Diabetes Report Eyes on Diabetes Wednesday 14 November 2018 A complimentary supplement distributed with The Malta Independent.
02 Diabetes Report
‘Structured national scre be part of national strate World Diabetes Day THE BLUE CIRCLE has been the global symbol for diabetes since 2006. According to the INTERNATIONAL DIABETES FEDERATION the purpose of the symbol is to give diabetes a common identity. It aims to: support all existing efforts to raise awareness about diabetes; inspire new activities, bring diabetes to the attention of the general public; brand diabetes; and provide a means to show support for the fight against diabetes.
CHRIS J. DELICATA, president of the Maltese Diabetes Association and former president of the International Diabetes Federation Europe, reflects upon those who are working towards more awareness and promotion of living with diabetes and the initiatives currently happening to highlight the importance of World Diabetes Day. Giulia Magri writes November marks the birthday of Sir Frederick Banting, who in 1921 codiscovered insulin, together with Charles Best. According to The International Diabetes Federation (IDF), 13.2% % of all 20-79 year olds in Malta suffer from diabetes. The theme for World Diabetes Day for 2018 and 2019 is The Family and Diabetes. The aim of this year’s campaign is to raise awareness of the impact that diabetes has on the family and promote the role of the family in the management, care, prevention and education of diabetes. Founded in 1981 by the late Tancred Zammit and its headquarters found in Valletta, the Maltese Diabetes Association is a non-government organisation with a mission to create more awareness on diabetes and its complications. It is an active member of the International Diabetes Federation and works closely with its European Region. Apart from the Association, there is also Diabetes Association in support of Youth (DAISY) which focuses on youths and adolescents. Throughout the summer holidays a camp is organised for children with diabetes, giving them a unique experience to learn more about their condition and empower themselves in a relaxed and enjoyable environment. With the aid of social media, it is much easier now to reach out to seek support and help. Founded by a group of parents who wished to share their own experiences of raisingtheir children with type 1 diabetes, ‘T1D Little Warriors’has been set up exclusively for parents and carers of children living with Type 1 Diabetes.
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An increase in educational campaigns for diabetes Delicata spoke about the importance that educational institutions should be in the forefront on diabetes, stressing that information should be provided to schools. For this reason, a few years back informative leaflets were distributed to various schools around Malta by the Association. The leaflets were launched to assist teachers, carers and learning support assistants, providing guidelines as to what one should do when a child has hypoglycaemia, when practicing sports or when ill. Delicata said the Strategy for Diabetes (Diabetes: A National Public Health Priority 2016-
Testimonials Rachel Portelli, 25 Living with diabetes for over 21 years, I do not remember a life other than that with type 1 diabetes. It seeps its way through everything, whether it is school, relationships, jobs or any other area of my life. Growing up with diabetes was not a walk in the park and I hated it for a number of years, however, I never let it get in the way of what I wanted to do. I am lucky enough to have amazing supportive family and friends who always try their best to understand and help me. However, diabetes did get in the way of creating new relationships because the highs and lows could sometimes be seen as a burden. In 2016, I graduated from a Bachelor of Arts (Hons) in Social Policy. Studying at University is already tough on its own, and adding diabetes makes it even more since stress makes my blood sugars unstable. It was even more difficult when less than a week before my University finals, I was told I had diabetes Retinopathy. However, I was still able to graduate with my class in 2016 and now am doing a Masters in Health, Medicine and Society. 2020) launched by the government in 2016 was a step in the right direction. The ultimate aim of the strategy is to prevent diabetes, expand treatment options and improve the integrated management of diabetes so as to prevent or postpone the onset of diabetes- related complications. Earlier this year the government extended the blood glucose monitoring devices for people living with type 2 diabetes,
Martina Erika Mallia, 19 Keeping a proper balance between school and maintaining a social life is undoubtedly stressful for most teenagers. For a person living with diabetes, it further complicates things. Diabetes affects even the simplest day to day tasks such as driving, going out with friends and studying. In spite of this, it does not limit or restrict me in anything I do. I was diagnosed with type 1 diabetes at the age of twelve, when, like any child at that age, I was eagerly looking forward to starting my teenage years. Taking insulin multiple times daily was definitely not something I was anticipating and, needless to say, required getting tuned into a more systematized lifestyle. Till this day, it is still a challenge to control diabetes whilst taking on different commitments, be it University and extracurricular academic commitments or casually going out with friends. However, knowing that I am surrounded with friends and family, who are fully aware of my situation and supporting me through every single day, encourages me not disregard my diabetes.
therefore giving persons living with diabetes a more efficient and regular means of checking their blood sugar levels. Undoubtedly, ensuring better diabetes management would result in fewer complications and hospitalisation. The president of the association hoped that in the near future the government would consider the introduction of Continuous Glucose Monitoring
devices for persons living with diabetes. The device tracks glucose levels throughout the day and night to help such persons to proactively manage their glucose levels. Delicata says that such devices should be fully reimbursed by the government to ease the financial burden on patients and/or their carers who opt to purchase this innovative and effective device from their own pockets.
Diabetes Report 03
eening programmes should egy to ensure early detection’
Chris J. Delicata with EU Commissioner for Health and Food Safety Vytenis Andriukaitis
42,300 cases of diabetes (20-79 years) reported in 2017 alone When discussing the major contributors for the increase in type 2 diabetes, several causes arise, including genetics and lifestyle. Obesity, an issue which is extremely predominant in Malta is linked to type 2 diabetes. People at risk of getting diabetes due to a family history or who are at high risk should take regular health check-ups said Delicata. As breast cancer and colon cancer screenings are successful in early diagnosis, Delicata believes that ideally there should also be structured national screening programmes for those over a certain age group and/or at risk of getting diabetes and/or with a family history of diabetes. Numerous complications may arise if diabetes is not managed or neglected. Foot complications, kidney disease, nerve damage, retinopathy and stroke can all be prevented or delayed with the correct treatment and recommended lifestyle changes.
Events being held for World Diabetes Day Delicata said that the association will be organising two main events to mark World Diabetes Day. A national seminar will be held on Saturday 17 November ‘Family & Diabetes’ at the Grand Hotel Excelsior in Floriana from 9.30am till 12.30pm. The speakers will include both the clinical and personal perspectives focusing on this year’s theme for World Diabetes Day – Family & Diabetes. On Saturday 1 December the Association will be holding a Free Diabetes Test event at Pavi Supermarket in Qormi from 9.30am till 12.30pm, giving the public a chance to take the first step to get tested for diabetes. As part of its fundraising initiatives, a Sunday Buffet Lunch in aid of Diabetes will be held on Sunday 2 December at the Palace Hotel, High Street, Sliema. Further details are available from the association’s website www.diabetesmalta.org.
04 Diabetes Report
Sugar free and healthy When left untreated Diabetes can result in severe complications, ones that put the lives of those effected at risk. Words by Mariella Camilleri lthough there is a lot of awareness about Diabetes, not much is said about its complications and the stress that arises when one suffers from this condition. My father was first diagnosed with borderline Diabetes in his forties and for most of my life I watched him abstain from sugary foods, monitoring his intake of starchy dishes – this and a rather hectic lifestyle helped to keep his blood glucose levels in check and Diabetes was never viewed as a serious threat to his health. Worldwide, Diabetes afflicts more than 380 million people, and the World Health Organization estimates that by 2030, that number of people living with diabetes will more than double. The illness occurs when the pancreas fails to produce the necessary insulin that turns the food we eat into glucose that is needed for energy. There are two types of Diabetes: type I effects children and young adults and occurs when the immune system attacks part of its own pancreas; thus with this type of diabetes no insulin is produced and those effected must use insulin injections to control the levels of glucose in their bodies. With type II, the patient suffers from insufficient insulin or his/her body fails to use insulin effectively. As the conditions gets worse the pancreas fails to produce insulin completely. Unlike type I Diabetes where young people experience malaise and weight loss, type II can be very silent and may go undiagnosed for years. Blood sugar in Type II diabetes can rise with little warning as was the case with my father. The severity of his condition was discovered in the winter of 2016 when he taken ill with Pneumonia. He felt unwell, lethargic and his appetite was supressed. Unable to take his antibiotic, my sister and I decided to admit him into a hospital where he could be given his antibiotic intravenously. By the time we reached the A&E he could barely walk, and doctors began to work on him right away.
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What I learnt Type II diabetes
• In patients with type II Diabetes the body doesn’t make proper use of insulin. • Being overweight increases your risk of type II however even those with a normal weight gain can develop the condition. • When glucose builds up in the blood instead of going into cells, it can cause two problems: right away your cells may be starved for energy and over time, high blood glucose levels may hurt your eyes, kidneys, nerves or heart. • Although type II can sometimes be managed with healthy eating and exercise over time most patients will require medication. • Type II affects 90% -95% of all Diabetes patients. • This kind of Diabetes effects mostly adults however the condition can also occur in children. • Diabetes can virtually affect all organs. Bacterial and fungus infections on the skin, neuropathy, nerve damage, hearing impairment, retinal damage, heart attacks, stroke, kidney failure and cardiovascular disease are some complications that may arise from diabetes.
The early symptoms of Diabetes • • • • • • •
His blood sugar levels where extremely high and his blood pressure had risen to dangerous levels. Before this terrifying episode, my father had minor wounds that took long to heal, he also complained of a dry month; often he awoke at night parched, we told him off for not drinking enough however, his symptoms had little to do with lack of drinking. Later the specialist explained that when the body fails to produce insulin, one becomes dehydrated. We also learned that untreated Diabetes makes a person more susceptible to pneumonia and other common infections. Four days later my father was released from hospital and so began a journey of blood sugar monitoring and round the clock medication. Due to the long recovery process from Pneumonia, my father came to recuperate at our home – a long and arduous experience where we tried our best to make him as comfortable as possible. Initially despite the medication, his blood
sugar levels remained abnormally high. A small portion of pasta would cause his blood sugar levels to plummet, this led his doctor to prescribe stronger oral medications to keep his insulin stable. With diabetes there is no such thing as irregular meal patterns. Once the patient is given oral medication or direct insulin (injected) meals cannot be missed. But like most families we learnt through trial and error, and evitable things do happen in the early days of diagnoses. One morning my father took his oral medication later than usual and then went on to have lunch at my sister’s house. Later in the evening just before dinner he returned in high spirits; he was talking and laughing but there was something strange about the way he was resting against the sofa, he tried to get up but his body gave way. My heart leapt. Fearing a stroke, my husband called a friend who works in A&E and soon an ambulance was sent. A quick
Hunger and fatigue Excessive thirst Cuts and wounds that don’t heal after a few days Dry mouth and itchy skin Blurred vision Numbness in legs or feet Yeast infections
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Unfortunately many people fail to go for check-ups and due to its rather elusive symptoms Diabetes can go undetected for years, this results in serious complications; ones that may lead to kidney failure, blindness and loss of lower limbs
blood test check revealed that his sugar levels had dropped dangerously low. Despite several sugared teas, toast and chocolate, his sugar levels failed to rise and my father was taken to Mater Dei were glucose was injected into his arm. Within half an hour he seemed stable again and had regained his balance. We were told that he had gone for a few hours
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without food and the medication had caused his blood sugar to drop. After this episode his medication was adjusted and soon after his recovery, he became accustomed to his tablets and also with regular meal patters. Hypoglycaemia, low blood sugar levels, is common in Diabetic patients who are on medication, hence meals need to be as regular as possible. After his recovery from pneumonia my father moved back home and went back to living a relatively normal life. Blood glucose monitoring is still an essential part of our lives; I check this once or twice a week and thankfully his Diabetes is under control. Unfortunately many people fail to go for check-ups and due to its rather elusive symptoms Diabetes can go undetected for years, this results in serious complications; ones that may lead to kidney failure, blindness and loss of lower limbs. Diabetes is diagnosed through a blood and/or a urine sample. For accurate results these tests are best done two hours after meals where sugar levels should stabilise at a range between 8-10 on a blood sugar monitor (higher levels should be discussed with a medical practitioner.) Although type I Diabetes is not preventable, the risk of type II Diabetes can be reduced through a healthy lifestyle. A diet rich in protein with fewer carbohydrates and regular exercise can work wonders for those with borderline Diabetes. Type II Diabetes tends to be genetic and thus regular check-ups are highly recommended for those whose family members are effected. Although a Diabetes diagnosis can be a life altering condition, refined medication and regular doctor follow ups can help to keep the disease under control. Education about the subject is also vital. Last year I googled diabetes regularly; the illness can be complex and confusing however seeking medical advice helped me to clarify several mindboggling facts about this common disease.
Diabetes Report 05 MATERNITY
Bitter sweet Treatment for gestational diabetes can reduce risks to mother and child estational diabetes affects a small percentage of pregnant women. Diabetes in pregnancy is diagnosed as gestational when the mother does not ordinarily suffer from diabetes but develops high glucose (blood sugar) levels during pregnancy. The condition occurs because the mother’s body does not produce or use insulin properly. This may be due to insulin resistance caused by placental hormones. A low level of insulin means that glucose cannot be converted into energy. This means that glucose levels build up, causing hyperglycaemia. Gestational diabetes is more likely to occur if the mother is obese, has high blood pressure, or another related medical condition. The risk is higher for moth-
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ers who have already had a stillborn child or who have had a baby whose birth weight is higher than normal. If you have a family history of diabetes and you have had gestational diabetes in earlier pregnancies, the probability is that you will develop gestational diabetes when pregnant again. In other words, if it’s happened before, it is more likely to happen again. Age is another aggravating factor – if you are over thirty and pregnant, you have a greater possibility of developing the condition than you did when you were younger. Around half of the women who develop the condition will not suffer adverse consequences themselves. However, if it is not treated, gestational diabetes can cause serious complications for the baby. One such risk is the baby growing too large, possibly causing birth complications including injury to the baby during childbirth, or increasing the need for delivery by caesarean section. Babies of mothers with gestational diabetes could also be at
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Gestational diabetes is more likely to occur if the mother is obese, has high blood pressure, or another related medical condition
risk of developing jaundice or breathing problems. However, as the condition usually develops in the late stages of pregnancy when the baby is more or less fully formed, at that stage the risk of physical birth defects is relatively low. Babies born to mothers who had gestational diabetes do not run a higher risk of developing type 1 diabetes during childhood but they do have a higher risk of being overweight and of developing type 2 diabetes later on in life. As for the mother herself, she can expect her blood sugar levels
to return to normal following delivery, yet she still has a high risk of developing diabetes within 10 to 20 years. Detecting and treating gestational diabetes is essential for the health of both mother and child. That’s just one more reason to stick to regular appointments with your doctor throughout your pregnancy, and to follow professional advice. In suspected cases, your doctor may recommend an oral glucose tolerance test. This usually involves drinking a glucose solution and having your blood or urine tested for glucose over the course of a few
hours. To help keep gestational diabetes under control, ensure you have a healthy diet and keep physically active regularly. In some cases, treatment may include daily blood glucose testing, together with insulin injections where necessary. If in doubt, always seek your doctor’s advice even if you think your concerns are trivial. Keeping your gestational diabetes in check will keep you healthier, and will help avoid future health problems for your unborn child. What greater incentive can there be than that?
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Losing weight is hard, but it’s not any harder if you have type 2 diabetes cerns about potential confounding by insulin resistance or medications may be unfounded. As for the spouse study, it turns out they ate less than their diabetic partners. This is of course key to any successful diet, along with moving more. In fact, reducing body weight by 7% through eating less and moving more (at least 2.5 hours of physical activity per week) helps prevent diabetes.
ANDREW BROWN, MIKE LEAN & WILMA LESLIE study has found weight loss could reverse type 2 diabetes. The UK clinical trial showed that 46% of people who followed a low-calorie diet, among other measures, for 12 months were able to stop their type 2 diabetes medications. This confirms a position outlined in a previous paper that people can beat diabetes into remission if they lost about 15 kilograms. Another study showed that prediabetes (a blood sugar level that is high, but lower than necessary for diabetes diagnosis) can be prevented by losing as little as 2kg. If weight loss isn’t already hard enough, many people think it’s more difficult if you have diabetes. One small study perhaps sowed the seed for this defeatist idea. A dozen overweight diabetic subjects and their overweight nondiabetic spouses were treated together in a behavioural weightcontrol program. After 20 weeks, the diabetic group lost 7.4kg on average while their non-diabetic spouses lost 13.4kg. But there’s more to this story than meets the eye. In fact, losing weight with type 2 diabetes is no harder than it is without it.
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Where does this idea comes from? Type 2 diabetes triples the risk of heart attack and stroke, and is the leading cause of blindness, amputations and kidney failure. Treatment with modern drugs improves the outlook, but complications still develop and life expectancy is substantially reduced, especially for younger people. So beating it into remission is the ultimate goal of management.
If weight loss helps reach that goal, people need to know if it’s harder to achieve than without diabetes. From all the information out there you might think it is. In diabetes, the fat-burning mitochondria (the powerhouse of our cells) may be more sluggish and hunger hormones may be out of whack. Then there’s the insulin angle. In response to high levels of blood sugar (glucose), the pancreas pumps out insulin and packs glucose away into tissues like muscle to store or use for energy. Type 2 diabetes is characterised by insulin resistance, because the muscle cells are not sensitive to insulin. So glucose accumulates in the blood or is taken up into fat cells where it can be made into more fat. Most people with type 2 diabetes are eventually given insulin to help control the disease, but
GSD Marketing Ltd to reduce added sugars by 10% In 2017 Malta’s soft drink producers have announced that they will reduce added sugars in their products by 10% by 2020. GSD Marketing Ltd played an important role to get the industry aligned so as to achieve this important goal. This decision will contribute to the delivery of the recent European soft drink industry (UNESDA) 10% sugar reduction commitment. The initiative responds to changing consumer preferences regarding sugar intake and the calls from Member States and the European Commission for a coordinated approach to reformulation and sugar reduction. To reach its ambitious target, the soft drinks sector in Malta will reformulate existing products including the use of low calorie sweeteners; introduce new products with no or reduced sugar and low-calorie sweeteners; increase the availability of smaller pack sizes to allow portion control and moderation; invest in the promotion of drinks with reduced or no sugar to educate and actively encourage consumer choice towards low and no calorie products and commit to monitor the progress of added sugar reduction achieved using independent external research and to share this with stakeholders.
this has been associated with weight gain. Other drugs that stimulate insulin production, such as sulfonylureas and thiazolidendiones, can both increase weight. And medications such as metformin (the mostly widely used drug to treat type 2 diabetes) can contribute to weight loss. So it seems both physiology and anti-diabetic drugs may be conspiring against people with diabetes trying to lose weight. But it’s not true Earlier this year, a systematic review explored whether it is harder to lose weight if you have type 2 diabetes. Researchers combined data from five studies, totalling 150 people with diabetes and 387 non-diabetic subjects, who all used a low-energy liquid formula diet. They concluded that weight loss was the same – around 0.5kg per week – for both groups. A recent large study, also using
a liquid formula diet for weight management, had similar findings. There were 339 patients with diabetes, 1,669 nondiabetics and a third group of 225 patients with impaired fasting glucose (indicative of insulin-resistant prediabetes). Weight loss over six months was comparable between the three groups (around 0.9kg per week), with most of the weight lost in the first six weeks. The substantial weight loss achieved by the prediabetic group is notable, given insulin resistance is often blamed for weight gain. This study also found no discernible differences in the rates or overall weight loss with medications associated with weight gain relative to those that aren’t. So the good news is that by using intensive modern formula diets, people with diabetes can lose weight as readily as those without this disease. And con-
Tips to lose weight Although liquid formula diets are increasingly recommended for remission of diabetes, real food diets can be enough for less extreme weight loss. Also it’s necessary to resume a foodbased diet after a period on formula diets. Most guidelines for managing type 2 diabetes with lifestyle measures agree on the following recommendations: • eat fewer calories than previously, but more vegetables and dietary fibre • replace saturated with unsaturated fats • avoid added sugars and excess alcohol • combine aerobic exercise with resistance training for regular physical activity • avoid tobacco smoke • develop a plan with a qualified health professional and a support network to stay motivated. What should help is knowing that although losing weight might be hard, it really is no harder with diabetes. Andrew Brown is Professor and Head, School of Biotechnology and Biomolecular Sciences, UNSW Mike Lean is Chair of Human Nutrition, University of Glasgow Wilma Leslie is Research Associate, Nutrition, University of Glasgow