular exercise to battle the bulge. This is not the only reason for avoiding or limiting artificial
sweeteners. According to new research in the American Journal of Clinical Nutrition, the consumption of artificially sweetened soft drinks, both carbonated and noncarbonated, has been associated with an increased risk for birth occurring before 37 weeks gestation. The researchers found no such association between sugar-sweetened beverages and preterm births. Adding to this evidence, it has also been shown that drinking too many diet soft drinks may result in a negative calcium balance, a marker of low bone mineral density, which is associated with increased risk of fracture. Understanding the pros and cons of sugar and artificial sweeteners and how each affects your body, can help you make informed choices and smarter decisions about the foods you eat and avoid being caught in the “sugar spin-cycle”.
CDE Service Provider Classifieds For a comprehsive list of the over 270 CDE Centres nationwide, please see the CDE web site, www.cdecentre.co.za
Dr PD Badul Accredited CDE Provider General practitioner with interest in diabetes and occupational health Winkelspruit Telephone: 031 916-3430
Dr BPBH Majozi Centre for diabetes management Craister Street, Mthathe, Umtata, Eastern Cape Telephone: 047 531-0080
Dr Wynand Jacobs
Dr D Jacobs MBBCh (Pret)
Morningside Telephone: 011 883-5012
Dr Charles Waggler Muzamhindo Johannesburg City Centre Telephone: 011 333-2408
Dr L Gagiano
Specialist Physician Call us to set up an appointment and to join our Centre for Diabetes Centurion Telephone: 012 664-1414 or 082 413-2398
South Coast Mall, Shelly Beach Telephone: 039 315-0343
Niel Venter Mill Park, Port Elizabeth Telephone: 041 374-6550
Diabetes Care Centurion
Sr Jen Whittall
Dr Kahanovitz Manor Medical Diabetes Centre Morningside Manor, Sandton Telephone: 011802-5338
Phalaborwa Diabetes Clinic Diabetes education and weight loss programme Sr. Annelie Jordaan Telephone: 083 655-9147
Dr J Reyneke Parkland Clinic, Springs Telephone: 011 815-1883
Vaal Diabetes Centre Dr GW Anderson (Specialist Physician CDE Centre with comprehensive diabetes education provided Vereening Telephone: 016 455-5939
Dr Wayne May Specialist Endocrinologist CDE Centre with comprehensive diabetes management. Specialising in insulin pump therapy and bariatric surgery. On-site GP and affiliated ophthalmologists, podiatrist and dietician. Claremont, Cape Town Telephone: 021 674-6414
Mokgophong Medical Centre Registered CDE Practice Telephone: 014 743-3445
CDE Diabetes Management Programme Committed to excellence in diabetes care. Telephone: 012 664-7831
Dr N Govender Eden Terrace, Edenglen Telephone: 011 452-4124
Dr N Bernard and Sr. Beckert Registered CDE Centre Paarl Telephone: 082 355-0392
Dr SR Ramdharee Registered CDE Centre Dundee Telephone: 034 212-1959
Diabetes Care Centre Doctor SKPM Molefe Temba, Pretoria Telephone: 012 717-2000 or 087 809-0766
CDE Diabetes Centre offering counselling, education and well structured diabetes management for all ages and types of diabetes. Telephone: 011 987-3192
Sr Sheradin Williamson and Dr
Diabetes Specialist Nurse Specialising in children, adults and insulin pumps Bryanston, Johannesburg Telephone: 011 706-5648 or e-mail jenwhittall@global.co.za
Dr Khalid Ismail FCP (SA) Diabetes (Cardiff)
Dr Kaamila Ismail MBBCh (Wits) Polokwane Telephone: 015 291-1598
Dr David Segal Specialist Endocrinologist CDE Parktown Telephone: 011 726-0016