Understanding
Diabetes

Professor Rudy Bilous

Published by Family Doctor Publications Limited in association with the British Medical Association

IMPORTANT

This book is intended not as a substitute for personal medical advice but as a supplement to that advice for the patient who wishes to understand more about his or her condition.

Before taking any form of treatment YOU SHOULD ALWAYS CONSULT YOUR MEDICAL PRACTITIONER. In particular (without limit) you should note that advances in medical science occur rapidly and some information about drugs and treatment contained in this booklet may very soon be out of date. All rights reserved. No part of this publication may be reproduced, or stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. The right of Professor Rudy Bilous to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988, Sections 77 and 78. With contributions from Andrea Miller, BSc, SRD, Lorna Hall, BSc and Debbie Black, BSc, Senior Specialist Dietitians, South Tees Acute Hospitals Trust, and Sharon Martin, Chief IV Chiropodist, Tees and North Yorkshire Community and Mental Health Trust

© Family Doctor Publications 1995–2006

Updated 1996, 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006

Family Doctor Publications, PO Box 4664, Poole, Dorset BH15 1NN

ISBN: 1 903474 36 1

Contents

Introduction ............................................................................................................ 1

Making a diagnosis ............................................................................................ 13

Treatment: diet .................................................................................................... 18

Treatment: medication ....................................................................................... 44

Checking your glucose levels ........................................................................... 64

All about hypoglycaemia ................................................................................... 78

Breaking your routine ........................................................................................ 88

Children with diabetes .................................................................................... 102

If it gets complicated ....................................................................................... 109

Diabetes care ................................................................................................. 128

Future prospects for people with diabetes ...................................................135

Questions and answers ................................................................................. 141

Useful addresses ........................................................................................... 146

About the author

Professor Rudy W. Bilous is Professor of Clinical Medicine at the South Tees Hospitals NHS Trust, researching into diabetic kidney disease and methods of achieving optimum blood glucose control. Professor Bilous was Chairman of the Professional Advisory Council Executive of Diabetes UK until September 2005.

Introduction

How widespread is diabetes?

If you have just found out that you have diabetes, this doesn’t mean that you have become sick or turned into an invalid. Millions of people in this country have diabetes and most lead normal, active lives. Some of them have had the condition for over 50 years.

With advances in our understanding of the disease and improvements in treatment, the prospects for someone with diabetes are better than ever before. This book is meant to help you understand what diabetes is and how to control it.

Personal responsibility

Doctors nowadays encourage people with diabetes to take a lot of responsibility for their own health, paying careful attention to their diet and carrying out regular tests on their blood and urine to monitor their progress. We explain, step by step, how you can do this and how you can develop confidence that you really are in control of your diabetes.

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The history of diabetes

Diabetes is one of the oldest known human diseases. Its full name – diabetes mellitus – comes from the Greek words for syphon and sugar, and describes the most obvious symptom of uncontrolled diabetes: the passing of large amounts of urine that is sweet because it contains sugar (glucose). There are descriptions of the symptoms by the ancient Persians, Indians and Egyptians, but a proper understanding of the condition has developed only over the last hundred years or so.

The discovery of insulin

In the later part of the nineteenth century, two German doctors worked out that the pancreas – a large gland behind the stomach – must be producing some substance that stopped the level of blood glucose rising.

In 1921 three Canadian scientists discovered that the mystery substance, which they named insulin, was produced in small groups of cells within the pancreas called the islets of Langerhans.

When insulin became available as a treatment for diabetes after 1922, it was seen as a medical miracle, transforming the future prospects of those with the condition, and saving the lives of many young people who would otherwise have died after a painful wasting illness.

Some 30 years later, it was found that one form of diabetes could be treated with tablets to lower levels of blood glucose. This new development led doctors to distinguish two forms of the condition.

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The location of the pancreas

Insulin and glucagon are produced by specialised cells in the pancreas. This organ also secretes digestive enzymes into the gut; it is situated behind the stomach.

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Type 1 (insulin-dependent diabetes mellitus or IDDM)

This starts most commonly in younger patients who have to have regular injections of insulin to remain well.

Type 2 (non-insulin-dependent diabetes mellitus or NIDDM)

Also called age-related or maturity-onset diabetes, this is more common in middle or later life and can be controlled by tablets or just diet.

What is diabetes?

Diabetes is a permanent change in your internal chemistry that results in you having too much glucose in your blood. The cause is a deficiency of the hormone insulin.

A hormone is a chemical messenger that is made in one part of the body (in this case the pancreas) and released into the bloodstream to have an effect on more distant parts.

There may be complete failure of insulin production as in type 1. In type 2, however, there is usually a combination of a partial failure of insulin production and a reduced body response to the hormone. This is called insulin resistance.

What goes wrong?

The glucose in your blood comes from the digestion of food and the chemical changes made to it by the liver. Some glucose is stored and some is used for energy. Insulin has a unique shape that plugs into special sockets or receptors on the surface of cells throughout the body. By plugging into these receptors, insulin makes cells extract glucose from the blood and also prevents them from breaking down proteins and fat.

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It is the only hormone that can reduce blood glucose, and does this in several ways:

•  By increasing the amount of glucose stored in the liver in the form of glycogen

•  By preventing the liver from releasing too much glucose

•  By encouraging cells elsewhere in the body to take up glucose

•  By preventing cells elsewhere in the body from breaking down protein and fat.

Other mechanisms in the body work together with insulin to help maintain the correct level of blood glucose. Insulin is the only means that the body has of actually lowering blood glucose levels, however, so, when the insulin supply fails, the whole system goes out of balance. After a meal, there is no brake on the glucose absorbed from what you’ve eaten, and the level in your blood goes on rising. When the concentration rises above a certain level, the glucose starts to spill out of the bloodstream into the urine. Infections such as cystitis and thrush can develop more easily when the urine is sweet because the germs responsible can grow more rapidly.

Passing more urine

Another consequence of rising blood glucose is a tendency to pass more urine. This is because the extra glucose in the blood is filtered out by the kidneys, which try to dispose of it by excreting more salt and water. This excess urine production is called polyuria and is often the earliest sign of diabetes.

If nothing is done to halt this process, the person will quickly become dehydrated and thirsty. As previously

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The effect of insulin in a healthy person

After a meal blood sugar levels rise. In a healthy person, the pancreas responds to this by producing more insulin, which has the following effects in the body.

mentioned, as well as regulating blood glucose, insulin acts to prevent weight loss and help build up body tissue – so a person whose supply has failed or isn’t working properly will inevitably lose some weight.

Symptoms of diabetes

The severity of the symptoms and the rate at which

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they develop may differ depending on which type of diabetes you have. Symptoms caused by type 1 and type 2 diabetes:

•  Thirst

•  Dehydration

•  Passing large quantities of urine

•  Urinary tract infection (such as cystitis) or thrush

•  Weight loss

•  Tiredness and lethargy

•  Blurred vision resulting from dehydration of the lens in the eye.

Ketoacidotic coma

Type 1 (IDDM)

As the person isn’t producing any insulin at all, the symptoms can come on very rapidly because internal blood glucose control is lost.

Insulin has a very important role in maintaining stability in the body by preventing breakdown of proteins (found in muscle) and fats. When insulin fails, the byproducts of the breakdown of fat and muscle build up in the blood and lead to the production of substances called ketones. If nothing is done to stop this, the level will rise, until eventually it causes the person to go into what’s called a ketoacidotic coma.

This is much less common these days because diabetes is usually diagnosed long before coma develops. However, when it occurs patients need urgent hospital treatment with insulin and fluids into a vein. This is not the same thing as a coma induced by low blood sugar (or hypoglycaemia) – see page 78.

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Type 2 (NIDDM)

As the supply of insulin is reduced or is not quite as effective as normal, the blood glucose level rises more slowly. There is less protein and fat breakdown so ketones are produced in much smaller quantities, and the risk of a ketoacidotic coma is lower.

Who gets diabetes?

Almost three per cent of people in this country have diabetes, although as many as half of them may not realise it. This number is steadily increasing. The vast majority have type 2, and more women than men are affected, probably because diabetes is more common later in life and women tend to live longer. As the age of the population as a whole is rising, type 2 diabetes is likely to become even more common over the coming years.

In addition, the incidence of diabetes is increasing worldwide and is estimated to result in a near doubling of the population with type 2 diabetes by 2025. Moreover, children in the UK seem to be developing type 1 diabetes at an earlier age, and there are increasing numbers of patients developing type 2 diabetes in early adulthood.

What causes diabetes?

There are many reasons why insulin secretions may be reduced and an individual could be affected by more than one cause.

Genetic

Researchers studying identical twins and the family trees of patients with diabetes have found that heredity is an important factor in both kinds of

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diabetes. With type 1 diabetes, there is about a 50 per cent chance of the second twin developing the condition if the first one has it, and a five per cent chance of the child of an affected parent developing it.

With type 2 diabetes, it is virtually certain that, if one of a pair of identical twins develops it, the other will do so as well.

It is difficult to predict precisely who will inherit the condition. A small number of families have a much stronger tendency to develop diabetes and scientists have identified several genes that seem to be involved. In these circumstances, it may be possible to test family members and determine their risk of developing the condition. For the most part, however, it is difficult to identify the genes involved and this makes it different from some other conditions such as cystic fibrosis, where a single gene is operating.

So even if a close member of your family has diabetes, there is no certainty that you will develop it

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yourself. Some people who inherit a tendency to diabetes never actually get it, so there are obviously other factors at work here.

Infection

It has been known for some time that type 1 diabetes in children and young people is more likely to come on at certain times of the year when there are a lot of coughs and colds about.

Some viruses, such as the mumps virus and Coxsackie virus, are known to have the potential to damage the pancreas, bringing on diabetes. As far as individual patients are concerned, however, it is very rare that doctors can link the onset of their diabetes with a specific bout of infection. A possible explanation for this is that the infection may have begun a process that comes to light only many years later.

Environment

People who develop type 2 diabetes are often overweight and eat an unbalanced diet. It’s interesting to note that people who move from a country with a low risk of diabetes to one where there’s a higher risk have the same chance of developing diabetes as the locals in their new country.

There is a close link between body weight and the development of type 2 diabetes. Recent surveys have shown a dramatic increase in obesity in the UK, especially in young people, and this is partly responsible for the increasing incidence of diabetes.

A good example of this is shown by the Pacific islanders of Nauru who became very wealthy when phosphates were discovered on their island. As a consequence, their diets changed dramatically; they

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put on a lot of weight and they became much more prone to developing diabetes.

All this points to important connections of diet, environment and diabetes. However, there is no precise link between developing diabetes and the individual consumption of sugar and sweets.

Secondary diabetes

There are a small number of people who develop diabetes as a result of other disease of the pancreas. For example, pancreatitis (or inflammation of the pancreas) can bring on the condition by destroying large parts of the gland. Some people with hormonal diseases, such as Cushing’s syndrome (the body makes too much steroid hormone) or acromegaly (the body makes too much growth hormone), may also have diabetes as a side effect of their main illness.

It can also be a result of damage to the pancreas caused by chronic over-indulgence in alcohol. Some long-term treatments such as steroids and beta-blocker tablets are also associated with an increased rate of development of diabetes.

Stress

Although many people relate the onset of their diabetes to a stressful event such as an accident or other illness, it is difficult to prove a direct link between stress and diabetes. The explanation may lie in the fact that people see their doctors because of some stressful event, and their diabetes is diagnosed opportunistically at the same time.

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KEY POINTS

■ Diabetes arises when either an individual cannot make enough insulin or the insulin that an individual does make is ineffective at controlling blood glucose levels

■ Insulin is a hormone (chemical messenger) that is critical for maintaining healthy life

■ Symptoms of diabetes are weight loss, passing more urine, thirst and feeling run down

■ There are several causes including genetic (inherited) predisposition, infections, environmental factors and stress, and any or all of these may be important in each individual case

■ Being overweight greatly increases your chances of developing type 2 diabetes

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Making a diagnosis

Discovering that you have diabetes

People find out they have the condition in different ways. With type 2, the first port of call is usually your G P, either because you have some or all of the symptoms listed on page 7, or because you are having a general check-up.

Some people are advised to see their doctor by their optician (or optometrist). This is because an eye examination will pick up the early signs of a condition called diabetic retinopathy – changes in the blood vessels of the eye that can develop as a complication of diabetes (see page 112).

Tests for diabetes

If your symptoms suggest to your doctor that you may have diabetes, he or she will want to do a blood test to measure your glucose level, and will also ask for a urine sample to be tested. The samples may have to be sent off to the lab for analysis, although many GPs today have blood glucose meters in the surgery, and can give you the result on the spot. Some pharmacies

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Diabetes is often diagnosed by chance as the result of a visit to
the optician (or optometrist), because an eye examination will
detect diabetic retinopathy.

are also offering blood tests for people who are worried that they may have diabetes.

The structure of diabetes care

Above-average readings from either or both of these tests will probably be sufficient for your doctor to confirm that you have diabetes and, if it’s type 2, it’s likely that you will be cared for by your GP rather than having to see a hospital doctor.

Many GP practices run regular diabetes clinics but, if yours doesn’t or you feel that you need more support, you can ask to be referred to a hospital diabetes clinic.

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A simple fingerprick blood test will determine your blood glucose level.

As mentioned above, type 1 diabetes can often come on quite suddenly, and this may mean the person being admitted to hospital while the diagnosis is made and the condition stabilised.

People with this form of diabetes will often continue to be under the care of the specialist team at a hospital. Nowadays, many patients with type 1 and type 2 diabetes have shared care between the hospital and the GP.

Although, for most people, the diagnosis is straightforward and quite clear cut, a few may need an extra test because their blood glucose level is borderline. In this case, you may be asked to have an oral glucose tolerance test. After an overnight fast, your blood glucose level will be measured on arrival at the clinic; then you’ll be given a drink containing a measured amount of glucose. Your blood will be

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Oral glucose tolerance test

If your blood tests show that your blood glucose level is borderline you may need an oral glucose tolerance test. There are three possible outcomes, depending on the results of your test:

1.  Your blood glucose may be within the normal range, so you don’t have diabetes

2.  Your level may be higher than average, although not high enough to mean that you have diabetes. This condition is called impaired glucose tolerance (IGT) and your medical advisers will want to keep an eye on you because there is a possibility of developing diabetes in the future. In the meantime you will be given advice on diet, although you don’t have diabetes and don’t need any other specific treatment

3.  Your blood glucose level may be sufficiently raised to indicate that you do have diabetes.

If so, you will need to see your doctor to discuss what treatment you need

re-tested at half-hourly intervals for two hours to see how your body is dealing with the glucose that you’ve absorbed. You may also be asked to pass a urine sample at the start and at hourly intervals.

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You may be asked by your doctor to provide a urine sample. This will be tested for glucose levels.

KEY POINTS

■ Diabetes is usually diagnosed from a simple urine or blood test in patients who have symptoms (see page 7)

■ A small number of patients need to have a more formal test called an oral glucose tolerance test

■ Early diagnosis is very important and patients with symptoms are recommended to attend their GP’s surgery or local pharmacy for a test

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Treatment: diet

Coping with diabetes

Diabetes can be tackled in three main ways.

Diet

A diabetic diet actually means following a healthy eating plan rather than a difficult or restrictive programme. This applies to everyone with diabetes, regardless of which type they have, and may be enough by itself to control type 2 in some people.

However, if you have type 1 diabetes, you will need to learn about balancing your intake of food with your insulin injections in order to achieve the best possible control of your blood glucose levels.

Tablets

These are used to control type 2 and there are different types. For more about this kind of treatment, see page 44.

Insulin

Everyone with type 1 diabetes will have to take insulin by injection, but only a minority of those with type 2

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diabetes will be treated this way. More about insulin on page 49.

Your healthy eating plan

The sort of diet that you should follow when you have diabetes definitely does not mean a future of self-denial on the food front. What it does mean is eating more of the foods that are good for you, and cutting right down on those that are not so good. Actually it’s the kind of eating that experts recommend for everyone, whether or not they have diabetes.

The difference that it can make to your overall health and well-being is even more worthwhile when you do have diabetes, however, because without it your medication will not be nearly as effective.

A balanced diet

It is important to have a good mix of foods so eat a wide range of different nutrients; also try to cut back on those that are high in fat and sugar. Once you get used to the basics, however, it’s mostly quite simple, as you will see from our guidelines on the next few pages.

Eat regular meals

You should find it easier to keep your blood glucose levels under control if you eat at regular mealtimes. This may also be beneficial to aid weight loss. Aim to have three meals per day or eat approximately every four hours, that is breakfast, lunch and evening meal (see ‘Healthy eating menu’, page 20).

Some people may need to have a small snack, for example cereal or toast or snacks between meals, but this should be discussed with your diabetes team.

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The different food types

Carbohydrates

There are different types of carbohydrate, which are broken down by the body at different rates to produce glucose (sugar). In simple terms a carbohydrate can raise blood sugar levels dramatically (quick release), moderately or a little bit (slow release). Foods that have only a slow release have a small effect on blood sugar, whereas those with a quick release cause a rapid and massive rise in blood sugar level.

Try to have some slower-release carbohydrates at each meal, because they are a good source of energy and help to fill you up. They can also keep your blood glucose levels stable. Slow-release carbohydrates can be found in bread, pasta, rice, chapattis, breakfast cereals, potatoes, and so on.

Sugary foods are digested quickly and are rapidly absorbed into your bloodstream and increase your blood glucose levels, for example sugar, sweet fizzy drinks, sweets and chocolate, cakes and biscuits. There is no harm in having these foods occasionally but try to

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How much to eat of each food type

At each meal your food contribution needs to be in the above illustrated proportions.

Two-fifths of your plate should be covered with starchy food preferably of high-fibre variety (e.g. wholemeal bread, potatoes, pasta and rice).

Two-fifths of your plate should be covered with vegetables/salad or fruit.

The remaining one-fifth of your plate should be a protein source, e.g. meat, fish, eggs, pulses or cheese.

By ensuring that these proportions of nutrient sources are achieved and maintained, your blood glucose should stay within desirable ranges.

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Slow-release carbohydrates: bread, pasta, rice, chapattis, breakfast cereals, potatoes and fruit.

take sugar-free or low-sugar alternatives. Use diet or no-added-sugar drinks, have plain biscuits and cakes occasionally, and limit portion size.

The best time to have something sweet is with or after a main meal because the sugar is more slowly absorbed with other food types.

Modify your favourite recipes to use less sugar, for example cakes. Sugary foods are high in calories so it is best to limit these foods if you are concerned about your weight.

Carbohydrate counting

As carbohydrate is the main immediate source of glucose from the diet, there is a school of thought that suggests that people with diabetes should try to calculate how much there is in each meal and adjust the insulin

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Avoid or limit sugary carbohydrates as they will cause a sudden rise in blood glucose level.

dose accordingly. Thus, a meal with more carbohydrate would need a larger dose of insulin and vice versa.

This system is called carbohydrate counting and is particularly useful for patients using multiple insulin injections (see page 52) or an infusion pump (page 60). The convention is to have 1 unit of insulin for every 7 to 20 grams of carbohydrate, depending on age and body size.

This method is similar to the old system of carbohydrate exchanges but does not involve a daily limit on the amount in the diet. It is simply a method of trying to match insulin dose to meal size.

The table opposite shows examples of the amounts of some common foods that are equivalent to 15 grams of carbohydrate. This system has been tested in a large research study sponsored by Diabetes UK – the Dose Adjustment For Normal Eating (DAFNE) Project.

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By teaching type 1 patients how to adjust insulin to the carbohydrate content of an unrestricted diet, blood glucose levels were much better controlled at the end of one year than in a group of patients in whom this training had been delayed. It is planned to extend this programme to other units in the UK.

For type 2 patients, a programme called DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) is under trial and is also showing promising results. More information can be obtained from Diabetes UK (see page 149).

Fat

A diet rich in fat can lead to weight gain, raise blood cholesterol and contribute to heart disease. It can also make the body less responsive to insulin. There are two main types: saturated and unsaturated fat.

Saturated (animal) fat

This is found in butter, lard, fatty meats, pastries, and so on. This type of fat can increase your cholesterol level (see ‘If it gets complicated’, page 109). It is therefore important to reduce the intake of these types of foods. Instead try to increase the amount of fruit and vegetables, pulses such as lentils and beans, oily fish and oats.

Unsaturated fats

These are slightly better for you than saturated fats and come in two forms:

1. Polyunsaturated fats are found in sunflower oil, pure vegetable oil, corn oil and sunflower margarines. They have little effect on cholesterol levels.

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2. Monounsaturated fats are found in olive oil and olive oil-based margarines, rapeseed and safflower oil, and most nuts. This type of fat is thought to be most beneficial because it may reduce blood levels of your ‘bad’ cholesterol (low-density lipoprotein or LDL for short) and increase your ‘good’ cholesterol (high-density lipoprotein or HDL for short). This type of fat should be used instead of saturated or polyunsaturated, whenever possible.

Trans-fatty acids are formed when fats undergo a chemical process to make them hard, termed ‘hydrogenation’. Trans-fat raises LDL-cholesterol and lowers HDL-cholesterol levels, and so can increase the risk of heart disease. It is therefore important to limit the amount of foods containing them.

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They are found mainly in hard margarine, crackers, biscuits, cakes, fried foods, pastries, baked goods and other processed foods made with or fried in partially hydrogenated oils. They may also be found in small amounts in various meat and dairy products.

Remember that all fats are high in calories and may lead to weight gain if taken in excess.

Oily fish

Oily fish such as mackerel, herring, kippers, salmon, trout, sardines and pilchards contain beneficial oils known as omega-3 (or ω-3) oils. Research has shown that these oils help to reduce the stickiness of the blood and lower cholesterol levels.

They may also protect against heart disease by helping the heart beat more regularly and protecting blood vessels. They are also thought to be beneficial in reducing inflammation and can help reduce arthritis symptoms.

Despite the recent research suggesting only a modest benefit, dietary experts recommend trying to have oily fish once or twice a week. Buy them fresh, tinned in brine (tinned tuna does not count because the omega-3 oil is destroyed during processing) or in tomato sauce, but avoid fish in any type of oil.

There are omega-3 supplement capsules available, which contain beneficial fish oils. However, there is not enough evidence to support their use in people with diabetes at the moment and they are expensive. It is best to obtain oils from fish themselves rather than from supplements.

If you do not like fish, then try the following instead: green leafy vegetables, nuts and seeds or omega 3-enriched foods, for example Columbus eggs.

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Fibre

Fibre (also called roughage) can be either soluble (dissolves in water and slows absorption of food) or insoluble (cannot be digested and helps to prevent constipation). Insoluble fibre is also useful when you are trying to lose weight because it makes you feel full up.

Increasing the fibre content of your diet doesn’t mean having brown rice and bran with everything, but you should aim to consume around 30 grams of fibre a day. It is essential to keep your intestine working well, and some food types such as soluble fibre can help with both good blood glucose control and keeping your blood cholesterol levels down.

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Soluble fibre foods

Foods such as baked beans, mushy peas, lentil soup and dahl, plus oat-based dishes such as porridge and other cereals and oat cakes, are high in soluble fibre.

Insoluble fibre foods

Food such as high-fibre cereals, wholemeal or granary bread, unpeeled vegetables and fruit, plus wholemeal versions of pasta, flour and rice, have mainly insoluble fibre.

The importance of water

If you increase the fibre content of your diet it is important to increase fluid. Aim to drink eight to ten glasses of fluid per day – for example, squash with no added sugar, water, tea – because this helps to soften your motions and prevents constipation.

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Fruit and vegetables

These are important, because they are low in fat and calories and provide plenty of vitamins, minerals and fibre. All fruit contains a small amount of natural sugar. It is therefore important that you spread your fruit intake over the day in order to minimise the amount of sugar that you ingest at any one time.

It is recommended that you aim for five portions per day. This may help to protect against heart disease and decrease cholesterol levels. Fresh, frozen and tinned fruit in natural juice are all suitable. Potatoes are not usually counted as a vegetable portion but they are of course an important source of carbohydrate. If you are eating a well-balanced diet, you really should not need to take any extra vitamin or mineral supplements.

Protein

Protein is an important part of your diet because it is required for repair of tissue and muscle and is needed to fuel normal growth in children. You need only a relatively small amount – look up the value in the table on page 34.

Good sources of protein include eggs, fish, meat and dairy produce. Some of these foods can be high in fat, so it is important to use low-fat or diet versions when you are able to.

Salt

Too much salt can increase your blood pressure (known as hypertension). You should not eat more than six grams (one heaped teaspoon) of salt per day. If you suffer from hypertension then you should eat less than three grams of salt per day (half a teaspoon). To calculate how much salt is in a product, multiply the sodium

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level (often found on the label of tins or packets) by 2.5.

Try to taste your food first. You may not need to add salt; instead use herbs, spices, lemon juice, pepper, garlic, and so on. Do not add salt in cooking or at the table. There is a lot of salt hidden in processed food such as tinned or ready-made meals, cured meats, pizzas, and so on, so try to eat less of these. Cut down on salty snacks such as crisps and salted/toasted nuts.

Special diets

High-protein/low-carbohydrate diets are marketed by some as being particularly good for individuals who wish to lose weight. There is some scientific basis for these claims, but, if you are on any form of tablet or insulin treatment, you should get expert advice from your diabetes team before starting such a diet. A dramatic reduction in carbohydrate intake might result in hypoglycaemia (see page 78).

High-protein diets may have a long-term damaging effect on the kidneys, particularly in patients with proteinuria and early kidney failure (see page 115). Until the long-term safety of these diets is confirmed a balanced intake of a mixture of proteins, carbohydrates and fats, as outlined above, is still the safest one of choice.

Diabetic foods

It is better to avoid those foods such as diabetic chocolate, sweets and jam because they offer no benefits to people with diabetes. They can cause diarrhoea if eaten in large quantities because they contain a sweetener called sorbitol, which is not absorbed. They can also be high in fat and are expensive.

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Controlling your weight

Type 2 diabetes is often associated with being overweight and obesity can make it more difficult to control blood glucose. If you are overweight (see chart opposite) then losing some weight will be beneficial to your health. Even losing just 10 per cent of your body weight can make huge improvements to your health by improving your diabetes control, blood pressure and cholesterol levels.

Remember that you will lose weight only if you eat less food than your body needs to fuel its daily activities. You may find it easier to introduce changes gradually rather than all at once. Your family may like to be involved and change their diet in order to eat more healthily. Our healthy eating menu (see page 20) shows how you might do this; substitute the foods listed for your usual ones.

If you would like to discuss any of these points or would like more information, ask your doctor to refer you to see a dietitian.

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What should you weigh?

• The body mass index (BMI) is a useful measure of healthy weight

• Find out your height in metres and weight in kilograms

• Calculate your BMI like this Your weight (kg)

• You are recommended to try to maintain a BMI in the range 20-25

• The chart below is an easier way of estimating your BMI. Read off your height and your weight. The point where the lines cross in the chart indicates your BMI.

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Glycaemic index (GI)

The glycaemic index (GI) can be used as a guide to measure how quickly foods that contain carbohydrate raise blood glucose levels. The index has been calculated by looking at the rise in blood glucose levels after ingesting 50 grams of carbohydrate contained in individual carbohydrate foods.

High and low GI foods

Foods are given a value of 0 to 100, with glucose being 100. Foods with a GI greater than 70 are classed as high GI foods, so they increase blood glucose quickly; those with a GI of 58 to 69 are classed as medium GI foods and have a moderate effect on blood glucose; those with a GI less than 55 are classed as low GI foods because they have a slow or only minor impact on blood glucose levels.

It seems sensible to follow a low GI diet, but you need to be aware of the following points:

•  Foods with a low GI value tend to be high in fibre. They are digested slowly and so lower the GI response; they will have less effect on blood glucose after a meal.

•  Foods with a low GI value tend to fill you up for longer, which can be beneficial for weight loss because you may be inclined to eat less.

•  There is some evidence to suggest that glycaemic control improves in people who eat foods with a low GI value.

•  Low GI foods have been found to increase HDL-cholesterol and lower the total cholesterol and triglyceride levels – a good thing!

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•  The addition of seeds or grains tends to lower the GI, for example granary bread has a lower GI than wholemeal bread.

•  The GI takes into account only single foods. If you eat more than one type of carbohydrate at a time then the GI changes. If high and low GI foods are eaten together, the GI value of the meal will be halfway between the two individual values.

•  Cooking and preparation of food can alter the GI value, for example mashed potato (high) or chips (medium). Cooking breaks down the chemical bonds in complex carbohydrates, which makes them easier to absorb and will therefore increase the GI. This does not happen with pulses, however, which have a GI that remains low after cooking. The bonds are also broken when food is chewed, which can therefore raise the GI.

•  Highly processed convenience foods tend to have a high GI, for example pastries.

•  Ripeness can affect the GI. A ripe banana will have a higher GI than an unripe one.

Some low GI foods are so slowly absorbed, for example pulses/nuts, that insulin may be absorbed more rapidly than digested food. A diet high in these types of foods may predispose to low blood glucose levels (see ‘All about hypoglycaemia’, page 78).

Fat and protein slow down the absorption of carbohydrate and therefore lower the GI value, for example chips and crisps have a lower GI than potatoes because of their fat content. However, eating low GI foods that are high in fat can lead to weight gain.

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As a result of these concerns there may be problems in following a GI diet to the letter, but it is useful to be aware of the GI of foods that you eat regularly. It is sensible to have a low GI food at each mealtime.

Overall it is important to follow a balanced diet, rich in fibre, fruit and vegetables, low in fat and salt, so use any knowledge of GI as part of an overall dietary strategy.

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Alcohol

Having diabetes doesn’t mean turning teetotal unless you prefer to, but you do have to follow a few commonsense rules, particularly if you are on tablets or insulin. Remember that alcohol can cause hypoglycaemia in certain circumstances (low blood glucose, see page 78).

•   Limit yourself to three ‘units’ or less in any one day. One unit of alcohol means a single measure of spirits, half a pint of beer or a small glass of wine.

Avoid ‘diabetic’ or Pils-type beers or lagers because, although they have less sugar, they are high in alcohol and more likely to cause a low blood glucose.

•   Drink alcohol with or just after a meal and make sure that you have some slow-release carbohydrate with it. You will need a snack before you go to bed in order to help prevent your blood glucose levels from dropping during the night.

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•  You may find that your face flushes red if you mix alcohol with some kinds of diabetes tablet treatment.

•  Remember to allow for the calorie content of alcoholic drinks and mixers, which should be diet/slimline versions.

Current government recommendations for alcohol intake are as follows:

•  1–2 units per day, 14 units per week for women

•  3–4 units per day, 21 units per week for men

•  Always have some alcohol-free days during the week.

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KEY POINTS

■ Eat regularly

■ Include some starchy food (carbohydrate) with each meal, choosing high-fibre versions where possible

■ Reduce your fat intake and remember to watch the type of fat

■ Limit your intake of sugars and sugary foods

■ Aim to keep to your ideal body weight and exercise regularly when possible

■ Use salt sparingly

■ Do not drink too much alcohol

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Treatment: medication

Tablet treatment

There are five main kinds of tablet treatment for people with type 2 diabetes:

1   sulphonylureas

2   biguanides

3   acarbose

4   thiazolidinediones

5   glitinides.

They all come under the general name of oral hypoglycaemic agents (OHAs), and any of them may be taken alone or in combination. Most people with type 2 diabetes find that these medications, together with a healthy eating pattern, keep their diabetes well under control, although it may take a while to find out which combination or dose suits them best. However, with the passage of time, patients can gradually lose

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their responsiveness to the tablets and blood glucose levels rise to the extent that insulin injections are needed.

If you do experience side effects or find that your blood glucose levels are higher than they should be, you should go back to your GP to discuss possible changes to your treatment.

Sulphonylureas

Sulphonylureas (SUs) work by stimulating the pancreas to release stored insulin. You could say that they raise the insulin level by proxy, and so help to keep blood glucose down. You have to remember that, although you’re not actually taking insulin, these tablets have a similar effect because they increase the amount of insulin in your bloodstream, and it is possible for it to increase too much. If this happens, your blood glucose levels will drop too far, and you may sometimes experience the symptoms of hypoglycaemia (too little glucose in the blood, see page 78). To prevent this happening, you should make sure that you eat regularly, and take your tablets either with or just before a meal.

As with insulin, SUs can be short, medium or long acting (see below), and must be taken once, twice or three times a day depending on how fast they work. The long-acting versions do not always suit older people or those whose lifestyle makes it difficult to have regular mealtimes because of the risk of hypoglycaemia.

Side effects

Apart from having to be aware of the risk of low blood glucose (hypoglycaemia), most people taking SUs find

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that they have few, if any, serious side effects. Probably the most annoying one is that some patients find that their faces can get very flushed and hot when they drink alcohol. The precise reasons for this side effect are unclear.

As you’ll soon discover once you’re taking them, the fact that SUs lower your blood glucose will make you feel very hungry so you could gain a lot of weight if you’re not careful.

A minority of people won’t be able to take SUs because they’re allergic to them, and if you’re allergic to the antibiotic Septrin you may also have a reaction to SUs.

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Biguanides

This type of drug has been in use for over 50 years, and the only one available in this country is metformin. No one is sure precisely how it works, but it seems to slow down the absorption of glucose from the intestines, reducing the blood surge after a meal, and it may also have a more complicated effect on the liver.

As a result of this, you can’t take it if you have any kind of liver disease, and it is also best avoided in patients with kidney complications (see page 115). You don’t have to worry about your blood glucose level dropping too far when you’re on metformin because it doesn’t stimulate the release of insulin.

It’s often prescribed for people who are overweight because it doesn’t make you feel hungry or put on extra pounds. You normally start on a low dose, taking it once or twice a day with meals, and then gradually build up the amount that you’re taking as you get used to it.

Side effects

The main side effects are stomach upsets – nausea and diarrhoea – and some people have to stop taking it because of this problem.

Acarbose

This works in quite a different way from the other OHAs. By interfering with the breakdown of carbohydrates into sugar, it stops your body from absorbing glucose from food; it interferes with the breakdown of carbohydrates into sugar in the gut.

Unfortunately, this means that more sugars remain unabsorbed in the large intestine where lots of bacteria and micro-organisms lurk. These feed on the abundant sugar and proliferate, which can mean that

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you suffer from loose motions and flatus. Nevertheless, it could be the right option for you if you find it difficult to follow a healthy eating plan or tend to be overweight.

Thiazolidinediones (glitazones)

Thiazolidinediones increase the sensitivity of cells to the effects of insulin. Rosiglitazone and pioglitazone are licensed for use in the UK. They are usually used with either an SU or metformin and, although they do not cause hypoglycaemia directly, they can produce it in combination with SUs.

The most common side effects are weight gain and fluid retention. Extensive clinical trials are ongoing.

Recently these tablets have been licensed for use on their own and one of them (rosiglitazone) is available in a single-tablet combination with metformin.

Glitinides

A new class of tablets that has been derived from SUs has recently been developed. Two of these tablets are available in the UK (repaglinide and netaglinide). They are taken immediately before meals and lower glucose by stimulating insulin release. However, because of their short action they are thought to be less likely to produce hypoglycaemia than conventional SUs.

Newer treatments

Recently, scientists have discovered a hormone called glucagon-like peptide 1 (GLP-1), which is a very powerful stimulator of insulin production and release. Research using a form of GLP-1, called Exenetide, has found it to be very effective at both lowering blood glucose and losing weight. Its drawback is that it has

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to be given by injection, but only once a day. Exenetide should be available in the UK soon.

When you need insulin

When you have type 1 diabetes, there’s no alternative to replacing the missing insulin by means of daily injections. People whose diabetes is not effectively controlled by diet and tablets may also have to change to a regime of insulin injections.

If you’ve just found this out, it’s bound to take you a while to adjust to the idea but, with the right information and back-up from your diabetes care team, you’ll soon realise that you will be able to cope and keep yourself well. They will show you how to give injections, and take time to teach you how to manage your condition effectively.

Don’t worry if you need to see them several times to get things clear – no one will mind. In fact, they will encourage you to keep asking questions and coming back until you feel comfortable with all the masses of new information. Here are some of the questions that people with newly diagnosed diabetes ask most often.

Why inject the insulin?

This is the only effective way of getting it into your bloodstream. If you swallow it, it is partly digested and so becomes less active, which means that it can’t do its job of controlling your blood glucose level. Although other ways of giving insulin have been tried, they’ve all had problems, so injection is the only practical option for the time being. Studies using inhaled insulin have just started and early results are promising.

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Why is insulin injected under the skin?

In theory, it could be injected into a vein or a muscle, as happens with some other medicines such as antibiotics. In practice, however, injecting the insulin into a vein several times a day would be difficult, and intramuscular injections can be painful. Both these methods are sometimes used in special circumstances – for instance when you are ill or can’t eat regularly, perhaps because you’re having an operation.

What types of insulin are there?

The basic difference is in how quickly they take effect, so that they can be divided into short-, medium- or long-acting varieties. The short-acting insulin is always clear or colourless, whereas the other two are usually cloudy because they contain additives to slow down the absorption of insulin from under the skin. It is possible to mix short- and medium-acting insulins in the same syringe, but care must be taken not to contaminate the clear insulin with any cloudy insulin. For this reason the clear insulin is always drawn up first.

If you find it difficult to mix insulins yourself, you may be able to use one of the ready-mixed kinds that contain quick- and medium-acting insulins in different proportions.

Where does this insulin come from?

All three types of insulin may be produced from animal sources – pig or beef – or from genetically engineered human hormone. Recently, scientists have been able to create modified insulins using the new genetic technology. These insulins, called analogues, are absorbed either more quickly or more slowly and smoothly.

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Insulin injections

Injecting insulin is the most effective way to take it, since if taken by mouth insulin is partly destroyed by digestive juices before reaching the bloodstream.

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Quick-acting analogues (Humalog or NovoRapid) can be injected immediately before, during or even after a meal, and are therefore more convenient to use, particularly for people with variable mealtimes. They also enable you to have a bit more insulin if the meal was larger than expected.

The only long-acting analogues available in the UK at the moment are glargine and detemir. These insulins can be given once daily at any time but preferably at the same time each day. Unlike other long-acting insulins, glargine and detemir are clear solutions and care must be taken not to confuse them with fast-acting preparations.

Detailed research trials are ongoing to discover the best way of using these new insulins, but early results suggest that analogues may be associated with less hypoglycaemia.

Is human insulin better than pig or beef?

This is a controversial area and some patients who changed from animal to human insulin have said that they feel less well since the switch. It seems that human insulin is absorbed slightly more quickly from under the skin.

However, no measurable differences in blood glucose levels have been found when human and animal insulins were tested under control conditions, but some people do prefer the animal preparations. At the moment supplies are still available and said to be guaranteed for the foreseeable future.

Why do I have to inject insulin several times a day?

The object of insulin therapy is to imitate the body’s

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natural supply as closely as possible. In a person who doesn’t have diabetes, insulin is released by the pancreas in response to food (see diagram on page 56). As the blood glucose level falls between meals, so the insulin level drops back towards zero. It never quite gets there, however, and there is no time in the 24 hours when there is no detectable insulin in the bloodstream. What you are trying to do when you give yourself insulin injections is to reproduce the normal pattern of insulin production from the pancreas.

There are several ways of doing this using different types of insulin and numbers of injections per day. For example, many people follow a system of injections of short-acting insulin before the three main meals of the day, plus a night-time injection of a medium- or long-acting insulin to control blood glucose while they’re asleep.

Another popular and equally successful system involves two injections a day of a mixture of short- and medium-acting insulins. The idea is that the short-acting component covers the meal that you’re about to have (say breakfast or tea/evening meal), while the medium-acting component covers you at lunchtime or overnight. Many people have been using one or other of these systems very happily for years, and the choice between them is often simply a matter of personal preference.

If you’re one of the relatively few people who simply can’t get used to giving themselves several injections a day, or if you have only a partial failure of your insulin supply, you may be able to make do with just one or two daily injections of medium- or long-acting insulin.

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How and where do I inject myself?

Your diabetes care team will show you how to do the injections and explain the various types of equipment available. Many people today use disposable plastic syringes and needles, although a few still prefer the old-style glass ones with disposable needles.

Disposable syringes and needles can be used many times with little risk of infection. They are usually thrown away when the needle becomes blunt and injections become less comfortable.

Insulin injection pens are also very popular, largely because of their convenience and portability. The pens

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themselves and the needles are now available on prescription. There are several types of pen to choose from, but the principles of the device are much the same. It’s simply a matter of which one suits you best.

As we’ve already seen, you inject insulin under your skin rather than into a vein or muscle. Recent research has suggested that many people may have been getting the depth wrong so that insulin is going into the muscle beneath the skin by mistake.

Judging the depth accurately can be quite difficult, especially if you’re slim, but it’s important to master the technique because insulin can be absorbed from muscle more rapidly than expected.

Your diabetes care team will show you how to do it properly, but a lot of people find that the simplest way is to inject at an angle of 90 degrees. There is a range of different length pen needles now available so it is

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Levels of insulin and blood glucose

These graphs of the levels of glucose and insulin in the blood show the normal pattern of insulin release, and the way in which insulin injections relate to mealtimes.

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Levels of insulin and blood glucose (cont)

Description of treatment regime

Natural insulin release

In a person who does not have diabetes, insulin is released by the pancreas in response to the rise in blood glucose levels produced by eating food.

Insulin injections before meals and before bedtime (basal–bolus)

To reproduce normal conditions, many people inject themselves with short-acting insulin three times a day before meals, plus a night-time injection of medium- or long-acting insulin to control blood glucose overnight.

Mealtimes are flexible with this method.

Two types of insulin injected twice daily

Two injections a day of both short- and medium-acting insulins cover the meal that you are about to have as well as a later meal or overnight. Timing of meals is important to avoid low glucose levels.

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easier to control the depth of injections. It is important for you to find the right type of needle depending on your injection site and body size. This needs to be discussed with your diabetes care team.

You’ll be given advice about the best sites for injection (see figure opposite). The tops of the thighs, buttocks and abdomen are the most common sites, and it’s best to avoid using the same area every time, otherwise you could develop a small fatty lump (called lipohypertrophy) which could affect the smoothness of insulin absorption.

It’s probably a good idea to inject medium- or longer-acting insulins into your thigh or buttock and use your tummy for quick-acting injections, but the most important thing is that you should be happy about the sites that you’re using.

Will the injections hurt?

People who’ve been giving themselves injections for years say that they don’t feel a thing, but many beginners may find it slightly painful at first. Try to be as relaxed as you can and follow the technique that you’ve been shown. Some people find that it helps to rub the skin with ice for a few seconds beforehand to numb it, and you might like to give this a try.

As you get more practice, you should find that the injections rarely hurt, but, if things don’t improve, it’s worth asking someone at the diabetes care centre for advice on what’s causing the problem.

Will the injections leave a mark?

The needles are very fine and usually do not leave a mark. Sometimes you may get a little bleeding after an injection or even a bruise, but this is nothing to worry

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Insulin injection sites

The thighs, abdomen and buttocks are the main sites in which to inject insulin.

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about. It just means that you’ve probably punctured one of the tiny blood vessels under the skin, and this happens from time to time. There is virtually no chance of insulin directly entering the bloodstream, so don’t worry if you notice some bleeding.

Can you give insulin by other routes?

Inhaled insulin is now available. It requires a rather large device, which is much bigger than an asthma inhaler. Insulin given this way is no more effective than by injection, and you still need to inject overnight insulin because only short-acting preparations can be inhaled.

Although there have been no safety concerns so far, long-term effects on the lungs cannot be completely ruled out. Finally, inhaled insulin is wasteful, needing 10 times the dose used by injection, and it is expensive. It is probably most useful if you are needle phobic and cannot contemplate injections, and definitely need insulin for your diabetes control.

Can you take insulin and tablets at the same time?

Some type 2 patients who need insulin and are also insulin resistant can benefit from a combination of injections and metformin. Increasingly, doctors prescribe a combination of long-acting insulin and an SU or glitinide before meals. These combinations are currently being researched in the UK.

What about an insulin pump?

Some patients have found that giving insulin by a constant infusion under the skin via a thin plastic tube and needle gives smoother blood glucose control.

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Insulin pump therapy

An insulin pump delivers a continuous infusion of insulin through a tube (catheter) that is placed underneath the skin on the abdomen.

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These pumps are, however, expensive (around £2,800) and cost more than £1,000 every year to run. They also require considerable medical expertise as back-up, and a great deal of time and commitment from patients.

The National Institute for Health and Clinical Excellence (NICE; see ‘Useful addresses’, page 151) has recently approved insulin pump therapy for patients with type 1 diabetes who find it difficult to achieve satisfactory blood glucose control without experiencing hypoglycaemia.

Specialised diabetes units have been set up around the UK. Funding should now be available but how soon may vary from place to place. To check the situation in your district, contact your diabetes care team.

It is hoped that the ‘postcode lottery’ for pumps should soon become a thing of the past.

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KEY POINTS

■ Tablet treatment is useful for type 2 patients

■ Tablets work in different ways and have different side effects. Be sure to check these with your diabetes care team when they are prescribed

■ Insulin injections are necessary for all patients with type 1 and many with type 2 diabetes

■ At least two and maybe four injections of insulin are needed a day

■ Injections rarely cause discomfort or leave any mark

■ Insulin preparations can be short, medium or long acting

■ Pre-mixed short- and medium-acting preparations are now available

■ A combination of insulin and tablets may suit some patients with type 2 diabetes

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Checking your glucose levels

The objective of diabetes treatment

The point of all treatment for diabetes – whether it’s diet, tablets or insulin – is to keep the levels of glucose in your bloodstream as close as possible to normal. The nearer you get to achieving this, the better you will feel, especially in the long term.

Blood glucose monitoring

There are two ways in which you can monitor glucose levels for yourself and your doctor will advise you about which one you should use and how often to do the checks. The two methods available are:

1   blood tests

2   urine tests

and neither is particularly difficult once you get the hang of it.

The development of simple fingerprick blood testing methods in the last few years has transformed

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life for patients taking insulin. Keeping a close check on your glucose levels is very useful when you’re on insulin because it means that you can make adjustments to your dose depending on the results.

When your diabetes is being controlled by tablets and/or diet, urine tests can give you almost as much information as blood tests and may be more convenient.

In addition, there are blood tests, which can be performed, that measure an average blood glucose level over a period before the test – from two to eight weeks. Each of these three approaches is looked at in turn.

Blood tests

There are two systems available for self-blood glucose monitoring (or SBGM as you may hear it called). Both give accurate results and, as well as helping you improve your blood glucose control, they can be useful if you suspect that you may be about to have a hypoglycaemic reaction (see page 78).

Taking an exact reading will either reassure you that all is well or confirm that you need to take action. Blood testing strips are available on prescription but the special meters for reading them have to be purchased separately, although many diabetes centres are able to offer them for free.

Method 1

The glucose in the drop of your blood reacts with a pad or pads on the end of a plastic strip. These pads have been impregnated with chemicals and form colours when exposed to glucose. These colours are then either matched against a chart on the side of the

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blood-testing stick container or inserted into the appropriate meter, which gives a more precise reading.

There are several different strips available, each of which has a different reaction time, so it is vital to follow the manufacturer’s instructions carefully, otherwise your reading could be too high or too low.

Method 2

A slightly more complicated chemical reaction takes place when a drop of your blood is put on the specially designed testing strip. There is no colour change involved and the strips can be read only using a special meter. This system needs slightly less blood than the conventional colour pad system.

It is now possible to measure both blood glucose and ketones using a fingerprick test and a special strip and meter. This technique may be particularly useful in pregnancy and in young people who are prone to recurrent episodes of ketoacidosis.

How to do the test

The main drawback for some people is that both these systems mean that you have to obtain a fingerprick sample of your own blood (although occasionally someone else may be able to do this for you).

Pricking your finger can be especially difficult if you are a manual worker or if you have very sensitive fingers. Rather than having to nerve yourself deliberately to stab your finger, you might find it easier to use one of the devices incorporating a spring-loaded lancet (needle). It allows you to adjust the depth of the prick to suit yourself, but the disadvantage is that, although the lancets are available on prescription, the spring-loaded devices sometimes have to be paid for.

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Testing blood to determine the glucose level

A blood sample must first be obtained which is dabbed on to a testing strip. The strip is placed into a special meter to give a very precise blood glucose reading.

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Examples of blood glucose meters

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Glucose sensors

Glucowatch

There are now several methods for measuring glucose continuously. One of these consists of a wrist-watch device, which uses a mild electric current to extract fluid through the skin (the Glucowatch – see page 70). This fluid is then drawn into a membrane under the watch and the glucose level in it is measured every 20 minutes. If it is low or high, an alarm sounds, warning the patient.

Early studies with this device are promising, but a lot of false alarms have been recorded at low blood glucose levels. Patients also report itchiness and redness where the watch is worn. The Glucowatch costs around £300 and the testing membranes are extra and have to be changed every 12 hours.

Devices implanted in the body

A second method uses a fine needle that is placed under the skin, usually on the abdomen or tummy. This needle is connected via a fine tube to a small device worn on a belt. Special enzymes on the needle break down glucose in the fluid under the skin and this creates a small electric current, which is detected by the device and converted into a glucose level. The results are stored and downloaded into a computer after three days.

A similar device using a different method has recently been developed. A small pump pushes fluid under the skin, which absorbs glucose from the tissue. This fluid is then returned back into the device and the glucose concentration is measured. This system can measure glucose levels for up to two days.

These machines can be useful to detect patterns of glucose control and provide a basis for treatment

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How the Glucowatch works

A low electric current pulls glucose through the skin. The glucose accumulates in two gel collection discs. Periodically the sensor measures the glucose and a level is displayed on the readout.

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changes, but they cannot tell the individual patient his or her blood glucose at any specific time.

A new device using a similar method does measure glucose levels every three minutes and shows the reading on a small screen. It is currently rather expensive and is undergoing further intensive research. It is hoped that it will be available for more general use over the next few years.

Infrared devices

A third method uses an infrared light shone across small blood vessels. The level of glucose in the blood will affect the impedance of the light across the vessel and generate a signal, which can be converted to provide a blood glucose value. This method is, however, still highly experimental.

Experimental devices

New results have been published from workers in France who have developed a very fine tube that is passed into a large vein leading to the heart. This tube can measure blood glucose every few minutes for periods of up to six months or more. The information from the blood glucose levels has been fed into an insulin pump and this combination is a form of artificial pancreas. At the moment, the results are very preliminary, and further results from trials in large numbers of patients are eagerly awaited.

There seems little doubt, however, that these technologies will eventually result in real-time glucose monitoring that will be sure to revolutionise diabetes care for all patients, although it will be some years before these technologies become widely available.

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Urine tests

Kidney (or renal) threshold for glucose reabsorption

Glucose appears in your urine when your kidneys can no longer reabsorb the amount being filtered. The problem with urine testing is that this ‘overflow point’ isn’t the same for everyone. The correct term for this overflow point is the kidney (or renal) threshold for glucose reabsorption.

Some people who don’t have diabetes have a low threshold, and they often need the glucose tolerance test, described on page 16, to confirm the fact and explain why glucose has appeared in their urine.

The normal threshold is around a blood glucose level of 10 millimoles per litre (mmol/l) so, for a person with diabetes, a negative urine test can mean that your blood glucose level is anywhere between 0 and 10 mmol/l, depending on your personal threshold. A positive test, on the other hand, doesn’t tell you the exact level of blood glucose or by how much it exceeds your own personal threshold.

Despite this relative lack of accuracy testing, however, testing your urine and getting mostly negative results may be all you need to confirm that you have your diabetes well under control, especially if you’re being treated with diet and/or tablets.

How to do the test

Nearly everyone these days uses stick tests similar to those used for testing blood glucose. You dip a stick either into the stream of urine or into a specimen that you’ve just passed, wait for the chemical reaction that results in a colour change, and then read off the colour

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Kidney threshold for glucose reabsorption

The kidneys can only reabsorb a certain level of glucose, typically 10 mmol/l. If this level is exceeded, as it may be if blood glucose levels are out of control, glucose appears in the urine.

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against the chart, which is usually printed on the side of the container.

As with the blood testing sticks, how long you wait varies from one type of urine stick to another, so do check the manufacturer’s instructions.

The test must be done on fresh urine if it is to reflect the level of glucose in your blood at the time that it’s done. This is especially important first thing in the morning, when urine may have been accumulating in your bladder over several hours.

What you have to do is empty your bladder about half an hour before you want to do the test, then pass another sample about half an hour later which is the one you actually check.

What the results of blood or urine tests show

When you do either a blood or a urine test, you’re really measuring how effective your previous dose of insulin or tablet treatment has been. In other words,

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doing a test just before lunch will tell someone on insulin the effect of the early morning injection of quick-acting insulin. In the same way, a pre-breakfast test will reflect the effectiveness of the previous night-time dose. The same interpretation applies in principle to tablets.

Adjusting doses

When the test result shows a high level of glucose, you may have to increase the size of your next dose of medication to restore the balance. This solves the problem short term, but ideally you want to prevent the problem arising in the first place by adjusting the dose that preceded the test.

It’s a good idea to vary the time of day when you do your test, and also to wait for a series of results over a period of, say, three to five days, before making too many adjustments. That way, you will see whether there is any pattern to the changes in your blood glucose level.

Until you have more experience of handling your diabetes, it would be better to consult your GP or someone in your diabetes care team before altering your insulin or tablet dosage. Later on, once you’ve learned more about your body’s reactions, you’ll be able to make the necessary adjustments on your own because you’ll know what works for you.

Clinic monitoring

If you have type 1 diabetes, there may be situations where your medical advisers feel that it would be useful to assess the effectiveness of your treatment by means of more sophisticated blood tests. They are not a substitute for your own routine testing, but can give

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additional information, which will help your diabetes care team decide whether your treatment needs adjustment. Both tests usually require a blood sample to be taken from a vein, although some new machines use only a fingerprick blood sample.

Glycated haemoglobin

This is a test that measures your average blood glucose level over a period of some six to eight weeks. It is reported as a percentage, unlike blood glucose (units of millimoles per litre or mmol/l), and the normal (non-diabetic) range is usually between four and six per cent.

Good control is usually defined as a value of 7.5 per cent or less; poor control is 10 per cent or more. Roughly speaking, a glycated haemoglobin of 7.5 per cent is equivalent to an average blood glucose of 10 mmol/l, whereas a value of 10 per cent is equivalent to an average of 15 mmol/l. Like all averages, however, it could be the result of lots of small variations or much larger swings in either direction. For this reason, this test isn’t useful for making day-to-day adjustments of insulin treatment, but is a good guide as to whether your treatment is working well overall.

Fructosamine

This test works on the same principle as glycated haemoglobin, but measures treatment effectiveness over a shorter period – about two to three weeks. Again it is a useful guide as to whether your current treatment is working well or needs adjustment.

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KEY POINTS

■ Blood tests provide accurate information about glucose control

■ Blood tests are helpful to exclude hypoglycaemia (low blood glucose)

■ Urine tests are perfectly adequate for monitoring patients on diet control or low doses of oral hypoglycaemic agents (OHAs), but are not very helpful for alerting the patient to hypoglycaemia

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All about hypoglycaemia

Who is affected?

You need to be concerned about ‘hypos’ only if you are being treated with insulin, a sulphonylurea (SU) or glitinide tablets. If your diabetes is controlled just by diet or you are taking metformin, thiazolidinediones or acarbose, you will not experience this problem.

What is hypoglycaemia?

Hypoglycaemia means low blood glucose and, in a person who doesn’t have diabetes, the levels never fall much below 3.5 millimoles per litre (mmol/l). This is because their natural control system will sense the drop, and correct the situation by stopping insulin secretion and releasing other hormones such as glucagon, which boost blood glucose. What’s more, the person will start to feel hungry, and so do the right thing by eating, so raising the blood glucose.

When you’re on insulin or SUs, this feedback system no longer operates. Once you have taken

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insulin or stimulated its production with tablets, you can’t switch it off again, so your blood glucose will go on dropping until you have some food in the form of carbohydrate.

As the level falls, it usually triggers a variety of warning symptoms (see box on page 79). Hypoglycaemia is dangerous because the brain depends almost entirely on glucose for normal functioning. If levels drop too low, it starts to work less well and produces the symptoms shown in the box. If the level drops even lower, unconsciousness (coma) may result.

Preventing hypos

In past years, someone who was being started on insulin might have had to go through a deliberately induced hypoglycaemic reaction so that he or she would know how it felt. These days your doctor is unlikely to suggest this because it’s not very pleasant!

Doing a blood glucose test yourself means that you can find out quickly and easily whether your level is getting too low and take action if necessary.

One of the most important aspects of caring for patients with diabetes is trying to ensure that they don’t suffer from hypoglycaemic reactions. This involves the individual concerned discussing treatment and adjusting it if necessary to fit in with his or her lifestyle, especially with mealtimes and work patterns. This is not always easy, and sometimes it means compromises will have to be worked out.

You usually have to accept that there is no alternative to sticking to regular mealtimes, however inconvenient you find it. With the wide range of different insulins and types of injection device, it is

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usually possible, however, to arrive at a treatment programme that will suit you.

Having regular hypoglycaemic attacks is a sign that you need to go back to your doctor or nurse to see how your treatment and/or eating pattern can be adjusted to prevent them happening.

What causes hypos?

You’ll soon get to recognise the situations where you are especially vulnerable, but the most common are:

•  Eating later than you had expected or planned, which is bound to happen sometimes. If you’ve had your insulin injection and then can’t eat for some reason, you should eat a small carbohydrate snack (such as a boiled sweet or a biscuit), which you ought to have handy at all times.

•  A burst of unexpected exercise – such as running for a bus (for more on this, see page 88).

•  Drinking too much alcohol. When your liver has to break down excessive quantities of alcohol, it can’t produce glucose at the same time. This is why you’ll be advised not to drink too much alcohol if you’re on insulin or taking SUs or glitinides. Always eat something whenever you do have an alcoholic drink.

Treating a hypo

A reaction that’s relatively mild can usually be dealt with quite simply – a glass of Lucozade or lemonade should do the trick. Remember, however, that diet drinks contain artificial sweetener rather than sugar, so are of no use to you in this situation.

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Do make sure, too, that, wherever you are, you always carry some sort of readily available carbohydrate in the form of a boiled sweet or biscuit. Chocolate is not very useful in this situation because it is a slow-release form of carbohydrate. Having readily available carbohydrate is especially important if you’re a driver or if you’re about to take some form of vigorous exercise. For more on this, see the sections on diet (page 18) and exercise (page 88).

Severe hypos

Very occasionally, you may find that your blood glucose level drops so rapidly that you don’t have time to take the corrective action described above. You may become drowsy or unconscious, and might even have an epileptic fit.

This is obviously a frightening prospect both for you and for those close to you, and you need to take action to make sure that it doesn’t happen again. This means getting advice from your medical team to get the problem sorted out. There are various ways of dealing with a person who’s having a severe hypo:

•  When you’re not in a state to eat or drink anything, a sugary gel called Hypostop can be squirted into your mouth or rubbed on your gums. This should not be done if you are having a fit.

•  A hormone called glucagon, which causes blood glucose to rise, is available in injectable form. You can be given an injection into your arm or buttocks to bring you round, so you can then have something to eat or drink. Glucagon should not be used if hypoglycaemia is the result of SU or glitinide treatment, or alcohol intoxication.

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Night-time hypos

It’s natural for you and your family to worry that you might have a hypo while you’re asleep, or even that you might have one and not wake up. This is an especially frightening prospect when you are the parent of a small child with type 1 diabetes – for more on this, see page 102.

In reality, the problem is by no means as dramatic as that. First, you are quite likely to be woken up by the symptoms of falling blood glucose. You may feel sweaty, restless or irritable. Occasionally, your restlessness may wake your partner even if you stay asleep.

It’s not unusual to sleep right through a severe hypoglycaemic reaction. Your body mobilises various hormones in response to the falling level of glucose, which stimulates the release of stored glucose to correct the situation. After a reaction like this, you would wake up with a headache and symptoms much like a bad hangover.

Sometimes, there may be a swing too far in the opposite direction, so that your blood glucose rises too far. If you regularly wake up feeling bad with these sort of symptoms it’s a good idea to take a few early morning (2 to 4am) blood glucose tests to see if you are having hypoglycaemic reactions that you’re not aware of at the time. At least then you’ll know why you’re feeling so bad and you can talk to your diabetes care team about whether your night-time dose of insulin needs adjusting or altering to a different type.

Losing your hypoglycaemic awareness

You may well have read various stories about some people with diabetes complaining that they have lost their ‘early warning system’ of a hypoglycaemic

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reaction. Many of them believe that this has happened as a result of changing from animal to human insulin. Before we consider this aspect, we should look at other reasons why this awareness might be lost.

It has become increasingly clear for some years that people who have had diabetes for a very long time become less able to predict when they are about to have a hypo. The warning signs seem to become less noticeable after they’ve been on insulin for about 15

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to 20 years. Although no one knows quite why this should be so, it is true that the ability of the pancreas to release glucagon in response to low blood glucose diminishes over time. Some people say that their symptoms change, whereas others say that the symptoms come on so much faster that they don’t have time to take corrective action.

The problem is also more common in people whose average blood glucose levels are on the low side of normal. Sometimes, adjusting the treatment so as to allow the blood glucose level to rise slightly may mean that the person gets the old pattern of symptoms back, but any change of this kind must be discussed carefully with the diabetes care team.

Is human insulin to blame?

The question of what role human insulin may play in changing hypoglycaemic awareness is even more complex. Although some patients feel that changing from animal insulin is responsible for their difficulties, their doctors often disagree. Carefully controlled experiments have shown no measurable difference in hypoglycaemic symptoms in people taking animal or human insulin. All the same, some people are quite sure that they feel better on animal insulin and, if so, there is absolutely no reason why they shouldn’t go on taking it.

Can hypoglycaemia be avoided by constant high blood glucose levels?

Having persistently high blood glucose levels will avoid hypoglycaemia, but unfortunately this also increases the risk of dramatically developing complications of diabetes (see page 109).

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Maintaining the balance between risky hyperglycaemia (too much) and troublesome hypoglycaemia (too little) can be very difficult for patients on insulin, but is much easier these days with the different preparations and injection devices available.

If you are having troublesome hypo attacks, followed by high blood glucose levels, consult your diabetes care team because it may mean that your treatment needs adjusting or changing. It may also be worth considering insulin pump treatment (see pages 60–2).

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KEY POINTS

■ Hypoglycaemia can occur in any patient taking insulin or sulphonylurea (SU) tablets

■ Individual patients differ in their warning signs of hypoglycaemia

■ If you think a hypo may be coming on, try to confirm with a blood test first

■ If this is not possible take some fast-acting carbohydrate such as Lucozade, lemonade (not low calorie) or glucose tablets

■ Milk and biscuits are not ideal because they are not rapidly absorbed, but can be useful after initial correction

■ If hypoglycaemia is a recurrent problem, seek advice from your diabetes care team

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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.

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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.

It’s important to let the people you’re with know when you’re taking insulin and explain to them what to do if you have a hypo.

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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 have 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

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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!

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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 148). 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.

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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 pre-breakfast 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.

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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 the 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 149) 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.

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MedicAlert Foundation offer an emergency medical information service 24 hours a day. See ’Useful addresses’, page 150.

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

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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 (IDDM)

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 (NIDDM)

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.

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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 can be 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

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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.

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Pregnancy and type 2 diabetes

Type 2 diabetes is becoming more common in younger women who wish to become pregnant. Tablet treatment is not recommended in pregnancy, so all 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 insulin injections.

You won’t be treated with tablets while you’re pregnant. After the birth, you’ll be advised to keep an eye on your weight and stick to a healthy diet because you are possibly at a greater than normal risk of developing type 2 diabetes later in life.

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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

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■ 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 early obstetric and medical advice once they realise that they are pregnant

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Children with diabetes

Managing a child’s diabetes

Type 1 (insulin-dependent) diabetes most commonly comes on between the ages of 11 and 13. It is, however, becoming more common in toddlers and infants, and there are increasing numbers of cases of babies developing it within a few months of birth.

You can’t stop children racing around and burning up energy, which can make it difficult to keep their eating and insulin in the right balance. The usual answer is to give two or three injections a day each containing some short-acting and some medium-acting insulin.

It’s only to be expected that you’ll worry about your child having hypoglycaemic reactions and find it hard to let him or her out of your sight. As they get older and you both get more used to dealing with diabetes, you’ll probably find it easier to allow them more independence.

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Children can learn to inject themselves from any age, although you will probably want to check the insulin doses. Injector pens have been a big help in getting around this problem, because of their convenience and ease of dialling the insulin dose.

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Home monitoring

Blood tests can be hard for young children, and quite difficult because their fingers are so small, so urine tests are often recommended instead, either on their own or combined with occasional blood tests. Once your child is a bit older, you will have to encourage him or her to be disciplined about monitoring blood glucose levels on a regular basis.

However, don’t be surprised if he or she is awkward about it. Rebellion is of course a natural part of growing up, and many teenagers go through a period of refusing to cooperate over this aspect of their diabetes care. This is a difficult situation to deal with, but it’s best to steer clear of direct confrontation as much as you can. Remember that it’s very important for your child to keep taking his or her insulin regularly.

Hypoglycaemia

Children’s blood glucose can fall quite quickly, especially if they are active, so it may be difficult to spot the warning signs in time. Very young children may not recognise them at all. When