Type 1 diabetes used to be diagnosed in the young; Type 2, mostly in older people. But the picture is changing. Why? And what can we do about it? Carine Visagie asks the experts.
Since the 1980s, diabetes has rapidly increased – so much so that the global prevalence has nearly doubled since 1980, rising from 4.7% to 8.5% in adults. Over the past decade, Type 2 diabetes has become a massive problem in low- and middle-income countries and, for the first time in history, it’s a significant problem among the world’s children. What’s more, Type 1 diabetes is also on the increase.
It’s estimated that about 1.396 million of South Africans with diabetes remain undiagnosed, which makes it hard to judge the scale of the problem here. “But diabetes certainly is on the increase here, too,” says Johannesburg-based paediatric endocrinologist Prof. David Segal.
While the worldwide increase in Type 2 diabetes can be explained by unhealthy, modern lifestyles, rapid urbanisation (linked to inactivity and unhealthy eating patterns), a wider spread of the genes linked to the disease, and an ageing population, the reason for the increase in Type 1 diabetes is less clear.
To complicate matters, an increasing number of adults are presenting with latent autoimmune diabetes (LADA) – a form of Type 1 diabetes in which the progression of the disease is slow. As such, many adults with LADA are misdiagnosed as having Type 2 diabetes.
Type 1 diabetes in adults and the very young
At the start of the 20th century, diabetes was rare in children. By the end of the century, it increased substantially in many parts of the world and, right now, many countries are documenting higher numbers of Type 1 diabetes than ever before. Plus, the profile of patients is changing.
Across the world, this autoimmune disorder now often strikes at a younger age. And while similar research hasn’t been done locally, research shows that 50% of people newly diagnosed with Type 1 diabetes in the United Kingdom are over 30. This turns the long-held belief that Type 1 diabetes develops only in childhood on its head.
It’s long been known that both environmental and genetic factors contribute to Type 1 diabetes, but the exact triggers remain unknown. One of the theories, according to Johannesburg-based endocrinologist Dr Zaheer Bayat, is the hygiene hypothesis, which suggests that exposure to a variety of pathogens during early childhood might protect against Type 1 diabetes. A second theory suggests that certain viruses may initiate the autoimmune process involved. Another is that vitamin D deficiency plays a role. And a link between Type 1 diabetes and early exposure to cow’s milk is being explored.
According to Segal, being overweight or following the lifestyle of an obese person (being inactive and following an unhealthy diet) may also be a trigger. The “accelerator hypothesis” argues that Type 1 and Type 2 diabetes are in fact the same condition, distinguished only by the rate at which the beta cells in the pancreas are destroyed, and the triggers (or “accelerators”) responsible.
Type 2 diabetes still on the increase
In South Africa, Type 2 diabetes remains a massive health problem that accounts for more than 90% of diabetes cases. This condition, in which the pancreas either doesn’t produce enough insulin or the body doesn’t use it effectively, still predominantly occurs in adults. “But, for the first time, we’re also seeing young adults and adolescents with Type 2 diabetes,” says Bayat.
Ethnicity, family history and gestational diabetes combine with increased age, overweight/obesity and smoking to increase a person’s risk. In this country, the high incidence of Type 2 diabetes is also closely linked to the rapid cultural and social changes we’ve experienced over the last 20 to 30 years. With them came physical inactivity and unhealthy eating – both important risk factors.
According to Fiona Prins, diabetes specialist nurse practitioner, researchers are also currently investigating how, genetically, some of us store fat differently – a factor that could play a role in diabetes risk and management. “Some people may have ‘thrifty genes’, which would allow them to cope better on meals that are eight hours apart,” she says. “But this goes against all our messaging of eating three meals a day (or six, in the case of diabetics).”
Part of the problem, adds Segal, is that many of us don’t quite know what obesity is – we think we’re just overweight when, in fact, we’re obese. His advice is clear: “You have to lose weight to halt the progression to diabetes. It’s the only way.”
Jenny Russell, support group expert, adds: “Go and see a dietician who specialises in this field. They can do a thorough history and advise on an eating plan that suits you. Then simply get moving – every bit of exercise counts.”
If there’s one question we get all the time, it’s about the insulin pump: what is it, how it works and how to get it covered by medical aid. So we’ve gathered together all your Frequently Asked Questions, and found the answers.
Meet the expert
Name: Imke Kruger
How long have you been diabetic? 25 years
How long have you been on the pump? 5 years
What made you decide to get an insulin pump?
I battled to get my blood glucose under control on multiple daily injections, especially when doing sports. It was before my first 94.7 cycle challenge that my doctor suggested insulin pump therapy. It has changed my life! I can’t imagine life without my Accu-Chek Combo pump.
What do you love about the pump?
Everything! It helps me to live life the way I want to. I love the discreetness of it – I can give a bolus in a meeting or when going out with my friends, without anyone noticing.
What are some of the challenges?
The first two months were difficult to get used to sleeping with the pump, but now I don’t even realize that I’m wearing it. The challenge is more with diabetes – not the pump. It’s important to realise that insulin pump therapy is not taking the condition away. There are so many variables in diabetes, and that will always be a challenge.
When should someone consider getting an insulin pump?
- If they are experiencing severe hypoglycaemic (low blood sugar) episodes despite careful management.
- If they are on multiple daily injections, following a meal plan, testing their blood glucose levels 4 times a day, and still not getting target HbA1c results.
- If they have irregular eating, working and resting times.
Insulin pump therapy won’t work for those who aren’t committed to it, and there isn’t enough evidence to recommend it for Type 2 diabetics.
A more comprehensive description of the Indications and Contra-Indications to Pump therapy can be found in the SA Guidelines for Insulin Pump Therapy. A Amod, M Carrihill, JA Dave, LA Distiller, W May, I Paruk, FJ Pirie, D Segal, Association of Clinical Endocrinologists of South Africa (ACE-SA) JEMDSA 2013;18(1):15-19.
FAQ about the insulin pump from our community:
What is an insulin pump?
- Insulin pumps are portable devices attached to the body that deliver constant amounts of rapid or short acting insulin via an infusion set.
- The pump tries to mimic the release of insulin from a normal pancreas, but you have to tell it how much insulin to inject.
- It delivers insulin in two ways: a basal rate which is a continuous, small trickle of insulin that keeps blood glucose stable between meals and overnight; and a bolus rate, which is a much higher rate of insulin taken before eating to “cover” the food you plan to eat or to correct a high blood glucose level.
- Because the insulin pump stays connected to the body, it allows the wearer to change the amount of insulin they take with the press of a few buttons at any time of day. You can also program in a higher or lower rate of insulin delivery at a chosen time – when sleeping or doing sports, for instance.
Where do you buy an insulin pump and how much does it cost?
You need to be a patient at one of the accredited pump centres in South Africa. Your doctor will decide if you are a pump candidate according to the Association of Clinical Endocrinologists of South Africa (ACE-SA) guidelines. If you are, you will need a script to claim the pump through your medical aid, or buy it cash from one of the supplying pharmacies.
What are the advantages and disadvantages of using an insulin pump?
Insulin pump therapy improves metabolic control while giving you greater freedom and a better quality of life.
- Your metabolism stays more stable, with better HbA1c values and fewer low blood sugar episodes.
- You can be more flexible in your eating, if you understand the concept of carbohydrate counting.
- You can participate in sports whenever you feel like it — without having to plan in advance
Disadvantages are that you have too much freedom in making food choices, and that there is a risk of diabetic ketoacidosis (DKA) from pump malfunction or absorption problems.
Remember: Deciding on insulin pump therapy is not a simple decision and should be carefully discussed with your healthcare team.
Will my blood sugar control be better if I use an insulin pump?
It all depends on you. You can wear a pump and it can have no impact on your blood sugar. Or you can use a pump, and with the right settings, motivation and help from your healthcare team, you can have better blood sugar control.
Will I still have to test my blood sugar as much?
A pump patient needs to be a motivated patient who tests regularly, around 4 times a day.
Are there insulin pumps that have a Continuous Glucose Meter attached?
Yes there are – it’s a good idea to discuss with your healthcare team which pump would best suit your needs
How would the insulin pump be used for sports? Are there special casings made or will I have to play without it?
You can engage in any kind of physical activity while wearing an insulin pump. But for sports with intensive body contact and water sports we recommend temporarily disconnecting the insulin pump (not for longer than 1 hour). Special cases and pouches can protect the pump, but it’s always a good idea to insure it as well.
At what age can you put a child on the insulin pump and how easy is it for them to adapt?
I would say at any age, but it’s best to get advice from your pediatric endocrinologist. Children often adapt the easiest of all age groups to insulin pump therapy.
What is the risk of infection?
If you follow the right hygiene steps, the risks are low. You should always disinfect the pump site before inserting the infusion set. It is also critical to replace the infusion set every three days.
How much is an insulin pump with and without medical aid?
That depends on the type of medical aid plan and whether the medical aid covers the costs fully or partly. It would be best to discuss this with your healthcare team or your medical aid. If your doctor agrees that pump therapy is the best option for you, they will send an application to the medical aid.
Ask the expert: Dr Claudine Lee, GP
“Pump therapy is a beautiful and practical way of delivering insulin that tries to fit in with you, the patient, in terms of meals, exercise and illness, as well as just living a normal life.”
We all know that more and more people are now living with Type 2 diabetes. It used to be seen as a condition for the wealthy, but today it’s increasingly common in every community – rich and poor. Nicole McCreedy takes a look.
Diabetes in South Africa is often associated with the Indian community among whom – compared with other cultures – it is more widespread. According to a study by the Human Sciences Research Council and Medical Research Council, 61% of South African Indians over the age of 45 have pre-diabetes, and are more likely, with age, to develop Type 2 diabetes.
But the Indian community is no longer the only group facing the diabetes challenge. It is now being reported as one of the leading causes of death in areas where diabetes was once unheard of.
The rapid rise in diabetes
There are a number of factors that put a person at risk for developing Type 2 diabetes. A family history of the condition, your lifestyle – what you eat, whether you smoke and how often you exercise – as well as your environment all play a role.
In the past, the Indian and white population in South Africa were more likely to be urbanised and wealthier, while Africans lived in the rural areas. Living in an urban environment often means longer hours at work, commuting and easy access to cheap fast foods. This type of lifestyle is linked to higher levels of overweight and obesity, and in turn diabetes. A study from 2005 found South African Indians ticked all the boxes: a diet low in fibre and high in unhealthy fats, physical inactivity, and insulin resistance.
However, in recent decades, South Africa has undergone both political and economic change. As a result, many people living in rural areas, especially Africans, have moved to cities for work and better opportunities. Being less physically active and eating a more Western diet (high in carbs and fats) is contributing to the growing diabetes burden in the African and coloured communities.
South Africans are fat
The relationship between overweight/obesity and Type 2 diabetes is critical. An unhealthy diet and not enough exercise can lead to being overweight or obese. Carrying extra weight, especially belly fat, is bad for your health, specifically leading to insulin resistance, high cholesterol and high blood pressure. All of which are damaging to long-term health.
What’s scary is that in South Africa, 7 out of 10 women and 4 out of 10 men have significantly more body fat than is healthy. The issue of overweight and obesity is emerging as a particular health concern among black women living in urban areas where there is a high rate of HIV. Weight gain, especially among black women, has always been seen as a sign of wealth, health and success in traditional African society, while being thin is associated with being HIV-infected. But overweight and obesity is also linked to diabetes. In a study on body perception among urban-dwelling black women, as many as 90% were overweight and obese, while almost three-quarters had diabetes.
The next generation
Your lifestyle not only affects your own health; it can also impact the health of your children. High blood sugar levels in pregnancy impact the unborn baby’s genes, making them more vulnerable to Type 2 diabetes later in life. Babies exposed to high blood sugar in the womb may have a higher birth weight and this can continue into adulthood with serious effects on their long-term health. Among South African Indians, where high blood sugar has been a problem for much longer, diabetes is now showing up at a much younger age than ten years ago – as early as between 25 to 45 years old.
Ignoring the problem
For many individuals, diabetes is a problem they don’t want to acknowledge. “A big concern is that people with diabetes are not taking their condition seriously enough,” says Jenny Russell from Diabetes South Africa’s Durban branch. “They want to swallow their tablets and carry on their unhealthy lifestyles.” According to Jenny, “in the Indian community, it is almost accepted as ‘normal’ that if you have diabetes, you will have diabetes-related complications: limb amputation, blindness or needing kidney dialysis.”
Others struggle with feelings of guilt. But whatever your culture, as Jeannie Berg, a pharmacist and diabetes educator in Mpumalanga, says:
“Diabetes is the same for everyone. Don’t let it define your life: it is not who you are, it is a part of your life you need to manage.”
There are no two ways about it: insulin is a miracle drug. It was discovered in 1921 and has saved millions of lives in the last 95 years. Andrea Kirk explores the topic.
“In people with Type 1 diabetes, insulin is essential for maintaining good health, and many people died from Type 1 diabetes before insulin,” says endocrinologist Dr Joel Dave. “Insulin therapy is started as soon as the diagnosis is made, and although being diagnosed with Type 1 diabetes can be a traumatic experience, with the use of insulin, you can maintain good health and achieve anything in life that those without diabetes can.”
For people with Type 2 diabetes, however, there is often a reluctance to start taking insulin. Some people manage to control their blood sugar without it, by making changes to their diet, getting more exercise and going on oral medication. But for others, insulin is a necessity.
“There’s a huge stigma about this,” says Mark Smith, who was diagnosed with Type 2 diabetes a year ago. “I feel like starting insulin would mean that I’ve failed at controlling my blood sugar with lifestyle changes.”
Diabetes educator, Jeanne Berg, sees things differently. “Diabetes is a progressive condition and insulin therapy is inevitable. Some people take longer to get to the point of starting insulin than others, but every patient with diabetes gets there eventually. There shouldn’t be any shame or sense of failure in this.”
Jeanne says that in the past, doctors would try to intimidate people with Type 2 diabetes into changing their lifestyle. “They’d say: if you don’t change your diet and get more exercise, you’ll end up blind, or have your legs amputated, and eventually you’ll die.” This blame-filled approach may be part of the reason there is still such a stigma associated with Type 2 diabetes. “People would think ‘this is all my fault, I did this to myself’, but that is not the whole truth,” says Jeanne. “Diabetes has a genetic inheritance factor to it as well.”
Doctors and diabetes educators today steer away from using scare tactics and encourage people to accept insulin as a means of coping and having a more flexible life with diabetes.
Are there any benefits to starting insulin sooner?
“In people with Type 2 diabetes, there is a theory that glucose can cause damage to the beta-cells of the pancreas, which are the cells that make insulin,” says Dr Dave. “The longer the glucose remains high, the more damage occurs. Since insulin is the best way to lower blood glucose, some suggest that insulin should be taken sooner rather than later in order to preserve beta-cell function for longer.”
We all know that a healthy diet is key to managing your diabetes. But should you also be taking a diabetic supplement? Andrea Kirk asks the experts.
Living with diabetes can be challenging, so when you hear about a natural supplement that works wonders, it’s easy to get excited. “A number of supplements have been said to play a role in improving insulin sensitivity, blood sugar control, and helping to prevent complications of diabetes,” says endocrinologist Dr Joel Dave. “Although there is some observational evidence to suggest that some of these may be beneficial, unfortunately there are no large, long-term, placebo-controlled studies that prove any supplement is effective when it comes to diabetes.”
Dietician Cheryl Meyer agrees: “In some cases benefits have been shown, but at this stage there is just not enough scientific evidence.” Both experts believe that a well balanced diet should provide all the essential minerals and vitamins you need.
“I don’t recommend routine supplementation,” says Dr Dave, “but if someone is deficient in a specific vitamin or mineral, then I would recommend they take a supplement of that particular vitamin or mineral.”
When a supplement may be necessary
If you are experiencing specific symptoms and suspect you are deficient in a vitamin or mineral, speak to your doctor about having a blood test. Your doctor will make a recommendation based on the test results and may prescribe a supplement. Keep in mind that the type and dosage your doctor prescribes may be different from what is found on the shelf. Stick to your prescription rather than self-medicating.
Be careful of drug interactions
Dietary supplements can have adverse interactions with prescription drugs, other herbal products or over-the-counter medications, warns Meyer. The effects range from mild to potentially life-threatening, so it is important to disclose everything you are taking to your doctor.
Never replace your conventional prescription
“Don’t replace a proven conventional medical treatment for diabetes with an unproven health product or practice. The consequences can be very serious,” says Meyer.
“I generally advise my patients to steer clear of supplements unless we know for sure that it’s necessary,” says Dr Dave. “Rather focus on sticking to a healthy diet and lifestyle, monitoring your blood glucose and taking the medication your doctor has prescribed.”
Supplements and their claimed benefits
Alpha-lipoic acid (ALA) is an antioxidant made by the body. It is found in every cell, where it helps turn glucose into energy. Several studies suggest ALA helps lower blood sugar levels. Its ability to kill free radicals may also help people with nerve damage, which is a common diabetes complication. For years, ALA has been used to treat diabetes-related nerve damange in Germany. However, most of the studies that found it helps were based on using intravenous ALA. It is not clear whether taking it orally will have the same effect.
Source: University of Maryland Medical Centre
Chromium is an essential mineral that plays a role in how insulin helps the body regulate blood sugar levels. For many years, researchers have studied the effects of chromium supplements on those with Type 2 diabetes. While some clinical studies found no benefit, others reported that chromium supplements may reduce blood sugar levels, as well as the amount of insulin people with diabetes need. Good food sources of chromium include whole grain breads and cereals, lean meats, cheese, some spices (like black pepper and thyme), and brewer’s yeast.
Source: University of Maryland Medical Centre
Fenugreek seeds may be helpful to people with diabetes because they contain fibre and other chemicals that are thought to slow digestion and the body’s absorption of carbohydrates and sugar. The seeds may also improve the way the body uses sugar and increase the amount of insulin released. An Iranian study found that a daily dose of fenugreek seeds soaked in hot water may be helpful in controlling Type 2 diabetes. Another study from the US suggests that eating baked goods, such as bread, made with fenugreek flour may help to reduce insulin resistance in people with Type 2 diabetes.
Several studies have shown that American ginseng lowered blood sugar levels in people with Type 2 diabetes. The effect was seen both on fasting blood sugar and on glucose levels after eating. One study found that people with Type 2 diabetes who took American ginseng before or together with a high sugar drink experienced less of an increase in blood glucose levels.
Source: Penn State Milton S. Hershey Medical Center
Magnesium deficiency has been associated with increased risk of Type 2 diabetes. Some studies suggest that supplementing may be beneficial, but other studies have shown no benefit. A healthy diet should provide all the magnesium you need, so have your doctor check for deficiency before you consider supplementing. Good food sources of magnesium include legumes, whole grains, broccoli, green leafy vegetables, dairy products, seeds and nuts.
Source: Oregan State University and WebMD
Whether you battle to lose weight, or struggle to gain it, maintaining a healthy weight is a constant battle for many people with diabetes. Joanne Lillie explains how to make lasting changes.
Putting on weight
Controlling blood sugar levels is the starting place for achieving your target weight with Type 1 diabetes, as high blood sugar levels will cause glucose to be lost in the urine and result in weight loss, says dietician Genevieve Jardine. Many people find that once their glucose levels are under control, weight management becomes much easier.
Top tips to build mass:
- Go for low GI: To balance your glucose levels, lower-GI carbs such as wholegrains, beans, sweet potatoes and some fruit (like plums and apricots) are great choices, as they are less likely to spike your blood glucose. Milk and yoghurt also have a low GI. Just remember that low GI food still has to be eaten in the right portion.
- Eat more often: Rather than three meals a day, eat six smaller meals a day. Check your blood sugar more often and inject accordingly if you decide to try eating this way. Don’t skip meals as you will miss opportunities to increase your calorie intake.
- Fat has more calories than carbohydrates or protein: fat contains 9 calories per gram, while carbs and proteins contain 4 calories. So it makes sense to eat more fat when you’re aiming to put on a few pounds. Just be aware that you need to choose healthy fats. Cook with more olive or canola oil, get plenty of nuts and seeds, and add avocado and olives to salads.
- As long as your kidneys are in good shape, you can add protein powder to yoghurt or smoothies. This helps you gain weight as lean muscle mass rather than fat.
A normal body mass index (BMI) is vital for people with diabetes. “As the BMI increases, the amount of insulin required to maintain a normal glucose level also increases because patients become more insulin resistant,” explains endocrinologist Dr Joel Dave. An elevated BMI is also associated with high blood pressure (hypertension) and high cholesterol (dyslipidemia).
Healthy eating, regular physical activity, and medicine (if prescribed), are the key elements of Type 2 diabetes management. For many people with diabetes, the most challenging part of the treatment plan is working out what to eat.
Top tips to lose mass:
- Aim to reduce your energy intake while sticking to a healthy eating pattern. This means getting all the nutrients you need, in as few calories as possible. How? By focusing on nutrient-dense foods such as green vegetables, some fruits (especially berries) and beans.
- Carbohydrates from vegetables, fruits, wholegrains, legumes and dairy products are better than from other sources, especially those with added fats, salt and sugar. The most carb-dense foods include those with refined white flour: breads, biscuits, pastries, cakes, as well as white rice and potatoes. Limit these as much as possible!
- A Mediterranean-style diet may boost weight loss and benefit blood sugar control and cardiovascular risk factors. This means:
- Eating mostly plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
- Keeping carbohydrate levels as low as possible
- Using healthy fats, such as olive oil
- Using herbs and spices instead of salt to flavour foods
- Limiting red meat to no more than a few times a month
- Eating fish and poultry at least twice a week
Ask the expert: Genevieve Jardine, dietician
“Learn to respond to hunger and not appetite. Often a high carbohydrate diet makes people hungry whereas enough protein and healthy fats helps make people feel fuller for longer.”
Children with diabetes often experience stigma. Carine Visagie explains how to make life easier for your child.
When Njabulo Dlamini was diagnosed with diabetes at the age of 16, he didn’t reveal his diagnosis to his friends. Fear of being called a drug addict, and standing out from the crowd, made him keep it a secret until the age of 19.
After he met Jenny Russell from Diabetes South Africa’s Durban branch, this young man (also an Idols star) started using his experience to break down some of the myths about the condition. But many other children with diabetes still have to deal with rejection and ridicule – so much so that their mental and physical health suffers.
Is there something that can be done to eliminate this social side effect of diabetes? We asked the experts.
Don’t make a fuss
When parents, teachers and other role models make a diabetes diagnosis and the day-to-day management a simple part of life, other children are more likely to accept this model as the norm. “Children don’t usually have preconceived prejudices, and they tend to follow models of behaviour set out for them,” says paediatric endocrinologist Dr Michelle Carrihill. “There’s no reason for children with diabetes to feel stigmatised if everyone is shown the right way to behave.”
Parents have a special role to play in this process, which starts with giving school staff and classmates the correct info. The more informed others are, the less likely it is that they’ll treat the child with diabetes differently.
Not sure where to start? Here are some guidelines*.
How you can help:
- Learn as much as possible about your child’s condition and do a simple presentation to teachers and classmates explaining what diabetes is, and what blood glucose testing and insulin injections involve. This moves the kids’ response away from fear and suspicion towards acceptance.
- Provide teachers with written information about your child’s needs. Include:
- A care plan for your child’s routine school day.
- A plan for days when the routine isn’t followed (for example, during outings).
- Signs and symptoms that could indicate a problem.
- What to do in an emergency, including all necessary contact information.
Make these plans with the teachers’ input, so that their roles are clear and accepted. A diabetes educator, dietician or diabetes specialist nurse can assist.
- Explain to teachers that blood glucose testing, additional trips to the bathroom and eating extra carbohydrates may sometimes be necessary. No big deal should be made of this.
- Explain that your child can exercise and also take part in outings, just like the other kids: there’s no need to treat them differently.
- Some kids are okay to inject in front of friends, while others are not. Ask the school to provide an area where your child will feel comfortable to test and inject. This could be the corner of a classroom or the nurse’s office, as long as the space is clean and quiet. They shouldn’t have to resort to the school bathroom.
- Ask teachers to provide positive support and encouragement, especially if your child seems anxious. Also ensure that a staff member is always available to them, so that they know who to ask for help.
* From Dr Carrihill, Jenny Russell and diabetes educator Kate Bristow.
Remember: Your child should always have their medical info and emergency contact details on hand: an ICE band or MedicAlert bracelet will do the trick. Find out more at www.medicalert.co.za
Make sure your child’s backpack always has:
– Testing equipment (a glucose monitor, lancets and strips).
– Insulin in a small cooler bag.
– A quick-acting sugary food or drink (like Super Cs).
– A glucagon emergency kit for severely low blood sugar emergencies: be sure to show teachers and older friends how to use it!
Join the community: Does your child have diabetes? Come and talk to us about it at www.facebook.com/DiabeticSouthAfricans
Motherhood is a great adventure and (morning sickness aside!) being pregnant is magical. Inside of you, a perfect little baby is growing… Carine Visagie explains what you need to know to ensure everything goes smoothly.
If you have diabetes, or get diabetes during pregnancy, you’ll naturally want to know what you can do to stay healthy. We spoke to endocrinologist Dr Veronique Nicolaou, obstetricians Dr Veronique Eeckhout and Dr Manasri Naiker, and registered dietician Emily Innes to learn more about diabetes and pregnancy.
Get this right before pregnancy
Keen to start a family? Don’t ditch the contraceptives yet. To prevent miscarriage, stillbirth, birth defects and other complications, our experts say you first need to:
1. Tightly control your blood sugar levels. This means keeping your HbA1c below 6.1% for three months.
2. Lose excess weight. Being overweight ups your risk of complications during pregnancy.
3. Take a 5mg folic acid supplement (three months before pregnancy up until the 2nd trimester).
4. Stop smoking.
Stay healthy during pregnancy
If all goes according to plan, you’ll soon be pregnant. Congratulations! Now is the time to focus on your baby’s growth and development, which (still) means managing your blood sugar levels as well as you can.
Poorly controlled blood sugar spells trouble for pregnant moms. Apart from a higher risk of infections, hypoglycaemia (low blood sugar), pre-eclampsia (high blood pressure) and ketoacidosis, excess amniotic fluid is an increased risk, which could lead to premature delivery. Existing diabetes-related problems (like nephropathy) may also worsen during pregnancy. Additionally, your baby may grow too big, which increases the risk of stillbirth, birth trauma and respiratory distress. But this is all if your blood sugar is uncontrolled: stay in good control and you’re likely to have a perfectly normal, healthy pregnancy.
Five steps to stay in good control:
Step 1: Eat well.
- Choose high-quality, nutritious foods.
- Steer clear of refined carbohydrates.
- Include healthy fats and lean protein at each meal.
- Eat plenty of vegetables (and some fruit) every day.
- Don’t be tempted to eat for two!
Step 2: Exercise.
Talk to your medical team about physical activity. Exercise is a key part of diabetes management, but can sometimes be risky (for example, if you have high blood pressure). Keep your pulse rate below 140 beats per minute at all times.
Step 3: Get your treatment plan right.
If you have Type 1 diabetes, talk about your insulin dosage with an endocrinologist: the amount of insulin you need may double or possibly triple during pregnancy. Women with Type 2 diabetes who use only oral medication (like metformin) before pregnancy may require insulin at some point. The good news is that metformin is safe to take during pregnancy.
Step 4: Monitor your blood sugar frequently.
As many as six times a day (before meals and snacks, and one hour after). Find out from your medical team if you should be doing any other checks (like ketone testing).
Step 5: Visit your obstetrician regularly.
Your doctor will tell you how often to come: some recommend very two weeks until 32 weeks of pregnancy. After this, schedule a weekly visit until your baby is born.
Natural birth or C-section?
If all goes well, it’s possible to deliver your baby naturally. The timing is more important than the method of delivery. Your doctor will most probably induce to deliver naturally at 38 weeks, or do a C-section if there are other problems (for example, if you have a large baby). To control your blood sugar during labour, an insulin pump and a dextrose drip will be used, and your sugar and ketone levels will be checked every 2 to 4 hours.
Gestational diabetes explained
Gestational diabetes occurs for the first time during pregnancy and goes away again after birth. Uncontrolled blood sugar levels in gestational diabetes can be as dangerous as in Type 1 and Type 2 diabetes. It may be possible to control your blood sugar with diet and exercise, or medication may be necessary. The medication will most likely be stopped after pregnancy, but it’s important to get your blood sugar tested again six weeks after delivery to rule out Type 2 diabetes.
- Dr Veronique Nicolaou, specialist physician and consultant endocrinologist, Chris Hani Baragwanath Academic Hospital
- Dr Veronique Eeckhout, gynaecologist and obstetrician, Medi-Clinic: Cape Town
- Dr Manasri Naiker, gynaecologist and obstetrician, theWomanSpace: Cape Town
- Emily Innes , registered dietician: Cape Town
From the artificial pancreas to new ways of testing blood sugar and more, we take a look at the future for those with diabetes.
Diabetes is a rollercoaster ride of blood sugar ups and downs, and tight control can be hard work. But there’s good news: while some researchers are working on a cure, others are making life easier for those with diabetes right now, through technology.
Carine Visagie brings you a roundup of the top new technologies out there.
Continuous glucose monitoring (CGM) devices are soon going to take blood sugar control to another level.
With the help of tiny electrodes stuck beneath the skin, CGM devices allow for real-time glucose readings throughout the day. The results are sent wirelessly to a monitor you can clip onto your belt and access on the go, and some devices can even send results to your doctor. Normal finger prick testing is still required (for a double check and to calibrate the CGM sensor), but you can rest assured that a CGM device will alert you if your sugar spikes or drops below your limits.
Examples include the Flash Glucose Monitoring System (Abbott) and the Guardian REAL-Time Continuous Glucose Monitoring System (Medtronic).
Ask the expert: Dr Joel Dave, endocrinologist
“24-hour glucose monitoring is going to be very helpful in patients that have difficulty controlling their blood glucose levels, as it will provide a 24-hour 360-degree view of their diabetes control.”
Ask the expert: Dr Wayne May, endocrinologist
“I’m looking forward to the Abbotts Flash Monitor, as it will stay on for 14 days and doesn’t require calibrating with a second machine.”
Insulin pumps keep getting smarter: some of the latest ones sync with CGM devices, while others are incredibly accurate at giving just the right insulin dose at the right time.
One example is the touch-screen Tandem t:slim insulin pump, which shows the date, time, how much insulin is ‘on board’ (seeing this before you bolus can help you avoid stacking your insulin*), duration of insulin action, and the amount of insulin in the reservoir. It looks like a smartphone and data is easily transferrable via a USB port. Plus, it can deliver insulin in very small doses.
*Insulin stacking is injecting a second dose too soon after a first, without taking into account the insulin already in your system. This can result in low blood sugar.
Another insulin pump to watch is the MiniMed530G by Medtronic – the first pump to shut off when blood sugar goes below a predetermined level.
Ask the expert: Dr Joel Dave, endocrinologist
“Although an insulin pump isn’t the ideal way of administering insulin for everyone, many diabetics find a pump improves their diabetes control and quality of life. Since the addition of CGM, the use of this technology has improved even more, especially in children and patients with very erratic blood sugar.”
Bionic (artificial) pancreas systems are the next big thing in diabetes management. These systems, the first of which is still being tested, combine the latest CGM tech with the most advanced insulin pump tech and add a sophisticated computer programme to simulate the function of the pancreas.
The system constantly checks blood sugar levels by means of a CGM, and responds automatically by administering either insulin (to lower blood sugar) or glucagon (to raise blood sugar levels quickly) via two separate pumps. The system hooks up to a programme on your smartphone that makes decisions every few minutes, telling the pumps via Bluetooth how much hormone to deliver.
The bionic pancreas should be available in the next 5 years.
Ask the expert: Dr Joel Dave, endocrinologist
“The artificial pancreas has been the ‘holy grail’ for diabetes care for many years. The system has been vastly improved and early studies are showing great promise. Although not for routine clinical use at the moment, in the near future it will be a life-changing addition to the diabetes care of many patients.”
What about now? Smartphone apps for diabetes
If the future of diabetes tech seems too far away, keep an eye out for apps that can help you deal with diabetes right now, on your smartphone. We like:
Glucose Buddy: to track blood sugar readings, insulin doses, carb intake, exercise, blood pressure and weight, and
Diabetic Connect: helping you tap into trusted advice, friends, support and tips.
But be warned: many international apps use mg/dL, the US blood glucose standard, instead of mmol/l, the South African standard.
Are dietary supplements really necessary if you have diabetes? Nicole McCreedy asks the experts.
Like many other people with diabetes, you may be wondering whether you need to take supplements to help manage your condition. Dietary supplements can be vitamins, minerals, herbs or other plants, amino acids (the building blocks of protein) or a combination of the above. They can be in pill, capsule, powder or liquid form.
Despite some of the claims being made, there is not enough scientific evidence to suggest that any dietary supplements can help prevent or manage Type 2 diabetes. That said, dietary supplements may provide extra nutritional benefit to people with special health problems, including diabetes. In such cases, they are usually recommended when there is a specific lack of something in the body.
Do: Eat correctly
It’s important to try and get the nutrition your body needs from a balanced diet. Making healthy food choices and choosing fruit, vegetables and whole grains over carbohydrates, refined sugars and foods high in saturated fats can make a big difference. Compared with supplements, whole foods provide a variety of different nutrients for health in one package, whereas single vitamin supplements are most often for a single purpose. An apple, for example, contains vitamin C, fibre, and antioxidants – all in one crunchy package!
Dr Claudine Lee, a GP from Hilton, says that following a balanced and healthy diet is essential. “If you think you’re not getting the vitamins and minerals you need from your diet, consult with your GP whether it is necessary to take a supplement,” she advises. Eating correctly, being physically active and taking your prescribed medication is vital for maintaining good control of blood sugar levels to avoid serious complications like strokes, heart and kidney disease, limb amputation and blindness.
Don’t: Go it alone
Talk with your doctor. That is the first step in deciding whether or not to use a dietary supplement. He or she can discuss the possible benefits of dietary supplements, and check that any supplements you take will not interact dangerously with your medications.
Be sure to list any dietary supplements you take whenever you tell your doctor or any other healthcare professional about your medications. Most importantly, keep in mind that a dietary supplement is not a replacement for the diabetes treatment and care advised by your doctor.
So who could benefit from a vitamin supplement?
- Those on low calorie diets, who do not eat a variety of foods.
- Those following vegan diets.
- Those with certain food allergies, kidney disease or diseases of the gastrointestinal tract that interfere with nutrient digestion or absorption.
- Pregnant women.
An A to Z of supplements and their benefits
Ask the expert: Andrea Jenkins, nutritionist.
“The following supplements have been shown to improve blood sugar control or limit diabetic damage.”
Carnitine (L-carnitine), a nutrient made from amino acids that helps the body turn fat into energy, has been found to be deficient in people with diabetes. Almonds, egg and cottage cheese are rich in this nutrient.
Antioxidants can help reduce oxidative stress and lower the risk of diabetic complications. Choose brightly coloured fruits and vegetables in smoothies, salads and soups to ensure a variety of antioxidants.
Digestive enzymes help ensure that mineral uptake is strong and can aid the management of diabetes. Pre- and probiotics are also helpful to maintain digestion and immunity.
Lipids and essential fatty acids
Omega-3 fatty acids lower blood pressure and triglyceride levels, and can help to relieve many of the complications associated with diabetes.
Magnesium, common in leafy green vegetables, is frequently lacking in people with Type 2 diabetes, as is chromium. Brewers yeast, mushrooms and non-refined grains all contain chromium. Zinc improves insulin function, and potassium (found in all fruits and vegetables), can improve insulin sensitivity.
A vitamin B complex improves the metabolism of glucose, and vitamins C and E can improve eye health.
Remember that dietary changes are important to treat diabetes successfully. Many foods can have a positive impact on blood sugar, for example artichokes, garlic, nuts, onions, olives, cinnamon, blueberries, avocado and fenugreek. Try to include some (or all!) of these in your next meal…
Ask the expert: Faaiza Paruk, dietician
“Some people believe that by taking a supplement they won’t need to exercise or take any medication. This is untrue. You need a balanced diet as well as exercise to help control your sugar levels. A balanced diet includes five servings of fruit and vegetables a day, a low intake of salt and fat, lean meat and complex carbohydrates found in foods such as brown rice, potatoes, beans and lentils.”
Did you know that if you have diabetes and you’re a member of a medical aid, they have to – by law – give you certain benefits for free? Nicole McCreedy explains all you need to know about PMBs.
If you’re a Type 1 or a Type 2 diabetic and you belong to a medical aid, you have the right to certain health services, known as Prescribed Minimum Benefits (PMBs). There are about 300 medical conditions where PMBs apply, and 26 of those are chronic conditions like Type 1 and Type 2 diabetes.
Your health is important
PMBs were introduced to the Medical Schemes Act to protect members. It doesn’t matter how old you are, how healthy you are, or which medical aid option you are on (yes – even hospital plan counts!) Your medical aid has to provide minimum healthcare if you have a chronic condition – at no extra cost. You shouldn’t have to pay extra (over and above your monthly medical aid contribution) for certain medical services for diabetes. Because the government has made this law, it is also impossible for medical aids to charge you more or force you to lose your medical aid cover because you have a serious medical condition.
When you can (and can’t) use PMBs
What does this mean? A medical aid must pay in full, without any co-payment from you, for the diagnosis, treatment and care costs of the PMB condition (your diabetes). The medical aid cannot use your medical savings account or day-to-day benefit to pay for PMBs. Remember, though, that PMBs are subject to pre-authorisation (you have to register your PMB with the medical aid first), protocols (specific treatment and medication guidelines), and making use of designated service providers (hospitals, pharmacies and doctors that they have chosen). So you can’t expect your medical aid to cover the costs of your diabetes care unless you play by their rules, and you may not be able to get the same doctors and medicine as you had before.
Sometimes, members will not have cover for PMBs from their medical aid. This can happen if you join a medical aid for the first time (without switching from another medical aid) or if you join a new medical aid more than 90 days after leaving the previous one. If this is the case, there is a waiting period, during which you won’t have access to the PMBs for any pre-existing condition for 12 months.
Diabetes treatment and PMBs
The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially nutrition and exercise, but most people with diabetes also use medicine (usually insulin) at some point. Treatment of other risk factors, like blood pressure and high cholesterol, is also very important.
Both Type 1 and Type 2 diabetes qualify as PMBs and must be treated according to PMB regulations for diagnosis, medical management and medication. You can ask your medical aid about the following treatments that should be covered:
- Visits to your doctor (GP or specialist – if authorised).
- Dietary and disease education.
- Annual eye exam for retinopathy.
- Annual comprehensive foot exam.
- Blood tests every 3 to 6 months.
- Disease identification card or disc.
- Home blood sugar testing.
How to get your Prescribed Minimum Benefits:
Step 1: Register
Phone your medical aid and tell them you want pre-authorisation for diabetes PMBs. They will ask for a code that your doctor will be able to give you. It is very important that you have the right ICD-10 code – this gives the right information about your condition and helps the medical aid to know what benefits you are allowed. A PMB condition can only be identified by the correct ICD-10 codes. If you give the wrong ICD-10 code, your PMB services might be paid from the wrong benefit (like your medical savings account), or it might not be paid at all if your day-to-day or hospital benefit limits have run out.
Step 2: Your service will be pre-authorised
After you have registered your chronic condition for PMB, your benefits will be authorised and you can ask for your PMB schedule, which tells you exactly what you get for free.
The A to Z of PMBs
Chronic Diseases List (CDL)
A list of the 26 conditions (including diabetes) that qualify for PMBs.
Medicine used for the long-term treatment (three months or longer) of a chronic condition. The chronic medicine must be used to prevent or treat a serious medical condition, to sustain life and to delay the progress of a disease. It must also be the accepted treatment according to treatment guidelines (protocols).
The difference between the cover provided by the medical aid and the cost of the medical service – payable directly to the service provider.
Designated Service Provider (DSP)
Doctors and other health care providers who have been chosen by the aid to “provide its members diagnosis, treatment and care” for PMB conditions.
Emergency Medical Condition
A medical condition that needs immediate medical or surgical treatment.
An official list of the medication that can be prescribed for the treatment of the 26 conditions on the Chronic Diseases List (CDL).
An international clinical code that describes a disease diagnosis. If you want to qualify for PMBs, you must be sure your doctor puts the correct ICD-10 code on all your forms.
Medicine for the treatment of the 26 conditions on the Chronic Diseases List (CDL) qualifies for PMBs, as long as you provide all the necessary information. This can be anything from a diagnosis by a specialist to results of certain tests – your medical aid will tell you what you need.
Prescribed Minimum Benefits (PMBs)
The minimum benefits that must be provided to all medical aid members. These include diagnosis, treatment and care costs for a number of conditions, including diabetes.
Protocols (Treatment Guidelines)
There is a minimum standard treatment for each PMB condition. Medical aids use these guidelines to come up with protocols (treatment guidelines) and formularies (lists of approved medication) to manage PMBs.
This article was reviewed by:
- Alain Peddle, Discovery Health
- Herman van Zyl, Principal financial advisor, HVZ Financial Consultants
- Rossouw van Zyl, Brokers, t/a Medinet, Authorised Financial Service Provider
- Michael A.J. Brown, Accredited Diabetes Educator, Centre for Diabetes and Endocrinology, Houghton
Recent research suggests that a certain kind of surgery may “cure” Type 2 diabetes. We find out more, and give you the facts.
One of the experts in the field of gastric bypass surgery is Professor Tess van der Merwe, the president of the South African Society for Obesity and Metabolism, who have been sharing information about the surgery. We found out what it could mean for Type 2 diabetes, then asked our experts to weigh in on the topic.
Is this surgery a cure for Type 2 diabetes?
Gastric bypass surgery has been used to help obese people lose weight since it was first performed 20 years ago. But now there is new research that this same surgery (specifically a type called “laparoscopic Roux–en–Y gastric bypass”) could cause Type 2 diabetes to go into long-term remission. What does this mean? Type 2 diabetes could be “paused” for a number of years. An international study shows that about 90% of obese patients with Type 2 diabetes who go for this surgery have normal blood sugar and no evidence of diabetes for three to fifteen years.
Is it a cure? No. But it is possibly a very long break from a chronic condition.
Some might say that any surgery that causes very overweight people to lose weight will have a good effect on blood sugar, but experts say the difference can be seen before the weight is lost. Professor Francesco Rubino (a leader in surgery for Type 2 diabetes) was in Johannesburg for the 3rd Centres for Metabolic Medicine and Surgery Workshop. He said that a few days after a gastric bypass, patients with Type 2 diabetes show normal blood sugar levels, even before any weight has been lost.
Ask the expert: Dr. Joel Dave, endocrinologist
“Bariatric surgery is becoming an important part of the treatment of diabetic patients with a BMI over 35. But although the results with this surgery are very good, it is still an invasive procedure with potential complications. It should not be considered a shortcut to weight loss and diabetes improvement, but a last resort after a low calorie diet and structured exercise programme has failed.”
What if the Type 2 diabetic ate badly and didn’t exercise, and returns to this same lifestyle – will the surgery still work?
The surgery doesn’t just help the patient by making their stomach smaller. It also triggers changes to the hormones, the appetite and the metabolism, so that long-term change is possible. But it is not a magical cure – the patient has to be ready to make changes to their diet and exercise. As Prof. van der Merwe points out, “There is not a single treatment in medicine that will be immune to an uncooperative patient.” In other words, if the patient goes back to a diet of fast food and no exercise, the same problems will return. One of the ways they guard against this in the Centres of Excellence (where they do the surgery) is by coaching the patient to start new, positive habits. They have a team of experts to help with this.
Ask the expert: Genevieve Jardine, dietician
“It is my opinion that gastric bypass surgery may be a good option for those who have a high BMI (above 35) and have tried for many years to lose weight. If they are managed well after surgery and take this opportunity to start over, it could mean a second chance at health. It is important to remember, though, that it still comes down to diet and exercise. Lifelong lifestyle changes are still the foundation of good diabetes management.”
How extreme is the surgery?
The surgery is minimally invasive. It is also known as laparoscopic surgery, keyhole surgery or bandaid surgery because the cuts made are so small – on average 0.5 to 1.5 cm. The doctor uses images on TV screens to magnify the surgery so they can see what they need to do.
Ask the expert: Dr. Joel Dave, endocrinologist
“Although the procedure is minimally invasive there are still some potentially serious complications. The patient’s decision to have this surgery must not be taken lightly.”
Is the surgery covered by medical aids?
That depends on how urgently you need it. In order to work that out, doctors look at your BMI (Body Mass Index), which outlines whether you are underweight, at a healthy weight, or overweight (see the box on this page). Diabetic patients with a BMI over 35 may be able to get the surgery covered if they have a motivation letter from a Metabolic Centre for Excellence, and if they are on the right medical aid option. There is usually a 20 to 30% co-payment that the patient would have to pay.
Have there been any local studies?
A South African study based at Netcare Waterfall City Hospital tracked 820 patients who had not been able to lose weight for up to 18 years before they had surgery. Three years later, 88.5% of the patients who had diabetes at the time of the surgery still had normal blood sugar levels.
Is there anyone it won’t work on?
This surgery is only an option for Type 2 diabetics who are very overweight – with a BMI greater than 35. They are doing research on lower BMI’s as well.
Want to find out more?
How to work out your BMI
There are many websites (http://www.smartbmicalculator.com/) that calculate BMI for you, but if you want to do it yourself, here’s what you need:
- Your weight.
- Your height in metres.
- A piece of paper and a calculator!
First, find out the square of your height in metres (your height times your height, i.e. 1,5m x 1,5m).
Then do this sum: (Weight in kg) divided by (square of height in metres)
You should get a number between 18.5 and 40.
- Less than 18.5 means you are underweight.
- 18.5 to 25 means you are at a healthy weight.
- 25 to 30 means you are slightly overweight.
- More than 30 means you are very overweight (obese).
Remember when low carb wasn’t as well known as it is today? We do! Here’s an article from Sweet Life magazine published a few years ago that explains all the ins and outs…
Professor Tim Noakes says that a low carb, high fat diet is the way to go. We gathered your questions and asked him how the low carb diet affects diabetics. Here’s what he had to say.
What exactly is this diet?
A low carbohydrate, moderate protein, high fat diet. This diet is most effective for people with diabetes – either Type 1 or Type 2, or pre-diabetes, like myself. It also helps treat obesity, but it’s obviously not the diet for everyone. The question is whether it’s for 10% of the population, or 90% of the population – I think it’s about 60% or more.
Low carb means no bread, pasta, cereals, grains, potatoes, rice, sweets and confectionery, baked goods. You have to be resolute – and the more severely affected you are, the more resolute you have to be. If you’re already diabetic, you have every reason not to eat these foods.
Can you explain what carbohydrate resistance is?
My opinion is different from the traditional teaching. Carbohydrate resistance is traditionally described as someone who is unable to take glucose out of the blood stream and store it in their muscle and liver. I disagree with this explanation: I think we’re all born with varying degrees of carbohydrate resistance, and the children who get really fat very young are the ones who are most carbohydrate resistant. The carbs they take in they simply store as fat. That’s the first group.
The second group are people who become pre-diabetic at 30 or 40, and then they become diabetic at 50. They are overweight, and that’s a marker of the high carbohydrate diet. They eat a high carb diet, they are carb resistant and it gets more and more severe until they become diabetic. I think it’s genetic, and the reason I think that is because in my case, although I’ve lost weight, I’m still carbohydrate resistant – I can’t go back to eating carbs.
What if you have high cholesterol? Isn’t it dangerous to eat so much fat?
Firstly, the theory that high cholesterol is a good predictor of heart disease is not true – it’s a relatively poor predictor. A far better predictor is your carbohydrate status. Everyone knows this – if you’re diabetic or pre-diabetic, your risk of heart disease is increased. Diabetes, hypertension and heart disease are linked, but most heart attacks occur in people with cholesterol below 5. It’s very frustrating, because the public has got the wrong idea.
A high fat diet corrects everything, in my opinion – your HDL goes shooting up, your triglycerides come shooting down and that HDL to triglyceride ratio improves dramatically: that’s one of the better predictors of heart attack risk. The LDL small particles are the killers, and on a high fat diet, those go down. Your total cholesterol can go up, but that’s because your HDL has gone up, and the large, safe LDL particles have gone up. So unless you measure all those variables: HDL and LDL and triglycerides and glucose tolerance, you can’t judge the effects of the diet.
What carbs do you eat?
The good carbs are veg – that’s it. Sweet potatoes (not regular potatoes), butternut, squash and then I also eat dairy: milk, cheese, yoghurt. I don’t eat any fruit except apples, but that’s because I severely restrict my carbs. You’re not cutting out nutrients if you eat nutrient-dense foods like liver, sardines, broccoli and eggs – those are the most nutrient-rich foods you can eat. You can get vitamin C from meat if it’s not over-cooked. The key is that you eat lots of fat, and you don’t avoid the fat. I eat lots of fish, like salmon and sardines. And you want to eat lots of organ meats – that means liver, pancreas, kidneys, and brains if you can get them, but particularly the liver. Liver is very nutritious.
Is this diet possible for people who don’t have a lot of money?
You don’t have to eat meat every day – you can eat sardines and kidneys, for example, which are both very cheap.
Could the positive effect of a low carb diet on insulin resistance be because of the weight loss and not because of the new diet?
No, absolutely not. Because it happens within one meal – your insulin requirements go down within one meal, because you’ve shut off the production of glucose by not eating carbohydrates.
What is wrong with the old fashioned idea of a balanced diet? Why does it have to be so extreme?
If you’re diabetic, you have a problem with metabolising carbohydrates. You have to understand that if you want to live a long life and have minimal complications, you want to minimise your carb intake. Start at 50g a day. What that looks like is two eggs for breakfast, with some fish – salmon or sardines, and some veg. And dairy: cheese or yoghurt. That will sustain you until early afternoon. For lunch, I think you should have salad and some more protein and fat – and exactly the same for dinner. Chicken, cheese, nuts, salad, tomatoes, broccoli. It’s an incredibly simple way to eat, but you don’t get bored.
Once you’re on this diet, you feel so good, and you get rid of all these aches and pains and minor illnesses: you won’t want to go back. If you do go back to eating carbs you’ll put on the weight again. It’s not a diet, it’s a lifelong eating plan. It’s not a quick fix.
I think the diabetics who live to 80, 90, 100 are the ones who eat this kind of diet.