Breaking your routine

Exercise

When a person who doesn’t have diabetes takes exercise, the release of insulin from the pancreas is shut down, whereas other hormones are produced that cause the blood glucose level to rise.
When you’re taking insulin or sulphonylurea (SU) tablets, however, your insulin level goes on rising and, if you’ve had an injection into one of the limbs that you’re exercising, the insulin may be absorbed faster than usual.
It’s important to let the people you’re with – say, your tennis partner or the other members of a football team – know when you’re taking insulin and explain to them what to do if you have a hypoglycaemic reaction.
When you know you’re going to exercise, you can adjust your medication and/or diet to make allowances. Your dose of insulin may have to be cut by as much as half, depending on how vigorous an exercise session you’re planning.
It’s more difficult when you take exercise unexpectedly, and this can be a particular problem with children. Once again, the solution is to have your quick-acting carbohydrate snack handy – a sugary drink, a biscuit or glucose tablets.

Watch out for delayed hypos

Vigorous exercise can also lead to a delayed hypoglycaemic reaction. For example, a strenuous workout in the evening may cause night-time blood glucose levels to fall as your muscles replenish glycogen stores. A reduction in the bedtime insulin dose may be necessary in these circumstances.

Don’t stop exercising

As long as you take sensible precautions, there’s no reason at all why you shouldn’t take part in any kind of sport that you want to and at any level. Both Gary Mabbutt and Alan Kernaghan had type 1 diabetes and played Premier League football, and Sir Steven Redgrave – five times Olympic rowing champion – developed type 1 diabetes before his last gold medal.
Many people with diabetes take part in just about every known sport – although there are some that require special considerations, such as scuba diving or hang gliding, and they might be better avoided! In any case, the high-risk sports often have special rules and regulations relating to people with diabetes, and it is important for your own safety that you abide by them.

Partying

With a little thought and pre-planning, you can feel free to go to any party and enjoy yourself as much as ever. The main considerations are that you will probably be eating later than usual, having different kinds of food and possibly dancing late into the night. When you’re on insulin, you will need to make certain adjustments to take account of these factors. When you know you’re going to be having a meal several hours later than normal, have a light snack before you go, then delay your injection until the food is ready.
If the party starts really late, you’ll probably need extra carbohydrate with your meal along with your normal insulin dose. Take some extra food with you – and perhaps some Lucozade too – if you plan to keep going into the small hours.
The best plan for those on a basal-bolus regime is to substitute the overnight medium-acting insulin with a smaller dose of quick-acting insulin plus a snack at around midnight.
A blood test around three or four hours later is a good idea if you can manage it. Dancing will mean that you have to have extra carbohydrate – how much depends on how much energy you put into your performance!

Some simple tips for enjoying a night out

There is no need for patients with diabetes to avoid social occasions and parties. Simply follow the commonsense rules below:

• When you’re treated with insulin or sulphonylureas, you’ll need to eat more to allow for extra activities such as dancing
• Never drink alcohol on an empty stomach; always have some carbohydrate first
• Keep some quick-acting carbohydrate with you on a crowded dance floor in case of hypoglycaemia – it may not be possible to get to a bar or eating area quickly enough

Travelling

There’s no reason why your diabetes should interfere with or restrict your travel plans in any way, although, if you’re going abroad, you’d be wise to take out comprehensive travel insurance. Medical care and treatment abroad are rarely free, although the UK does have reciprocal arrangements with some other countries.
If you’re going to one of the countries of the European Union, before you go you should obtain a European Heath Insurance Card (EHIC) either by filling in an EHIC form from your post office or by applying online on the Department of Health website (see page 146). Even when a country does offer a reciprocal
scheme, it’s still worth having your own insurance on top, and essential in those countries where the health care is not equivalent to that provided by the NHS or is very expensive (the USA, for instance).
There may be special considerations when you’re heading somewhere extremely remote or inaccessible, so discuss your plans with your diabetes care team.
Wherever you’re going, and especially if it’s off the beaten track, make sure that you will be able to obtain insulin or tablets there if necessary, just in case you somehow get parted from your own supplies. Never pack your insulin in your suitcase! It is a good idea to tell your travel agent or airline that you have diabetes.
You’ll need to check out the immunisation requirements for your destination well in advance – sometimes it takes several weeks to complete the course. Preventive measures of this kind may be particularly important for travellers with diabetes, and it is reassuring to know that taking antimalarial tablets will not interfere with treatment for diabetes.

Crossing time zones

You need to plan carefully if you’re going on a long flight, and it’s a good idea to do this with the help of your doctor or diabetes care team. Remember that travelling west extends your day, whereas travelling east shortens it.

When you’re on insulin

You will have fewer problems if you’re on a multiple basal-bolus regime using an injection pen than if you normally inject just twice a day. For an extended day, the simplest solution is to have an extra injection of quick-acting insulin before the extra meal that’s almost bound to be given during your flight.
When you reach your destination, have your normal evening dose of insulin followed by your evening meal. Next morning, have your insulin before breakfast as usual, then try to match your eating pattern to that of the locals, although this isn’t always easy if you have jet lag!
The night will probably be shorter when you’re travelling east, so you should have a smaller dose of medium-acting insulin (perhaps 10 to 20 per cent less than usual), either before your evening meal if you’re on twice-daily injections or before bed if you’re on multiple injections, followed by your usual pre­breakfast dose next day.
Don’t forget that you’re not obliged to eat all the meals offered on the flight if you feel that you don’t want or need them. It is important to let the airline staff know that you have diabetes, and make sure that they or your travelling companions know what to do if you have a hypoglycaemic reaction and how to give insulin if you need it. The same applies if you’re travelling by sea.
You don’t have to have a fridge to store your insulin as long as you can keep it somewhere relatively cool, but, if temperature is likely to be a problem, use
a wide-necked vacuum flask. Do not store insulin in a freezer compartment.

When you’re on tablets

You shouldn’t need to make any particular changes to your treatment schedule. It would be worth getting the advice of your diabetes care team before taking a very long flight, however, because if you are taking short-acting tablets before meals you may need either an extra one or perhaps one less depending on whether you are flying east or west. The principles are the same for those who are on insulin injections.

Prepare for your journey

You will have to find room in your hand luggage for your medication, blood glucose testing equipment and any other medical kit; luggage does sometimes go missing! When you’re carrying syringes and needles, it’s sometimes useful to have a letter from your doctor on headed paper explaining that you have diabetes and how it is treated. This is important if you’re going to some Middle and Far Eastern countries.
It’s also advisable for anyone with diabetes to carry some form of ID card or bracelet indicating that you have the condition and what medication you take.
Diabetes UK (see page 147) can supply ID cards giving details of your treatment in the local language of the country that you’re going to, and it’s worth getting one of these. You may never need to show them, but it won’t hurt to have them, just in case.
It’s quite safe to take travel sickness remedies along with your diabetes treatment if you need to, but, if you know you’re prone to suffer in this way, take a supply of fruit juice or other sweet drink in case you can’t eat much.
In other respects, you need only to follow the same commonsense rules as any other traveller – make sure that you don’t have too much sun, check out the alcohol content of unfamiliar local drinks and try to steer clear of unhygienic cafés or foodstalls!
Take particular care in countries known to have a high risk of water-borne stomach infections. Avoid iced drinks and any fruit or vegetables that you cannot peel, and salads. Use bottled water or drinks wherever possible.

When you are ill

Everyone gets colds and flu from time to time, and these, like other illnesses, can affect the control of your diabetes. The most likely result is that your blood glucose level will rise, so you need to make frequent checks to test whether this is happening, especially if you are on insulin.

Type 1

Many people think that if they’re ill and not eating they shouldn’t take their insulin, because they will have a hypo. In fact, the opposite is the case. Your blood glucose level is much more likely to be too high than too low in these circumstances. Even if you have a stomach bug such as gastroenteritis and are being sick all the time, you will still need some insulin to keep your glucose under control. If you can’t keep any fluids down, you must call your doctor straightaway. You may have to go into hospital for a while until you are able to eat and drink again.

Type 2

Continuing to take your tablets when you’re not able to eat or drink may cause a hypoglycaemic reaction. You may need a lower dose while you’re ill but, unless you’re monitoring your blood glucose regularly, you may need your doctor’s advice on how to make the adjustment. If your illness doesn’t settle down quickly, you may be admitted to hospital for a few days.

Having a baby

The fact that you have diabetes is no reason to put off having a baby. The condition does not affect your fertility, and you should have no problems conceiving unless you are one of the minority of women who have severe complications or whose diabetes is poorly controlled.
If you are planning to conceive in the near future, it’s a good idea to make sure that your blood glucose levels are as well controlled as possible. In addition, folic acid supplements should be taken.
Babies born to mothers with diabetes are more prone to medical problems with their heart or skeleton, but this risk can be reduced by very careful control of blood glucose levels before pregnancy. Ideally you should talk this over with your diabetes care team – you may find that your hospital offers a special preconceptual counselling service.
You need to watch your blood glucose levels particularly carefully when you’re pregnant because, if they get too high, they can affect the baby. This can mean that the baby grows too quickly or too much fluid accumulates in the surrounding membranes.
Your doctor will probably want to see you every few weeks, and you’ll also be asked to do your own blood glucose checks more often than usual. It’s likely that your insulin dose will double or even treble during this time, but it will go back to normal after the birth. The insulin can’t do your baby any harm, because it does not seem to lower the baby’s blood glucose, and there’s no need to worry that you could injure him or her by injecting into your abdomen. Hypoglycaemia is not known to harm the baby in any way.
There’s a good chance that you will be able to have a normal delivery, although some women do have to have a caesarean section. This is because some babies from mothers with diabetes whose glucose levels were higher than ideal may have grown too large for normal vaginal delivery. Your obstetric and diabetes care teams will discuss the options with you beforehand and, if a normal delivery is decided on, you may well have a drip containing insulin and a sugar solution to control your diabetes during labour.
Huge advances in the antenatal care of women with diabetes in recent years mean that, with careful preconceptual preparation and good blood glucose control, you can look forward to a healthy pregnancy and a normal, healthy baby at the end of it.

Pregnancy and type 2 diabetes

Type 2 diabetes is becoming more common in younger women who wish to become pregnant. Some tablet treatment is not recommended in pregnancy, so most women need to be switched to insulin, preferably before conception and certainly as soon as possible after pregnancy has been confirmed.

Gestational diabetes

Some women develop diabetes for the first time when they’re pregnant, after which their blood glucose levels return to normal. Usually, gestational diabetes, as it’s known, can be kept under control by eating the right kinds of foods, although some women do have to have metformin and/or insulin injections.
After the birth, you’ll be advised to keep an eye on your weight and stick to a healthy diet because you are at a greater than normal risk of developing type 2 diabetes later in life.

KEY POINTS

• If planning vigorous exercise, remember to take extra carbohydrate or reduce your insulin or sulphonylurea medication beforehand

• Remember that vigorous exercise can lead to delayed hypoglycaemia some hours later

• If exercising with others, always tell them that you have diabetes and explain what to do in the event of a hypoglycaemic attack

• For parties, remember never to drink alcohol on an empty stomach and have some quick-acting carbohydrate always available

• If eating later than usual or having extra food, you may need more insulin

• Remember to take out health insurance before any foreign travel

• If travelling between continents, when heading west have an extra dose of insulin with your extra meal and when heading east you may omit a scheduled meal and insulin dose

• Never pack your insulin in your suitcase – keep it in your hand luggage

• Always carry identification stating your diagnosis and medication

• Even if you are ill and not eating, you still need your insulin

• If you cannot take your medication or insulin because of vomiting, seek medical help

• Diabetic women should try, wherever possible, to plan their pregnancy and seek urgent obstetric and medical advice once they realise that they are pregnant