original articles - cde diabetes · original articles • culture, communication and the diabetes...

Editorial

original artiClES

• Culture, Communication and the

Diabetes Consultation

• Food Faddism - A Review

• Musculoskeletal disorders in diabetes

mellitus

• The Centre for Diabetes ‘Why Weight?’

Weight Loss and Lifestyle Change

Programme

• Diabetes: sharp and to the point

CPd aCCrEditEd diabEtES

training

The OfficialHealthcare Professional Journal

of the CDE~

Your Partner in Diabetes

South African Journal of Diabetes • May/June 2014 1

A pleasing aspect of this Issue is the absence of specific content related to novel or existing pharmacological

agents used for the treatment of diabetes.

It is refreshing to reproduce the first consensus document related to insulin injection technique. We often

overlook this vital aspect of diabetes care and this may be one of a number of factors contributing to the

persistently poor glycaemic control experienced by some people with diabetes. The pre-eminent take-home

message underlying the text of this contribution is that we should always examine injection sites.

A second collaborative piece is that from a large group of registered dieticians in Johannesburg. This practice

has produced a sound document wherein they reflect on the topical theme of the low carbohydrate / high fat

diet. Our role as healthcare providers includes sharing current knowledge and agreeing, together with our

patients, on what best plan of action to follow. After reading this piece, you should be better-equipped to answer

the many questions cropping up in consultations.

Knowing that most people with type 2 diabetes are overweight and that sustained weight loss remains

challenging, the novel ‘Why Weight?’ Programme offered by the CDE Houghton Branch is most interesting. This

inter-disciplinary approach, underpinned by regular patient attendance, seems to have very reassuring outcomes,

albeit in small numbers. On a personal note, I have seen some significant and durable results in my own patients.

Dr Paula Diab has written for us in the past and continues her theme of looking at the specifics of culture

and communication specific to a diabetes consultation. Finally, Durban based diabetologists, Dr Mac Robertson

and Dr Rajan Pillay, write for us on the musculoskeletal disorders in diabetes. The recently published long-term

Diabetes Control and Complications Trial (DCCT) outcomes allude to the fact that, over time, these very

complications have become more pronounced. Whilst little is written of them, their manifestations affect the

quality of life of many people with diabetes daily.

I would like to remind you of the 16th CDE Postgraduate Forum in Diabetes Management, which will take place at

the Birchwood Hotel & OR Tambo Conference Centre, Boksburg, Gauteng, from Friday 8 to Sunday 10 August 2014.

This CPD-Accredited event is the largest Diabetes-specific meeting in Sub-Saharan Africa and provides the

primary gathering point for clinicians from over 240 affiliated CDE Centres of Excellence nationwide; over

650 contracted general practitioners, other interested clinicians and representatives of the Pharmaceutical Industry

and Medical Funders who are interested in the provision of quality practical diabetes care solutions. The CDE will

provide further details on costs and registration on the CDE Website (www.cdecentre.co.za) shortly.

dr stan Landau

Editor

email: [email protected]

E D I T O R I A L

Editor’s comment


C O N T E N T S

VOLUME 7 NUMBER 2

MAY/JUNE 2014

CONTENTSEditorDr Stan [email protected]

Sub-EditorMichael [email protected]

Editorial contributorsRazana AllieG.I BergMayuri BhawanRia Catsicas: [email protected] Davel: [email protected] Paula N Diab: [email protected] DrummondRosemary FlynnNicqui GrantAndrew Heilbrunn - [email protected] Julsing-StrydomCheryl MeyerVhonani MufamadiZhan OttoDr Rajan PillayPetro Rautenbach Dr Mac Robertson: [email protected] SeeligerSimone StrybosLaurie van der MerweMichelle Watson

Advertising EnquiriesAngela BellCell: 082 451 0193 Tel: 011 787 9366 Fax: 088 011 787 9366Email: [email protected]

PublisherSouth African Journal of Diabetes is published by:Homestead Publishing (Pty) Ltd (Reg. No. 2011/128152/07).

Postnet Suite 354Private Bag X11Craighall2024

ProductionOutput Reproductions

PrintingBusiness Print Centre

CopyrightMaterial appearing in this Journal belongs to the South AfricanJournal of Diabetes and/or the individual contributors. Thecontents of this publication may not be reproduced in anypart without the written consent of the publisher. The viewsexpressed by contributors do not necessarily reflect theviews of the publisher, editors or advertisers. While everyeffort has been made to ensure accuracy, the editors,contributors and publisher do not accept responsibility forerrors, emissions or inaccuracies in the publication.

“To eat is a necessity, but to eat intelligently is an art.”

François La Rochefoucauld

EditoriaL 1

Dr Stan Landau

originaL artiCLEs

Culture, Communication and the Diabetes Consultation 5

Dr Paula N Diab

Food Faddism - A Review 11

Ria Catsicas, Claire Julsing-Strydom, Jade Seeliger, Mayuri Bhawan,

Michelle Watson, Nicqui Grant, Zhan Otto, Cheryl Meyer,

Petro Rautenbach and Linda Drummond

Musculoskeletal disorders in diabetes mellitus 14

Dr Mac Robertson and Dr Rajan Pillay

The Centre for Diabetes ‘Why Weight?’ Weight Loss

and Lifestyle Change Programme 19

Andrew Heilbrunn, Simone Strybos, Vhonani Mufamadi,

Rosemary Flynn

Diabetes: sharp and to the point 25

Hester Davel, G.I Berg, Razana Allie, Laurie van der Merwe

CPD Accredited Diabetes Training 32


O R I G I N A L

To which culture would you assign yourself? If youreceived an invitation to an end-of-year function andthe dress code was ‘Cultural Attire’, how would you

arrive? If you were on business overseas and had todescribe your culture to your new colleagues, how wouldyou do that? Would your description change depending onto whom you were speaking?

What is culture?

Each person is a complex mix of different cultures, some moreprevalent than others. They are interwoven in the individual

just as a patchwork quilt is made up from many differentthreads and fabrics. Removing or ignoring one of thosesquares of the quilt would make the whole worthless.

Culture was first described by Tylor in 1871 as “thatcomplex whole which includes knowledge, belief, art,morals, law, customs and any other capabilities and habitsacquired by man as a member of society.” Our culturedetermines how we view the world, how we experience itemotionally and how we behave in relation to otherpeople and environment.

the importance of health care professional-

patient relationships

To understand the influence of culture on the consultation,we need to first examine the relationship between healthcare professional (HCP) and patient. Traditional doctor-patient relationships are similar to that of parent-childrelationships - the doctor holds the power and knowledgeand the doctor guides the patient as to what managementplan would be best. This paternalistic relationship has thepotential to function if doctors remain the beneficent,competent, altruistic characters typified by the model andpatients are able to be ‘compliant’ and passive recipientsof care.

Culture, Communication andthe Diabetes Consultation

Correspondence:

Dr Paula N Diab


dr Paula diab

Lecturer, Department of Rural Health, University of KwaZulu-NatalFamily Physician, Highway Diabetes Centre

This article is adapted from a presentation given at therecent Diabetes Education Society of South Africa(DESSA) Workshop, 2014. It examines the concept of‘culture’ and its bearing on the medical consultation. I alsolook at some of the everyday concepts affected by culture.


O R I G I N A L

Other models have criticised this relationship pointingout the inherent disharmony in the doctor-patientrelationship that exists due to the unequal power andknowledge between the two and the fact that health care isa commodity for which there needs to be an exchange ofmoney. Even within the State health sector, patients areresponsible for minimal fees and the State has to providethe funds for the services of its professionals. Are patientsconsumers of health care in the same way that customersare consumers of purchased goods?

This model has also been criticised because health careis not only a commodity but also a fundamental humanright and therefore the laws of consumerism should notgovern it.

Over the last 50 years, the concept of patient-centredcare has arisen. Thisemphasises the ideas, beliefs,concerns, fears andexpectations of patients andhow their daily lives areaffected by disease.

Research has shown thatthe relationship betweenHCPs and their patients mayinfluence recall andunderstanding by patient andtheir resultant satisfaction withand adherence to a treatment relationship and therapeuticregimen. The notion of the ‘heart-sink’ patient maydescribe those patients who “don’t listen” or the ones whoreturn for follow-up but for whom “nothing can be done”.Can we reframe this idea? Perhaps the HCP is unable toderive satisfaction from the consultation because therelationship is incongruent. Patients also may perceive thisincongruence as inadequacy on their own behalf whichfurther compounds psychiatric morbidity and negativelyaffects patient satisfaction and adherence as well. All thesefactors are important determinants of ultimate healthoutcomes and can be influenced by the relationship thatlies at the core of the consultation.

What determines how patients will perceive their illnessor the care they receive? Can HCPs pre-suppose theseideas and concerns based on the culture from which apatient comes? Perhaps the way a patient dresses or speakswill determine the way in which they act and behave.

Life-worlds

The life-world of patients refers to the context that thepatient brings to the consultation. Their understanding oftheir illness and their beliefs of how it affects them is justas unique as each individual. Information obtained fromthe media and internet, information gained from socialrelationships with friends and family and other personal

experiences will all influence the life-world of a patient.Membership of a gender, racial or ethnic group may alsoinfluence a patient but this certainly does not define him orher. Thus, these things cannot predict or pre-determinebehaviour. Previous encounters with HCPs and the healthcare system in general also can have a profound effect onthe perception of future consultations.

Consider a child with diabetes admitted to hospital withsevere hypoglycaemia - how could this experience influencefuture behaviours? Many parents and HCPs will know ofsuch children who may under dose themselves with insulinin the future to prevent another hypoglycaemic event. Thisis an example of how previous experience influences thelife-world of the patient and changes future behaviour.Sometimes these behaviours are so entrenched that patients

do not even recognise themas being abnormal.

HCPs also have theirown life-world. They alsohave their own cultural,religious and scientificbeliefs. Students go througha process of enculturationduring their professionaltraining. This processinvolves an assimilation ofscientific beliefs upheld by

that professional body that becomes part of the life-worldof the HCP. It is for this reason that the public sees doctorswho smoke or dieticians who are overweight in a differentlight as they would the average non-medical person. Thepublic expects that the life-world of these HCPs will bedifferent due to the training and enculturation process theyhave undergone.

The term acculturation refers to how we incorporateother cultures into our life-world without losing our ownidentity. A doctor may still be perceived as such even if he isnot wearing a white coat or theatre scrubs. A patient maystill observe certain religious laws even if she does not dressin the traditional attire. By acquiring additional thoughtsand beliefs from other groups or cultures, we do not have tolose our own identity; we simply make that patchwork quiltmore intricate and more beautiful.

Patients may make judgements based on these beliefs oridentities. A young female patient may prefer to see ayoung female gynaecologist as it is someone with whom shefeels she can identify. A patient who identifies with theIndian culture may prefer to see an Indian dietician as hemore likely shares a common life-world with that chosenHCP. This shared journey with our patients is often the vitalmissing piece in the puzzle that influences adherence,patient satisfaction, understanding of illness and ultimately,health outcomes.

Over the last 50 years, the concept

of patient-centred care has arisen.

This emphasises the ideas, beliefs,

concerns, fears and expectations of

patients and how their daily lives

are affected by disease


O R I G I N A L

Most people are familiarwith the parodies of thefailed Second World Warmotivational posters thatcurrently appear in printmedia. In 1939, just beforethe outbreak of the SecondWorld War, the Britishgovernment produced theslogan “Keep calm and carryon”. This intended to raisethe morale of the Britishpublic as air attacks anddestruction of major cities become imminent. Although theposters never saw public display, they remain a comment

on stereotypical ‘Britishculture’. The parodies arejust as much of a commenton stereotypical cultures asthe original was. “I can’tkeep calm, I’m Lebanese /Italian / Greek” indicates thatpeople who identify withthese cultures recognise thatcertain traits are a part of thereality of their life-world.

The medical consultation is not an ‘a-cultural’ scenariowhere people should put aside their beliefs for the sake ofconforming to ‘medical culture’. The patient and the HCPbring their life-worlds to the consultation. This realityshapes the way in which both will interpret the outcome ofthe consultation.

Consider the scenario of commencing insulin. HCPswithin the field of diabetes management often see this as apro-active step in preventing future complications andmaintaining good glycaemic control. However, patients mayinterpret the very same act as a personal failure and adeterioration of their condition. If the HCP ignores the life-world of the patient and perceives the outcome of themedical consultation only in terms of biomedical riskreduction, he may well miss the point of the consultationcompletely. This lack of a shared understanding as to theoutcome of the consultation is the foundation fordissatisfaction, non-adherence and poor health outcomes.

theory of social constructionism

The theory of social constructionism provides a useful lensthrough which we can view, describe and explain therelationship between HCPs and patients. It implies that thereality of the consultation is a construct of the sharedexperiences of both parties. It explains how the outcome ofthe consultation is merely a product of the factors thatinfluence each individual. These background factors include

the culture, beliefs, expectations, fears, concerns andexperiences of both parties.

In ballroom dancing, both partners need to hear the samemusic, wear an outfit appropriate to the dance and step inrhythm to the melody to create the dance together. If onepartner was wearing a ball gown and listening to a waltzwhilst the other was dressed in a Latin outfit ready to move tothe rapid beat of the Samba, the dance would be chaos. Sotoo, do our consultations result in chaos when we fail toacknowledge the music in our own heads and in that of ourpatients. Perhaps one aspect where a medical consultationmay differ from the analogy of dancing is that it is not alwaysone person who leads the dance. Sometimes patients will beaware that their behaviour is placing them at risk and requireonly support in order to achieve the goal of reducing that risk;sometimes patients may want to lead the dance and decidewhat actions need to be taken, whilst at other times, thepatient may require a more directive approach in decision-making. Nevertheless, the result should always be a mutuallyagreed upon goal that is co-constructed by both parties.

the body and culture

Not many women will identify with the image of a femalebody builder. However, a well-built male physique isattractive to males and females alike. The male body isgenerally perceived in its functional state, ready for action.For females, the physical appearance and beauty of thebody is more attractive. These sentiments translate into howmen or women formulate concerns related to their illness. Aman is more likely to complain that dysglycaemia is causinghis erectile dysfunction (referring to the functional state ofhis body) whilst a woman is more likely to be concernedthat increased insulin requirements are causing weight gainand altering the physical appearance of her body.

Extensions of this metaphor may explain certain otherbehaviours by people with diabetes. A man may be able todemonstrate power over his physically ill body bydeliberately ignoring the advice not to drink alcohol. For themajority of adult men with type 2 diabetes not on insulin, asingle evening of indulgence will not result in any majorsymptoms the following day (other than perhaps ahangover). In this way, the man has exerted power over his‘ill’ body and gains perceived control over his diabetes. Wecan use this insight to understand the motivating factorsbehind patients engaging in certain activities. A man maybe interested in physical exercise to enhance the function ofhis body whereas a female may be interested in exercise toimprove the form or appearance of her body.

Food and culture

The link between food and culture is well known andunderstood. Foods are often a defining aspect of variouscultural groups. However, no person needs to adhere


O R I G I N A L

completely to a specific ‘diet’ because he or she identifies witha particular culture. Certainly, people are also at liberty tosample foods not part of their cultural identity without havingto redefine their culture. However, we do need to be takeindividual and cultural / traditional preferences into accountwhen negotiating a meal plan of food choices for a patient.Adaptions may only concern the portion size rather than theactual content of the food.

Recently, drug trials have investigated safer options forpeople who are required to fast as part of their religious beliefs.Medications that have a lower propensity for causinghypoglycaemia need consideration in such cases. Alterations indietary choices during periods of fasting or cultural feasts needto be well managed. Our social lives are bound to food customsand cultures that give people their identity. By removing theso-called ‘pleasure’ of toasting champagne and sharing a richfruitcake at a family wedding, we may also be attempting toremove part of our patient’s identity. No self-respecting SouthAfrican will watch the Currie Cup final whilst drinking a cup oftea. If watching rugby and drinking beer around a braai ispart of a patient’s cultural identity, we need to be able tomanage this situation in a way that is acceptable for thepatient and the medical profession’s cultural framework of alower-carbohydrate, reduced alcohol intake, nutrition plan.

Media culture

With the advent of the 21st century, came mass media. We canno longer hide and pretend not to get involved in this culture.However, we need to manage this resource. Television soapoperas provide images of HCPs who are kindly, nurturingcharacters whose competency and authority is unmatched.Newspaper reports comment however on sensational storiessuch as a doctor’s involvement in the death of Michael Jacksonor Dr Shipman, the world’s greatest serial killer. These extremesform part of the ‘past experiences’ that influence patientbehaviour. Imagine how difficult it would have been foranaesthetists in the wake of Michael Jackson’s death, to explainto their patients they were about to use the same drug asDr Conrad Murray had used, to induce general anaesthesia.

Social media is now part of our everyday lives. Theinternet is able to provide an unparalleled opportunity for self-help, support, activism and information exchange. iPad ‘apps’are available to keep track of weight, food intake and physicalactivity as well as glucose control. In an ideal scenario,patients can share these results with HCPs and receivecomment on them within a matter of seconds. We have theopportunity to embrace this new ‘culture’ and use it to theadvantage of both patients and HCPs.

A great deal of research has gone into the study of illnessnarratives. This is a process whereby the patient achievesbenefit out of telling their story and sharing their experiencewith others. The therapeutic effect of sharing the experiencemay result in a greater understanding for the patient and

knowledge acquisition for others. This process of sharingmeaning and experiences is emulated in the activity ofblogging. By sharing the knowledge we have, we create newmeanings for ourselves and allow the information to becomepart of another’s experience and understanding.

the importance of culturally sensitive health care

The modern world is a mobile, fluid society that is constantlychanging. People are not static, stereotypical members ofsociety but contributors whose opinions and experiencechange and adapt on a daily basis. The world has indeedbecome a ‘global village’ and people who identify withmultiple cultures and groups are commonplace. Technologyand rapid communication have made this global village evensmaller. It follows therefore, that as members of this globalvillage, we need to be aware of the opinions and beliefs ofothers and have respect for the differences. Conflict in healthcare interactions is growing and there is an increased demandon HCPs to respond to challenges outside of the traditionalbiomedical perspective.

By being open to these challenges and the multipledimensions of human nature, we may begin to respond to thediversity of different cultures. An awareness of different valuesand beliefs is required as well as a fervent desire to learn andunderstand more. Communication between HCPs and patientsis of paramount importance and lies at the heart of theconsultation. By being open to communicating with our patientsand building a relationship with them, we can negotiate the‘dance’ with them without stepping on each other’s toes.

Conclusion

We cannot stereotype cultures with a pre-supposed checklistof behaviours. People are a patchwork of experiences, beliefs,values, concerns, ideas and identities. This combinationmakes up the individuals of the global village. They are thegolden threads in the picture of life.

In this new paradigm of patient-centred care, weencourage our patients to question and to be critical of thetreatment they receive. We ask them not just to be consumersbut also producers of information – to educate their familiesand communities about diabetes. This is similar to sites suchas Wikipedia, a platform where other patients, professionalsand researchers have posted the facts they know about acertain topic in an easily accessible form so that others maylearn from their knowledge.

To relate to others, we need to be aware of differencesbetween people and people groups, to deal sensitively withthem and acknowledge our own make-up. What are theinfluences that affect us in our own personal and professionallives? Who are we? How do we come across to others? Perhapsthe answers to these questions remain the greatest challenge.

rEFErEnCEs aVaiLaBLE on rEQUEst


O R I G I N A L

introduction

One of the biggest challenges of treating patients withcardiovascular disease, the ‘metabolic syndrome’ as well assome people with type 1 (T1DM) and most people withtype 2 diabetes (T2DM), is offering the correct advice tolose weight successfully.

In treating these patients, physical activity andpharmacology have a limited impact on weight loss.Knowing how difficult it is for patients to change their eatinghabits, it can be enticing to agree on the new fad diet yourpatient may enthusiastically propose.

Fad diets refer to eating suggestions that promote short-term weight loss, and usually have short-term popularityamongst followers. Fad diets are often regimens that makepseudoscientific claims. These diets ignore establishedscientific methods and more often than not lack validity orpeer review. Anecdotal evidence and observations areoffered as proof of validity. This ‘evidence’ lures andultimately confuses the public, who inevitability suffer theconsequences of this confusion.

Although it is difficult to keep track of all weight lossregimens on the market aiming to profit from a vulnerable

and desperate market, the most common regimens currentlycapturing the South African market are the low-carbohydrate, high-protein, high-fat diets (low CHO, HP,HF diets). Those with the highest publicity are the high-protein Dukan and Paleo diets and the high-fat ketogenicregimen, the Banting diet, advocated by Prof Tim Noakes.

Problems in recommending ‘Fad diets’ for

weight loss

Some researchers suggest that only under the controlledconditions of a metabolic unit can it be shown that a“calorie is a calorie”. In free-living conditions however,food properties such as energy density, satiety value, tasteand the metabolic responses elicited can be significantdeterminants of the amount of food consumed. Whilesome reason that a high-fat intake can facilitate passiveover-consumption of calories, others suggest that fat has asatiety value and therefore should limit calorieconsumption. Neither takes into consideration that humanbeings easily override satiety signals for a variety ofreasons - numerous psychological, social and economicfactors influence not only what patients choose to eat butalso when, how much and why they eat. Planning andexecuting studies to measure the effect of macronutrientson fat loss in humans are challenging. Although thenecessity of a calorie deficit to facilitate fat loss is clear,much debate centres around which macronutrient

Food Faddism - A Review

ria Catsicas, Claire Julsing-strydom, Jade seeliger,

Mayuri Bhawan, Michelle Watson, nicqui grant, Zhan otto,

Cheryl Meyer, Petro rautenbach and Linda drummond

Registered Dieticians, Nutritional Solutions Journal Club

Correspondence:

R Catsicas



O R I G I N A L

composition is most beneficial. Most fad diets that manipulatemacronutrient proportions to high or low extremes of intake,reason that excluding mostly carbohydrate or fats contributesto additional metabolic benefits.

In terms of weight loss per se (not metabolic effects), themacronutrient distribution has proved to be less relevant.Sacks et al (2009), compared four diets with varying fat,protein and carbohydrate macronutrient compositionsranging from 20/15/65 % to 40/25/35 % respectively. All ofthese diets had similar effects on weight loss, levels ofsatiety, hunger and satisfaction. Furthermore, they foundcravings, fullness, hunger and diet satisfaction scores to besimilar at 6 months and two years among the different dietsinvestigated. The A TO Z Weight Loss Study measuredweight loss over a 12-month period in 311 pre-menopausalwomen who followed the Atkins (very low in carbohydrate),Zone (low in carbohydrate), LEARN (Lifestyle, Exercise,Attitudes, Relationships and Nutrition; low in fat, high incarbohydrate) and Ornish (very high carbohydrate) diets.Although the Atkins group achieved slightly more weightloss compared to the other groups, at 12 months, themacronutrient distributions of all four groups were notmuch different. Subjects in the Atkins group startedincluding more carbohydrates and those in the Ornishgroup included more fat into their diets. This indicates thatmost individuals prefer a variety of foods and over time,they will revert to a more moderate and sustainabledistribution of macronutrients.

The American Dietetic association (ADA) describes alow- to moderate-carbohydrate diet as containing 130 g ofcarbohydrate (26-45 % of an 8400 kJ energy intake perday), while an intake of less than 30 g (6 % of total energyintake) defines a very low-carbohydrate, ketogenic diet. Anumber of smaller studies in individuals with T2DM haveshown a lower carbohydrate intake to be beneficial towardsweight loss; however studies that proposed a ketogenic low-carbohydrate intake showed a high dropout rate suggestingan obstacle towards adherence. Johnston et al (2006) foundno difference with regard to weight loss and insulinresistance in 20 obese individuals following a moderate low-carbohydrate, low-fat diet (40/30 %) compared to aketogenic low-carbohydrate, high-fat diet (5/60 %). Ofsignificance is that the ketogenic groups reported negativeemotions and a low desire to be physically active. Bravataet al (2003) undertook a systematic review on the efficacyand safety of low-carbohydrate diets and reported posturalhypotension, fatigue, constipation and nephrolithiasis asconcerns with regard to the ketogenic diets. It was clear thatthe level of adherence to the low carbohydrate regimen andthe duration that the individuals followed the diet were thetwo main factors that contributed to the amount of weightloss achieved and not necessarily the level of carbohydratein the plan.

recommending fad diets to improve metabolic

outcome in treating chronic diseases

Cardiovascular disease and type 2 diabetes mellitus

Traditionally a high saturated fatty acid (SFA) intake affectingLDL cholesterol (LDL-C) has been associated with anincreased risk for cardiovascular disease (CVD). Recentresearch, however, has revealed that the risk analysis is rathercomplex and that individuals with a high SFA intake had asimilar incidence of developing CVD as individuals with alower SFA intake. This finding is used to promote a highsaturated fat intake by followers of low-carbohydrate, high-fat,high-protein diet regimens. The question arises - whatregimen should we recommended for our patients to follow?

It is important to consider that people eat a variety of foodsdaily. We cannot evaluate the effect of a single nutrient such asSFA in isolation, as food represents a combination of manynutrients. Recent research suggests that the effect of SFA ontotal cholesterol (TC) and LDL-C depends on the amount ofpolyunsaturated fatty acids (PUFAs) and cholesterol in thebackground diet. It seems that detrimental effects occur whenthe diet is low in PUFA and high in cholesterol and red meat.

It also seems that the quality of carbohydrate in the diet isof critical importance, as replacing SFA with carbohydratesdoes not improve the total cholesterol / HDL-cholesterol(HDL-C) ratio. Refined carbohydrates (sugar and refinedstarches) were associated with an increased risk towards CVDdue to the development of an atherogenic lipoprotein profileof low HDL-C, small dense LDL-C and high triglyceride (TG)levels that emerged in individuals who are overweight andhave the ‘metabolic syndrome’ and type 2 diabetes. Thedevelopment of arteriosclerosis and consequent CVD is acomplex condition and the risks go far beyond LDL-C. SFAincreases inflammation and it is recommended to replacedietary SFA with monounsaturated fat (MUFA). The latter hasanti-inflammatory effects and contributes to increasing HDL-cholesterol levels.

In terms of insulin sensitivity, it seems prudent to replacedietary SFA with monounsaturated fats as their beneficialeffects have been observed with a fat intake of up to 37 % ofenergy intake. Unlimited intake of SFA as promoted by lowCHO, HP, HF diets contributes not only to aggravation ofinsulin resistance. In the presence of a low CHO high fat diet(hypertriglyceridaemia), through intracellular TG lipolysis andfatty acid esterification, SFA, have a greater insulinotropiceffect on the B cells compared to MUFA. This can contributeto B cell exhaustion.

Looking at long-term survival, low CHO, HP, HF dietsfollowed on a regular basis without taking the quality of CHOand protein into consideration, are associated with anincreased risk of cardiovascular disease. The fibre content ofthe diet is beneficial in reducing risk for cardiovasculardisease; the lack of CHO in high-fat diet regimens often resultsin suboptimal fibre intake that increases risk for CVD.


O R I G I N A L

It is established that a high CHO diet of poor quality (highin refined carbohydrate and sugars) can, through chronichyperglycaemia, and hypertriglyceridaemia, contribute notonly to an atherogenic lipoprotein profile but also aggravatesthe inflammatory and oxidative stress processes thatultimately all contribute to beta cell failure, endothelialdysfunction and atherosclerosis.

In treating patients with CVD, it seems appropriate tocalculate a moderate intake (40 to 45 %) of high-qualitycarbohydrates consisting of high-fibre whole grains, fresh fruitand vegetables. These foods have cardio protective effectsdue to the synergistic effect the phytonutrients, vitamins andminerals (folic acid, magnesium, vitamin E and potassium),fibre and anti-oxidants generated in combination withunsaturated fats, soya and nuts.

Despite the quality of the carbohydrates in the diet, it isimportant to note that adequate evidence supportsrecommending a lower carbohydrate intake (45-45 % ofenergy intake) for individuals with the ‘metabolic syndrome’and type 2 diabetes due to the resulting improved lipid profile.

Renal function

Juraschek et al (2013) found that a diet with a higherproportion of calories from protein, increased estimatedglomerular filtration rate. They concluded that increased proteinintake might have adverse consequences on kidney function inthe long term. It is still uncertain whether or not long-termconsumption of a high-protein diet leads to kidney disease. Ahigh-protein diet followed for a long period may not be suitablefor patients with T2DM at risk for developing nephropathy.

Gut health

Two important factors that influence gut motility and integrityare the fibre content of the diet and the consequent metabolicproducts produced by the specific microbial community suchas methane and short chain fatty acids (SCFA). The amountand type of carbohydrates in the diet and the gut microbiotacomposition of the host determine the production of SCFA.This is due to non-digestible food components (fibre) that actas a food source of fermentation by the anaerobic colonicmicrobiota. SCFA, specifically butyrate, nourish the coloniccells. This contributes to a reduction in gut permeability andconsequent reduction in inflammation and improvedimmunity. Studies have shown that increased SCFAproduction in the distal colon proved to play a protective rolewith regard to gastrointestinal disease with special reference tocolon cancer, and the gluconeogenerator, propionate, furthercontributed to inhibiting cholesterol synthesis.

Low CHO, HP, HF diets have been shown to lower totalSCFA production. Adequate research now supports that high-calorie, high-fat feeding contributes to changes in microbiotacomposition and numbers, increased gut permeability and,ultimately, through the complex processes of metabolic

endotoxaemia, to increased inflammation.An inverse relationship exists between stool weight and

colon cancer risk. For adults, a critical faecal weight of 160 to200 g/day exists, below which colon function becomesunpredictable and risk of colon cancer increases. Data collectedfrom 20 populations in 12 countries showed that average stoolweight varied from 72 to 470 g/day and was inversely relatedto colon cancer risk. Pooled results of 13 case-controlled studiesof colorectal cancer rates and dietary practices led investigatorsto conclude that the results provided substantial evidence of aninverse relationship between consumption of fibre-rich foodsand risk of both colon and rectal cancers.

Conclusion

Fad diets proposing extreme macronutrient manipulations andexclusions are usually rigid and prescriptive in nature and mightbe beneficial for weight loss for a few highly motivated patientsin the short term. The key to successful weight loss and theachievement of better metabolic outcomes is adherence to abalanced food intake that consists of a moderate amount ofmacronutrients. In our experience, the following factorscontribute to improved adherence and outcomes: 1. Acquisition of knowledge – patients need to understand

food composition and classification, and how these affectweight and glycaemic control. This assists them to makeinformed food choices as part of their individual lifestyle.

2. Application of knowledge – patients often ‘know’ whatto do, but find it difficult to apply the knowledgepractically to achieve positive outcomes. The necessarytools must be provided by a registered dietician in theform of a personalized, practical eating plan and menusand shopping lists that meet the family’s lifestyle, culture,social and economic status and preferences. The moderatemacronutrient range as proposed by the ADA (CHO andMUFA 60-70 %, protein 15-20 %, SFA < than 10 % andPUFA 10 % of total energy intake) suits most individualsand allows for the inclusion of adequate vegetables, fruitand whole grains.

3. Practicing the knowledge to create a new mindset aroundeating and activity – it is evident from a large number ofstudies that ongoing monitoring and accountability are two ofthe most critical factors to change one’s lifestyle especiallywithin the first six months of following a new eating plan. Mostindividuals can lose 5 to 10 % of their initial weight within thefirst six months, especially when combining healthy eatingwith physical activity. During this monitoring process, skillssuch as goal setting, self-monitoring, problem solving, relapsehandling, controlling of environmental stimuli, reconstructivethinking and positive feedback and reinforcement need to bepracticed. This assists in making the transition to healthyeating habits and enhance self-efficacy.



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“My left shoulder aches all day, and I wake atnight when I roll over onto my left side. But ithurts most when I move the arm to the back,

like when I loosen my bra”.Ivy, aged 52, has had type 2 diabetes for the past 14 years

with moderate control. She has seen her General Practitionerand taken numerous nonsteroidal anti-inflammatory drugs(NSAIDs) and other analgesics, all without success. Whenasked to place her left arm at her side and slowly raise it untilshe touched her left ear, she was fine until she reached about15 degrees, when the pain started. At about 160 degrees (20degrees from the full upright position), the pain disappeared.

Now the diagnosis was clear and two minutes after aninjection into her left subacromial bursa, there was no morepain. Now, 15 months later it has not recurred.

Ivy had one of the musculoskeletal disorders, morecommon in, but not confined to patients with diabetes.

Diabetes affects connective tissues in many ways andcauses alterations in peri-articular and skeletal structures. Thisresults in chronic, progressive and immutable damage to

various organs and systems. Although the precise cause ofthese musculoskeletal [MSK] complications remains uncertain,there is evidence that persistent hyperglycaemia alters thestructural matrix and mechanical properties of tissues byaccelerating non-enzymatic glycation of and abnormalcollagen deposition in periarticular connective tissues. Thisresults in diffuse arthrofibrosis.

MSK complications of diabetes mellitus are the mostcommon endocrine arthropathies. Generally, these areunder-recognised and poorly treated compared withretinopathy, the neuropathies and nephropathy.

Both the incidence of diabetes and the life expectancy ofpatients with diabetes have increased, resulting in rising aprevalence and clinical importance of MSK complications ofthe condition.

Most studies of the association between diabetes and MSKcomplications have not included a control group. However,Cagliero et al at Massachusetts General Hospital DiabetesCentre checked a sample of 300 consecutive patients (200 ofwhom had diabetes) for hand and shoulder MSKcomplications. Those with diabetes had a prevalence of 36 %versus 9 % in those without diabetes. MSK complications weremore common in females, and in persons with a long durationof diabetes who also had microangiopathic complications.

Musculoskeletal disorders in diabetes mellitus

dr Mac robertson and dr rajan Pillay

Family PractitionersDot Shuttleworth Centre for Diabetes, Durban

Correspondence:

Dr Mac Robertson



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Limited Joint-Mobility syndrome [LJMs]

This is a painless, non-inflammatory limitation of mobility ofthe hands, feet and large joints. LJMS affecting the handsresults in Cheiroarthropathy or the Diabetic stiff handsyndrome. Here cutaneous changes start around themetacarpophalangeal and proximal interphalangeal joints,commencing in the fifth finger, progressing to involve all thefingers. The skin becomes thick, rigid and waxy, similar toscleroderma. Hand X-rays commonly show arterialcalcification. Unlike in scleroderma, these patients do notshow Reynaud’s phenomenon, dermal atrophy, telangiectasiaor auto-antibodies.

The classical clinical sign is the inability to place theirpalms together, the so-called ‘Prayer sign’ (or ‘Sanlam sign’for South Africans) (Figure 1).

Treatment requires physiotherapy, NSAIDs and tighterglycaemic control.

‘trigger Finger’ or stenosing Flexor tenosynovitis

This presents typically with fingers locked in flexion,extension or both, usually the thumb, third or fourth finger.It results from fibrosis with thickening of the tendon as itpasses through the pulley, limiting or preventing intra-sheathmovement, with locking and sudden release with a click.The prevalence in people with diabetes ranges between5 and 36 % compared with 2 % in the general population.

Treatment comprises the use of NSAIDs, splinting, earlyuse of corticosteroid infiltrations and surgery when advanced.

Carpal tunnel syndrome [Cts]

This is caused by compression of the medial nerve beneaththe transverse carpal ligament. It is also common inpregnancy, when oedema causes the compression. It is

characterised by pain and numbness from the thumb to theside of the fourth finger, worse at night. The diagnosis isestablished by one of two tests:• Tinel’s test (Figure 2): Tapping over the median nerve at

the palmar side of the wrist elicits tingling. The sameeffect results from firm pressure with the thumb over themedian nerve.

• Phalen’s manoeuvre (Figure 3): This manoeuvre isperformed either by stretching out the arms in front andletting the hands hang down while flexing the wrists for60 seconds, or by approximating the dorsal surfaces of thehands with elbows at right angles in front of the chest.Again, tingling and numbness makes the diagnosis, but indubious cases, electrophysiological studies may be needed.

The prevalence of CTS in people with diabetes ranges from11 to 25 % and it is more common in women.

Management is by splints and analgesics, whilecorticosteroid injection may offer temporary relief. Releasesurgery may be required, and whilst simple, it is not alwayssuccessful in patients with diabetes.

dupuytren’s Contracture (dC)

This is characterised by palmar fascial thickening and palmarand digital nodules, skin thickening and adherence, and

Figure 1: the ‘Prayer sign’

Figure 2: tinel’s test

Figure 3: Phalen’s Manoeuvre


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digital flexial contractures. Prevalence overall is between16 and 32 %, and it is more common in older persons withdiabetes and those with a longer duration. Compared withnon-diabetics, DC in the person with diabetes is unusual incertain respects. Firstly, it tends to affect mainly the third andfourth fingers, rather than fourth and fifth fingers in DC withother aetiologies (Figure 4 depicts an unusual presentation ofDC in a patient with diabetes. In this case, the DC developeda number of years before the development of his diabetes).Secondly, unlike in individuals without diabetes, it is morecommon in women, but males with DC and diabetes havemore severe manifestations. Intralesional corticosteroids mayhelp early on, as may injections of collagenase. Surgery willoften be required but again without uniform success.

Then we come to the disorder that plagued Ivy...

adhesive capsulitis of the shoulder

This disorder has numerous synonyms, depending on thestage of the condition or its main characteristics. Therefore, aswe saw with Ivy, the circumscription of her pain to an arcfrom 15 to 160 degrees when she attempted to raise the armlaterally, confirmed the diagnosis. Accordingly, orthopaedicsurgeons often refer to the disorder as the ‘painful arcsyndrome’. Other terms used are ‘rotator cuff syndrome’,‘supraspinatus tendinitis, ‘shoulder impingementsyndrome’, ‘adhesive capsulitis’ and when the tendon

becomes calcified, ‘calcific tendinitis’. When shouldermobility is severely impaired, it may be known as a ‘frozenshoulder’. All of these diagnoses refer to the same condition.

Early on, pain starts at night, when rolling over onto theaffected shoulder. Both passive and active movement of theshoulder elicits pain, particularly abduction and externalrotation, such as in the act of passing the arm through asleeve. This gets progressively worse. Increasing fibrosis leadsto contraction of the joint capsule and later, calcification of thesupraspinatus tendon. If diagnosed prior to adhesion orcalcification, an injection of corticosteroid in to thesubacromial bursa, either posteriorly or laterally, may givecomplete relief. The differential diagnosis is cervicalspondylosis, which may have a similar pain distribution.When the diagnosis is in doubt, and as corticosteroidinjections are expensive, and may cause a short-livedhyperglycaemia, I first inject 2 cc of lignocaine. Relief of painwithin 2 to 3 minutes confirms the diagnosis of adhesivecapsulitis, and now the intralesional steroid may be injected.Occasionally a second injection may be needed in two tothree weeks. When there is extensive calcification, surgery(preferably via arthroscopy) may be required.

Muscle infarction (Mi)

This is a rare MSK complication, usually seen in those with type1 diabetes of long duration, typically over 15 years. Clinically itpresents as muscle oedema and pain of sudden onset. In justless than half of the cases, a palpable mass can be detected.Thighs are involved in about 80 % of cases. Creatinephosphokinase (CPK) may be slightly raised, but confirmationof the diagnosis may require a magnetic resonance imaging(MRI) scan. Most of the patients have underlying microvascularcomplications such as diabetic retinopathy, neuropathy andnephropathy, so a fair assumption is that MI is associated withlocal ischaemia. MI resolves spontaneously in weeks or months,but half of these patients will have recurrences. Treatmentconsists of rest and analgesics.

diffuse idiopathic skeletal Hyperostosis (disH)

Also known as Forestier’s disease or ankylosing hyperostosis,DISH is characterised by entheseal ossification. Resnick et aldefined DISH and it requires the involvement of 4 contiguousvertebral segments with preservation of the intervertebral spacesand without apophyseal involvement or sacro-iliac inflammatorychanges. It occurs mainly in the thoracic spine, though lumbarand sacral segments may be involved. The pathophysiology isunknown, but some authors feel that hyperinsulinaemia is a linkbetween diabetes mellitus, DISH and obesity, and DISH is morecommon in patients with type 2 diabetes who are obese. Thediagnosis is a radiological one, and clinically, patients may beasymptomatic or experience pain, stiffness, dysphagia andodontophagia (painful swallowing). Treatment consists ofphysiotherapy and analgesics.

Figure 4: dupuytren’s Contracture


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Charcot’s joint

Also known as Charcot’s osteoarthropathy, or diabeticneuroarthropathy, this complication results from acombination of mechanical and vascular factors secondaryto diabetic neuropathy. Initially there is bone resorption,followed by a repair or hypertrophic phase. Tarsal andtarsometatarsal joints are most affected, followed bymetatarsophalangeal joints and ankles. Clinically, patientscommonly present with sudden-onset erythaema andunilateral oedema of the foot or ankle. This is oftenmisdiagnosed as cellulitis. Recurrent attacks result in chronicarthropathy characterised by plantar arch collapse withabnormal bony prominences (Figure 5). With mid-tarsalcollapse, the weight-bearing area of the foot changes, notinfrequently leaving a ‘rocker-bottom’ appearance withulceration as a consequence. In 20 % of cases, thecondition is bilateral, and may be painless, or havedisproportionally mild pain. The differential diagnosis isseptic arthritis. A high index of suspicion is necessary for thediagnosis, as early on, imaging may reveal onlyosteopaenia, soft-tissue oedema and a reduction in jointspaces. Later, areas of osteolysis develop with resorption ofphalangeal and metatarsal heads. In the final stagesluxations, bony fragmentation, sclerosis and neoformationcan be seen. Contrast-enhanced MRI may be required toexclude associated osteomyelitis. Treatment consists of theprevention of weight bearing with appropriate footwear andorthoses such as the ‘Moon Boot’ (Figure 6).Bisphosphonates like alendronate and pamidronate may beuseful, and I have used an annual intravenous injection ofzoledronic acid (Aclasta®) with successful prevention of, orregression of the Charcot’s.

osteo-arthropathy

Given the fact that the majority of people with type 2 diabetesare in their middle or late years and also obese,osteoarthropathy of weight-bearing joints like knees and hipsis common, as borne out by the fact that many of my regularshave already had total hip and/or knee replacement surgery.

diabetic amyotrophy

This is a disabling illness, which is distinct from other forms ofdiabetic neuropathy, and features muscle wasting andweakness and diffuse, proximal, lower limb pain, plusasymmetrical loss of tendon jerks. Less commonly, theshoulder girdle is affected. Typically, it affects older males withtype 2 diabetes, and is accompanied by weight-loss, oftensevere. The cause is not known, and it is a diagnosis ofexclusion, as the combination of severe weight-loss andneurological symptoms and signs mean that other and moresinister diseases have to be considered. Treatment consists ofimproved glycaemic control and physiotherapy.

Conclusion

Musculoskeletal complications of diabetes are common butoften less attention is paid to these compared with macro- andmicroangiopathic disorders. However, poor diabetes control isoften also contributed to by lack of physical exercise, and themany rheumatic disorders dealt with here result in pain,stiffness and reduced mobility which further prevent physicalactivity. This creates a vicious cycle. It is incumbent on allgeneralists to look for and treat these MSK complications tofacilitate the exercise programmes we encourage our patientswith diabetes to pursue.


Figure 5: Charcot’s Joint

Figure 6: off-loading of weight using a 'Moon Boot'

(removable Cast Walker)


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Obesity in the United States of America (USA), UnitedKingdom (UK) and in South Africa is increasing atan exponential rate. A recent finding revealed that

the prevalence of obesity might be worse in South Africathan in the USA, especially amongst South African women.This escalating incidence is leading to an epidemic of type 2diabetes, heart disease and certain cancers.

We have always known that weight loss is an essentialgoal of therapy in type 2 diabetes. Weight loss andsubsequent glycaemic improvement achieved through‘gastric bypass surgery’ and ‘the 600 calorie diet’ studyreinforced this notion.

Gastric bypass surgery is an extreme approach currentlyintended for the morbidly obese patient with a body massindex (BMI) greater than 35 kg/m2. The 600 calorie/day dietstudy reported observations of only eight people underexceedingly strict dietary restrictions and medicalsupervision. The long-term success of these two approachesis yet to be determined. However, a much larger study,observing 273 subjects using an 800 calorie/day diet, hasbeen initiated in the UK.

One of the questions that arose from these two methodsof weight loss was “Is weight loss and weight maintenanceas important as or more important than the conventionaltriad of treatment (exercise, nutrition education, andmedication) in people with type 2 diabetes?”

If we look back at the last 20 years of clinicaloutcomes in patients with type 2 diabetes at the Centrefor Diabetes and Endocrinology (CDE), the mostsignificant improvements noted in glycaemic control,blood pressure, lipid profile and overall cardiac riskwere achieved in patients who achieved substantial(10-20 kg) weight loss. However, significant weightloss and maintenance was only achieved in a limitednumber of extremely motivated patients. The latestevidence-based weight loss research stronglyadvocates appropriate and regular activity, weeklyweight monitoring, regular dietary follow up andconstant support to achieve weight loss and long-termweight maintenance. Bearing this in mind, and aftermany years of research and preparation, the CDE inHoughton, Johannesburg initiated the CDE ‘WhyWeight?’ Programme in July 2012. This is aninnovative approach to weight loss guided by an alliedhealthcare team. We set out to engineer a scientificallybased, multi-disciplinary weight loss programmedesigned to help people achieve a better overalllifestyle, with weight loss as one of the primary goals.

This Programme addresses three primary aspects ofweight loss:1. Physical activity in structured groups of three or

more patients, facilitated by biokineticists;2. Nutrition, facilitated by registered dieticians;3. Psychological support (and therapy when necessary)

facilitated by a clinical psychologist.

The Centre for Diabetes ‘Why Weight?’ Weight Loss andLifestyle Change Programme

andrew Heilbrunn, simone strybos, Biokinetic Department;

Vhonani Mufamadi, Dietetics Department;

rosemary Flynn, Clinical Psychologist;

Centre for Diabetes and Endocrinology, Houghton, Johannesburg

Correspondence:

Mr Andrew Heilbrunn



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The CDE ‘Why Weight?’ Team equips people with necessarylifestyle tools such as:• Information on exercise and daily activities that they could

participate in, from novice to an advanced level;• Knowledge of the appropriate daily macronutrient intakes

for each patient;• Skills to deal with daily hunger (i.e. managing hunger with

the appropriate food or fluid intake at the correct times asa means of preventing binge eating);

• Ways of dealing with the emotional pitfalls that tend tosabotage weight loss efforts.

1. the Biokinetic approach to Weight loss and

Weight maintenance

Regular exercise is a vital part of staying healthy. Peoplewho are active live longer, feel better, and have a greatersense of well-being. Exercise aids in the prevention oftype 2 diabetes and is one of the cornerstones of diabetestherapy. Furthermore, it has been widely acknowledgedthat regular exercise lowers the risk of cardiovasculardisease and certain cancers.

In terms of weight loss, one needs to expend more energythan one consumes. Regular activity is essential to achievethis. The amount of activity necessary to make a significantimprovement in weight or body fat percentage depends to acertain extent on how many calories are consumed and thecombination of activities that are performed. A suitablecombination of exercise, an acceptable eating plan and theright mind-set may be the most feasible way to control weightin the long term.

Biokineticists at the CDE identified certain evidence-based,practical weight loss approaches that could be implementedinto the Programme. We adopted an interval training approachthat the literature suggests may be more effective than thetraditional low-intensity, long-duration endurance approach. Aninterval training approach ensures that patients exercise at leasttwice a week and follow a diverse routine at varying intensities.In this way, the patient never gets bored with the activity. Wealso encourage patients to become more active on the daysbetween group exercise sessions and suggest that patients aimto achieve 60 minutes of activity per day.

We identified the following common barriers to exercise:• Not having enough time to exercise;• Lack of energy;• Boredom with activity;• Stress;• Laziness and lack of motivation;• Feeling self-conscious with exercise in public.

Starting ExerciseMost people know that they should exercise, and may evenwant to exercise, but they find it hard to summon up the

energy or motivation to get started. The ‘Why Weight?’ teamhad to initiate practical and creative ideas to get people moreactive on a daily basis. The following are some of the ideasformulated to get people active for at least 60 minutes a day:• Getup from your desk at least every 30 minutes and walk

around the office. Sitting for long periods may bedetrimental to your health and weight loss attempts;

• Wake up earlier in the morning and get active. If yournights are busy, wake up half an hour earlier everyalternate day and go for a walk, or use a stationary bike;

• Identify your most energetic time of the day and plan youractivity during that time;

• Try to park away from the entrance of a shopping mall towalk a little further when shopping;

• Go for 10-minute walks interspersed throughout the dayat home or at work;

• Find a group to walk with you at lunchtime;• Take the stairs instead of the lift.

“He who has no time for exercise must create time forillness” Edward Stanley, Earl of Derby. The conduct oflife, address at Liverpool college, December 20 1873

Excess Post exercise Oxygen Consumption (EPOC)Generally, the CDE ‘Why Weight?’ team encourages patientsnot to eat or drink anything besides water or tea for an hourbefore and after an exercise session. This advice is based onthe exercise concept of EPOC.

EPOC investigated the effect exercise had on metabolicrates. Metabolism essentially increases with exercise andremains elevated for at least one hour post-exercise. The bodyutilizes energy to return the metabolic rate to normal. Itgenerally takes one hour to return to the pre-exercise baseline.If one were to eat immediately after exercise, the metabolicprocess of EPOC would target energy from the food that thepatient ate and not the energy from the patient’s fat stores.

We advise patients to drink sips of water continuallythroughout the exercise session and immediately thereafter.Hunger immediately following exercise may occur in somepatients; however, we encourage patients not to eat unlesstheir blood glucose levels are low. If the patient’s bloodglucose levels are low post exercise, we correct their levelswith Dex4® glucose tablets before they drive home.

2. the dieticians approach to weight loss and

weight maintenance

The goal of the CDE ‘Why Weight?’ programme is to developa healthy sustainable eating pattern that will achieve an initial5 to 10 % weight loss and maintain this weight loss in thelong term.

Healthy eating and controlled energy intake plays animportant role in maintaining and achieving a sustainableweight loss. This can be achieved by including a variety of


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foods that will provide the body with adequate proportions ofcarbohydrates, protein, fat, fibre, vitamins, and minerals thatare essential to sustain and maintain healthy bodily function.

The UK Food Standards Agency (FSA) recommends thatenergy requirements for men are 10,500 kJ per day and8400 kJ per day for women. However, this depends on otherfactors including activity levels and age. It is suggested forweight loss that men have no more than 7560 kJ per dayand women no more than 5880 kJ per day, and we do notgo lower than 5040 kJ per day. The UK National HealthService (NHS) 12-week weight reduction programme alsouses this guide. In the CDE ‘Why Weight?’ Programme, weplan energy intake based on individual needs and we adjustthis as patients progress.

We do not encourage rapid weight loss, because althoughthis might provide short-term motivational benefit, in ourexperience it is usually not sustainable in the long term. Theliterature suggests that one should recommend attainableweight loss of 0.45-0.9 kg per week.

To understand an individual’scurrent nutritional status, anutritional assessment is undertaken.The assessment includes:• An eating and ‘diet’ history;• anthropometric measurements;• biochemical data (e.g. lipid

profile, HbA1c, full blood count);• clinical observations (e.g. pallor,

dry, brittle hair, skin condition);• a physical activity history, including, most importantly,

the patient’s previous experiences and current thoughtsand feelings regarding ‘getting more physical’.

• the socio-economic status and cultural background ofthe patient.

In most dietary evaluations, findings were that dietary historyand the lack of physical activity played a major role inpatients’ weight gain. Energy intake was usually higher withextra snacks rather than moderately portioned meals. Patientsgenerally regard meals as big or small based on portion sizerather than on the total energy intake. Some meals thatpatients thought were small were often very high in energy onfurther investigation.

In our assessment, we educate patients on energy awarenessand on how to read food labels. This in turn gives the patient abetter understanding of their food intake, improves theirknowledge and helps them make better food choices.

We provide individual and group education on healthyeating practices. Based on individual needs, we provide acalculated energy-intake meal plan. The aim of the meal planis to guide the patient on correct portion sizes and energycontrol during meals and snacks.

To empower patients with knowledge and skills, wedeveloped materials on topics such as:• How to approach eating out at restaurants;• How to lower energy intake;• Reading food labels;• Making smart food choices at breakfast, lunch and supper; • Which eating plan works best?

Food diariesParticipants in the CDE ‘Why Weight?’ Programme areencouraged to keep food diaries in which they note their foodintake, the time of food intake, their concurrent emotions andfeelings, and whether they share a meal or not. We requestthat food diaries be kept for seven consecutive days once amonth. Furthermore, the seven-day food diary should be keptduring different weeks of the month. This helps the dieticianto recognise if certain times of the month have an impact oneating patterns. By keeping records, patient accountabilityand awareness of food intake is improved. In addition, the

food diary may aid in identifyingtriggers for unhealthy eating or‘mindless’ intake of calories. It alsohighlights any improvements that thepatient has made.

When we review food diaries,most of the portion sizes are notrecorded, or the correct portion sizesin meal plans are not adhered to.Some individuals refuse to keep arecord of their intake. This makes it

difficult to identify problem areas and provide informedadvice. Some felt that the diary required too much time if theywere to measure or weigh portion sizes.

Most patients make their diary entries at the end of theday or even the following day rather than immediately beforeor after the meal. This may result in under- or over-recording.

3. the Psychological approach to weight loss and

weight maintenance

From an emotional point of view, many people with diabeteswho are overweight or obese really do want to lose weight, ifonly they could. More often than not, they have tried manydifferent ‘diets’ - some that are successful for a while but aredifficult to sustain, and others that do not achieve weight lossas expected. They try slimming tablets, quick fix plans, pre-packaged weight loss products, skipping meals or starvingthemselves, and even surgery to get rid of the unwantedexcess kilograms. Yet the weight remains. The CDE ‘WhyWeight?’ Programme addresses weight loss systematically, notexpecting dramatic loss in short periods but rather aiming forincreases in activity levels, eating in a healthy way andovercoming important and often forgotten or unseenemotional blocks, which counter these changes. These new

We do not encourage rapid

weight loss, because although

this might provide short-term

motivational benefit, in our

experience it is usually not

sustainable in the long term


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lifestyle patterns will lead to weight loss without an emphasison ‘dieting’ – a term that has represented failure for thepatient so many times before. Changing lifelong lifestylehabits will never be easy. Some people need to deal with afood addiction. Before they can change their eating patterns,they need to understand the underlying reasons for their foodaddiction and address them.

Emotional blocks can and do occur atevery stage of the Programme. Thefollowing are some commonemotionally troublesome areas:• getting started – wilfully doing

something about the weight in spiteof past failures

• committing to a long term planrather than a quick fix

• maintaining the plan consistently when it becomes difficult• dealing with discouragement when the weight loss is slow

or not happening easily• giving up favoured foods that do not fit into healthy eating

means dealing with cravings for those foods and wilfullysustaining healthy eating

• facing criticism, often self-criticism, but also from otherswho try to ‘police’ the person’s eating patterns or are‘prophets of doom’

• dealing with feelings like anger, sadness, or anxiety thatusually give rise to ‘comfort eating’

• fear of hypoglycaemia• restarting after a holiday or a relapse.

Any one of these blocks can make the person give up thequest to change, even if they know that these changes arelifesaving and worthwhile in the long term. When patientsconfront a block, both the ‘Why Weight?’ team and themembers of their group offer encouragement and support andhelp them to keep going. We consider each person’s specialneeds when we negotiate an eating plan or exercise schedule.We provide participants with the opportunity to work with thepsychologist to overcome their emotional blocks.

Although we have presented the information aboveaccording to the core role of each allied health professional,we must stress that our working team is interdisciplinary innature and function. All members of the team present acohesive and congruent set of messages across all topics asapplies to their discipline.

The OutcomeIt does not take too long before the patient begins toexperience the positive benefits of their commitment. Theysee weight and waist circumference losses. They noticereductions in their appetite and diminishing cravings for

unhealthy foods. They feel more ‘alive’ and inclined towardsbeing active rather than sedentary. They reduce the amountof insulin they need, often substantially, and keep their bloodglucose levels to their individualised targets. They formencouraging relationships with the others in their group,sometimes learning more about healthy social interactions.

Looking and feeling better, they begin tofeel more socially acceptable. Theydevelop self-confidence and self-worth.

These changes allow patients tobecome self-motivated and self-drivenand it is much more likely that theywill be able to continue the changesthey have made in their daily livingonce they have finished the ‘WhyWeight?’ Programme.

The CDE ‘Why Weight?’ Programme Overview1. Biokineticists, dieticians and a psychologist assess

patients.2. Biokineticists supervise exercise sessions on at least

2 occasions per week.3. The CDE ‘Why Weight?’ team and patients meet for

15 group-feedback sessions (one session per month).4. The team gives unconditional support to patients at all

times, especially when they are not successful.5. The following measurements are recorded:

a. Weekly weight;b. Waist circumference, every 2nd week;c. Blood pressure at every session if the patient is

hypertensive;d. Blood glucose measurement before and after all

sessions when necessary.6. We kept track of all hypoglycaemic episodes and adjust

insulin dosages where necessary.7. We ask all patients to keep a food and activity diary that

we analyse on a regular basis.

Statistics• Thirty seven people have been through the Programme

(31 with diabetes, 6 without diabetes).• Currently we have 18 active clients on the Programme

(for between 4 and 35 weeks).• For the purpose of this report, we chose those people that

have completed at least 14 weeks (3.5 months) n=13(10 people with diabetes and 3 without diabetes)

OutcomesWe present these interim outcomes in a descriptive mannerbecause of the small numbers of patients involved.• The highest achieved and maintained weight loss was

20 kg over 35 weeks, with a reduction of 13 cm in waistcircumference. This patient is still on the Programme.

Before they can change

their eating patterns, they

need to understand the

underlying reasons for

their food addiction and

address them


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• The least successful weight loss was 2 kg with a 4 cmloss in waist circumference over 14 weeks.

• The average weight loss for the group was 7.66 kg over14 weeks.

• The average reduction in waist circumference was 8.41 cm over 14 weeks.

• The average reduction in HbA1c measured in 7 of the13 patients was 0.95 %.

• The most significant change in HbA1c was 3.2 % in onepatient over a 23-week period.

• The most significant decrease in overall insulin dosagewas 80 % in one patient.

Patient satisfaction• Group exercise sessions in the gym were highly

successful. Patients motivated each other well.• Group feedback sessions (with the CDE ‘Why weight?’

team) were appreciated and beneficial.• Team availability throughout to answer any questions

that were exercise, lifestyle or emotionally related was asignificant part of the success of the Programme.

• Constant contact with patients via e-mail and SMSkept the ‘finger on the pulse’ and sustained thepatients’ interest.

• All patients managed to increase their daily activitiessignificantly.

Difficulties encountered• Transport problems, especially for patients that lived more

than 10 km from the CDE.• Work commitments prevented patients from attending

regular activity sessions.• If patients went on vacation, it often required a lot of

motivation to return to their exercise classes and calorie-restricted eating plans.

• Some group feedback sessions were not well attended.• Some patients were reluctant to return their food and

exercise diaries for review.• Individual patient complications or chronic orthopaedic

pathologies lead to disrupted group biokinetic sessionsfor some.

• Some patients were reluctant to exercise on their own ondays where we did not hold group sessions.

Conclusion

The CDE ‘Why Weight?’ Programme has shown good resultsfor those who have persevered. There have been somechallenges, but our team is addressing these as they arise. TheProgramme is evolving as we overcome obstacles to lifestylechange and create a blueprint for wellness. Successful weightloss and weight maintenance depends on the correctcombination of exercise, an acceptable eating plan, regularmonitoring and support and the right mind-set in the long term.

Are you

• Passionate about diabetes?• Striving to provide excellent care for people with diabetes?• Wanting to learn more about this epidemic condition?

Then diarise the

16th CDE Postgraduate Forum in Diabetes Managementat the

Birchwood Hotel and OR Tambo Conference Centre,Boksburg, Gauteng, 08-10 August 2014

The Annual CDE Forum is the premier meeting place for all healthcare professionals with aspecific interest in the management of diabetes. It provides a distillation of the mostimportant issues in the rapidly changing field of diabetes care. Our Programmes are tailoredto produce an event that is scientifically based whilst remaining practical, creative andentertaining. The large concurrent trade exhibition will expose you to the latest diabetesproducts. Attendance is compulsory for continuing accreditation as a Centre for Diabetes.

Keep up to date with all the Forum news and watch for the soon-to-follow registrationdetails. Follow the link from the Home Page of the CDE Website - www.cdecentre.co.za


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Diabetes is the world’s fastest growing chroniccondition, affecting people of all ages. Reliablestatistics are not readily available for South

Africa, but data held by companies that supply insulinsuggests that approximately 200 000 people in SouthAfrica use injectable therapies to treat their diabetes.Incorrect injection techniques affect health outcomes –this frequent problem can be remedied.

injection technique recommendations: a gap

that needs filling

All injectable agents rely on correct injection techniquefor optimal effect. Despite this, current diabetesguidelines do not include detailed advice on the subject.The United Kingdom (UK) National Institute for Healthand Care Excellence (NICE, 2009) makes a briefreference to providing education about injectabledevices for people with diabetes, while its 2011 Qualitystandard for insulin therapy recommends a structuredprogramme of education, including site selection andcare. The document also stresses that all healthcareprofessionals who initiate and manage people on insulinmust complete appropriate training and be able todemonstrate their competence.

In the 2012 Society for Endocrinology, Metabolismand Diabetes of South Africa (SEMDSA) Guideline for the

Management of Type 2 diabetes, it is recognised thatpatient education is the cornerstone of effective diabetescare and that one of the topics that should be covered bydiabetes self-management education is that of “insulininjection technique and sites of injection”.

Apart from these brief and indeterminate references,currently, no comprehensive, practical, evidence-baseddocument exists to outline best practices for insulininjection technique for South Africans living with diabetes.

introducing the Forum for injection technique

(Fit)

The Forum for Injection Technique (FIT) was formed in2010, initially in the UK, by experienced diabetes specialistnurses, following the publication that year of theinternational ‘New injection recommendations for patientswith diabetes’ in the journal Diabetes & Metabolism.

FIT has grown into an international effort, with itsSouth African chapter joining in 2013, supported byBecton Dickinson (Pty Ltd). As such, this growing body ofprofessionals aims to establish and promote best practice ininjection technique for all involved in diabetes care, and tosupport people with diabetes who require injectabletherapies to achieve the best possible health outcomes. Itspecifically desires to achieve this by ensuring the deliveryof the correct therapeutic dose to the correct site, using thecorrect technique, every time.

The first South African FIT Injection TechniqueRecommendations are now available and can be reviewedand downloaded from the FIT website(www.fit4diabetes.com). The main objectives of the

Diabetes: sharp and to the point

Hester davel: RN, Chronic disease management, Diabetes Specialist Nurse, Diabetes Coach,

DESSA ADEg.i Berg: B. Pharm. MSc Diabetes Management (Glamorgan) DESSA chair, DESSA ADE

razana allie: RN (ICU) Diabetes Specialist Nurse, Diabetes Coach, DESSA ADE

Laurie van der Merwe: RN, RM, Palliative N, PGDM (Cardiff), Diabetes Specialist Nurse,

Diabetes Coach, DESSA ADE

Correspondence:

Hester Davel



O R I G I N A L

Recommendations are to improve the quality of care andhealth outcomes, to minimise complications patientsexperience due to poor injection practices and to increasethe cost-effectiveness of resources devoted to diabetes care.

improving injection technique for practice nurses

Diabetes nurse educators (DNE’s) who work within ateam have been able to build knowledge and skillsthrough supervision, but developing and maintainingthese invaluable human resources is time-consuming andmade difficult by limitations such as funding.

To fill gaps in the provision of care, practice nurseshave increasingly taken on the role of teaching thepracticalities of injection technique to people living withdiabetes. Many practice nurses work in relative isolationand may not have access to specialist supervision orsupport. As they attempt to fulfil a number of roles, it ispossible that practice nurses lack the knowledge,expertise, and adequate training and education time tobe able to support people with diabetes on insulin andGLP-1 therapies.

Therefore, raising awareness about the consequencesof incorrect injection technique is important in allaspects of diabetes carebecause many healthcareprofessionals do notalways link erratic bloodglucose control with poorinjection technique.

FIT advocates that toeducate people withdiabetes effectively,healthcare professionalsmust themselves possessthe appropriate knowledgeand skills. FIT is committed to supporting theimplementation of its recommendations for all thoseinvolved in diabetes care, including practice nurses, andrecognises the need to develop and make accessible newand innovative educational approaches.

a snapshot of current injection technique practice

Correct injection technique is central to optimal glycaemiccontrol for those on injectable therapies. However,international evidence suggests that injection technique isoften flawed. While no comparative local data exists,there is reason to believe that findings from Europeanstudies reflect the South African situation too.

Strauss et al (2002) examined insulin injectiontechnique in 1002 people with either type 1 or type 2diabetes across seven European countries. They looked atsignificant factors including injection-site rotation habits,incidence of lipohypertrophy, needle length, timing of

injections, and the use of a lifted skin fold.Subsequently, Frid et al (2010b) examined the injectinghabits of 4300 people with diabetes using insulin, 999of whom were from the UK. Both studies revealedworrying practices in relation to injection techniquewith little improvement in technique over the years.

UK data from the 2009 Injection TechniqueQuestionnaire (Frid et al, 2010b) showed that:• 52 % of people used needles longer than 6 mm• 60 % had not changed their needle size since

starting injectable therapy• 75 % did not follow any site rotation routine• 54 % reported lipohypertrophy at some point• 28 % admitted injecting into areas of

lipohypertrophy• 45 % experienced bleeding or bruising• 43 % released the skin fold too soon• 17 % were using an incorrect technique for lifting a

skin fold• Only 41 % reported frequent and adequate

inspection of their injection sites.

Poor injection technique

linked with erratic

glycaemic control

All injectable agents fordiabetes rely on correctinjection technique for optimaleffect. Incorrect technique,including use of inappropriateneedle lengths, failure to rotateinjection sites and reuse ofneedles can lead to theunpredictable absorption of

injectable therapies. This can cause immediateproblems, such as hypoglycaemia (when insulin isinjected into muscle where it is absorbed at a fasterrate) and/or hyperglycaemia, if insulin is injected intoan area where it is poorly absorbed (Polak et al, 1996;Birkebaek et al, 2008).

It is well known that poor glycaemic controlincreases the risk of long-term complications ofuncontrolled diabetes, including kidney failure,blindness, and limb amputation (UK ProspectiveDiabetes Study [UKPDS], 1998).

The recommended site for injectable diabetestherapies such as insulin and the GLP-1 analogues isthe subcutaneous fat layer (Frid, 2006). Injecting intothe subcutaneous fat allows the insulin to be absorbedat a more predictable rate, which can result in betterglycaemic control (Hofman et al, 2007).

Lipohypertrophy (LH), the accumulation of fatty scar

It is well known that poor

glycaemic control increases the

risk of long-term complications

of uncontrolled diabetes,

including kidney failure,

blindness, and limb amputation


O R I G I N A L

tissue in the subcutaneous layer, is caused by repeatedlyinjecting into the same area. It has been estimated thatabout half of people with diabetes will experience LH atsome time in their life (Frid et al, 2010b). This is thus amajor problem associated with poor injection technique.Lipoatrophy, the wasting ofsubcutaneous fat, can also develop,but it is seen less often. Injectinginto areas of LH or lipoatrophyresults in variable absorption anderratic glycaemic control.

To date, there is a dearth ofrandomised prospective studies toestablish the causative factors ofLH. Observational studies suggesta link between LH and a failure torotate injection sites, repeatedlyinjecting into the same zonewithin an injection site, and thereuse of needles (Varder and Kizili, 2007).

Blanco et al (2013) examined the prevalence of and riskfactors for LH in people who inject insulin. The study foundthat almost two-thirds of people had LH (76.3 % of thosewith type 1 diabetes and 56.1 % of those with type 2diabetes) and this was strongly associated with a failure torotate injection sites. The correct rotation of injection sites wasthe strongest protective factor against the development of LH;only 5 % of people who rotated correctly developed LH.

Needle reuse is another identified causative factor ofLH and the risk rises significantly when needles are re-usedmore than five times.

Increased glycaemic variability occurred in 49 % ofthose with LH compared to 6.5 % among those withoutLH. Those with LH required, on average, 56 units ofinsulin per day compared to 41 units for those without LH.Blanco et al (2013) calculated that this 15-unit difference inthe total daily dose of insulin equated to an annualadditional cost to the Spanish health system of €122million. This is potentially avoidable cost if insulin dosingtechnique could be optimised and insulin doses reduced.More importantly, addressing poor injection techniqueimproves the quality of life for patients using injectabletherapies as less glycaemic variability leads to fewerdiabetes-associated complications.

detecting lipohypertrophy

Detection of LH requires both visual inspection andpalpation of injection sites, as some lesions are more easilyfelt than seen. It is important to teach people with diabeteshow to examine themselves for LH, in the same way ahealthcare professional might advise self-examination todetect signs of breast or testicular cancer. People who useinjectable therapies should understand LH and its possible

impact on their glycaemic control; they should be able toprevent and recognise it, and understand what to doshould it develop. Healthcare professionals should checkinjection sites at least annually as part of routine diabetescare. It is not adequate to ask individuals simply about

their injection sites, asproblems such as LH tend todevelop gradually and theindividual may be unaware ofthe problem. An experiencednurse can be taught how toidentify LH through visualinspection, as well aspalpation. Healthcare workersshould encourage theindividual to adopt systematicsite rotation, as this can helpto reduce the risk ofdeveloping LH.

teaching correct injection technique to be more

fit to for diabetes care

A number of factors contribute to good injectiontechnique, including injection site selection; injection sitecare; the injection process from start to finish; needlelength; the use of lifted skin folds (if appropriate) and therotation of injection sites. In the case of insulin, there areadditional considerations including the re-suspension ofcloudy insulins, as absorption rates vary at different sites(Frid et al, 2010a).

All of these issues are addressed in the FIT InjectionTechnique Recommendations (FIT, 2013) and some ofthe most critical are summarised below.

Preferred sites

Therapeutic agents are generally self-injected into one ofthe four preferred sites, which are the abdomen, thighs,buttocks and arms. Absorption rates from these differentareas depend on the pharmacokinetics of the injectedagent. The rate of absorption of GLP-1 receptor agonistsdo not appear to be site-specific, nor do those of therapid-acting and long-acting insulin analogues (Mudaliaret al, 1999). However, the rate of absorption of humaninsulin is affected by site. To achieve more physiologicalresponses, the abdomen is the preferred site for theinjection of short-acting soluble insulins, where absorptionis faster (Frid and Linde, 1993). The thighs and buttocksare the preferred site for intermediate-acting neutralprotamine hagedorn (NPH) insulins, as absorption isslowest from these sites (Henriksen et al, 1991). Whenpre-mixed insulin is being injected, it is suggested that theabdomen is used in the morning and the thigh or buttockin the evening (Guerci et al, 2005).

A number of factors contribute

to good injection technique,

including injection site selection;

injection site care; the injection

process from start to finish;

needle length; the use of lifted

skin folds (if appropriate) and the

rotation of injection sites


O R I G I N A L

Figure 1

rate of absorption

Other factors that increase blood flow through the injectionsite can speed up absorption and potentially increase therisk of hypoglycaemia. These include a hot environment,such as having a hot bath after injecting (De Meijer et al,1990) and massage or exercise immediately after theinjection. Therefore, individuals should avoid injecting intothe thigh after cycling or jogging (Ferrannini et al, 1982).Injecting intramuscularly will also speed up absorption.Factors that can slowsubcutaneous blood flowand reduce insulinabsorption rates causing arise in blood glucose levelsare cold environments,large volumes of insulin,and injections intodamaged, unhealthy tissue.

needle length

It is essential to assess eachperson individually whenadvising on correct needlelength. Skin thicknessranges from 1.2-3 mm regardless of gender, age, bodymass index (BMI), or ethnicity (Gibney et al, 2010).Subcutaneous depth can vary from person to personaccording to BMI and gender, but also from site to site.For example, in a person with android obesity, the depthof the subcutaneous layer may be as little as 2-4 mm onthe legs and arms, but 20-30 mm over the abdomen(Pledger at al, 2012).

A shallow intradermal injection results in unpredictableinsulin absorption and there is a risk of leakage and anallergic reaction.

Intramuscular injection increases the risk of the injectedagent being absorbed too quickly due to the richer bloodsupply to muscle, leading to an increased risk ofhypoglycaemia and greater glycaemic variability. Injectionsinto muscle are more painful and can cause bruising.

There is a misconception that patients with greatersubcutaneous tissue depth,particularly overweight andobese people, require alonger needle. In fact, itmakes no difference whetheragents are injected intoshallow or deepsubcutaneous tissue - theyare absorbed at similarrates. Previously, when onlylonger needles wereavailable, the only optionfor those with littlesubcutaneous depth was touse a lifted skin fold or an

angled injection to avoid an intramuscular injection. Today,with the availability of shorter needles (4, 5 and 6 mm),individuals can inject at a 90˚ angle without a lifted skinfold. A small minority of people with diabetes, such aschildren or very lean adults, may still need to perform alifted skin fold when using the shortest needles. For adults,there is no clinical reason for recommending needles longerthan 8 mm.

Intramuscular injection increases the

risk of the injected agent being

absorbed too quickly due to the

richer blood supply to muscle, leading

to an increased risk of hypoglycaemia

and greater glycaemic variability.

Injections into muscle are more

painful and can cause bruising


O R I G I N A L

Lifted skin folds

Teaching how to a lift skin fold correctly is not easy. If too muchflesh is pinched up, there is a risk of giving an intramuscularinjection. Recommendations suggest lifting the skin away fromthe underlying muscle with two fingers and a thumb (see Figure2). Furthermore, people should be advised to keep the needlein the skin (with lifted skin fold if necessary) for ten secondsafter the plunger of the delivery device is completely depressed.

sequence for injecting

The optimal injection sequence, as recommended by FIT,should be:• Make a lifted skin fold (if necessary);• Insert needle into the skin at 90° angle;• Administer insulin;• Leave the needle in the skin for at least 10 seconds after

the insulin has been injected;• Withdraw the needle from the skin;• Release the lifted skin fold, if applicable.

re-suspension of insulin

Cloudy insulin must be properly re-suspended before use.This is achieved by rolling the vial, cartridge, or pen, tentimes. Following this, it must be gently inverted ten timesbefore visually checking that it is a uniform milky white colour.

single use of needles

Although it is widely recognised that reuse of pen needlesand syringes is common amongst adults and children, mostinsulin needles (pen needles/syringes) are approved for singleuse and should therefore be used only once (FIT 2013).There is evidence that needle reuse is related to an increasedrisk of lipohypertrophy. Blanco et al (2013) showed a cleartrend towards an increased incidence of lipohypertrophy themore times a needle is reused, particularly when the needlewas reused more than five times.

With reuse, the needle may become distorted and bentand there will be a loss of lubrication. This can lacerate theskin (American Diabetes Association, 2002) and result in amore painful injection (Chantelau et al, 1991).

site rotation

Systematic site rotation helps to reduce the risk ofdeveloping LH. One scheme with proven effectivenessinvolves dividing the injection sites into quadrants or halvesand using one section per week, rotating within that sectionfrom day to day and then moving clockwise each week to anew area (Figures 3 and 4).

Figure 2: Correct (Left) and incorrect (right) methods of lifting a skin fold (Fit 2013)

Figure 3: abdominal injection rotation pattern by

quadrants*

Figure 4: thigh injection rotation pattern by quadrants*

*Diagrams adapted from Lourdes Saez-de Ibarra and Ruth Gaspar,

Diabetes Nurses and Specialist Educators from La Paz Hospital, Madrid,

Spain (FIT, 2013).


O R I G I N A L

site selection

The injection site should be inspected and palpated by theindividual prior to injection. Where LH is detected, theperson should be advised notto inject into the site until thetissue returns to normal,which may take manymonths. Abnormalitiesshould be documented andsites monitored at everysubsequent review. It isimportant to note that, whenswitching from areas of LHwhere insulin is likely to bepoorly absorbed to injectinginto normal tissue, theimproved, quicker insulinabsorption may require areduction in dose. The magnitude of the dose reductionwill depend on the individual and should be guided byfrequent blood glucose testing. The reduction may be asmuch as 50 % (Overland et al, 2009).

ongoing review of injection technique

Giving good advice at the initiation of an injectabletherapy is vital, but it is often at a later stage thatproblems related to poor injection technique arise. It is,therefore, important to revisit injection technique andexamine injection sites as part of routine, ongoingmanagement. Starting injectable therapy, especiallyinsulin, is a daunting prospect for most people. Thosewith type 1 diabetes may be struggling to come to termswith their diagnosis and those with type 2 diabetes oftenexperience feelings of failure (Polansky et al, 2005).Additionally, with so much new information to take in, itis not surprising that people with diabetes forget some ofthe practicalities associated with good injection technique.There is evidence to show that revisiting education on

injection technique is often rare. In one study, around30 % of participants did not recall being educated onlength of needle, how long to hold a lifted skin fold for, the

angle of needle entry, or re-suspensionof cloudy insulin (Frid et al, 2010b).

It is critical to reassess how peoplewith diabetes are injecting on a regularbasis. At consultation, people are oftenseen with erratic blood glucose levelsand healthcare practitioners scrutiniseblood glucose monitoring diaries to lookfor lifestyle patterns that may be thecause. However, a quick assessment ofthe person’s injection technique mayindicate a cause. A positive developmentwould be for healthcare professionals toregularly reassess injection technique aspart of routine follow-up, as, regardless

of how efficacious a therapy is, if it is not administeredproperly, it will not have optimal effect.

Conclusion

People who use injectable therapies should be taughtcorrect injection technique when injectable therapies areinitiated, but the subject must also be revisited andreviewed at subsequent consultations. Healthcareprofessionals have a responsibility to acquire knowledge,skills and competencies concerning current best injectiontechnique practice to support people who use injectabletherapies effectively and safely. FIT was created toprovide such resources and support and it remainscommitted to establishing and promoting best practice ininjection technique, raising awareness of existing researchrelating to injection technique, and highlighting theimpact that this may have on health outcomes for peoplewith diabetes who use injectable therapies.


It is important to note that,

when switching from areas

of LH where insulin is likely

to be poorly absorbed to

injecting into normal tissue,

the improved, quicker insulin

absorption may require a

reduction in dose


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Oral Agent Therapy Insulin Therapy

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