Type 2

How To: Keep Healthy with Diabetes

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This section is for everyone.

Overview

Meal Planning

Self-monitoring of Blood Glucose

Use of Insulin and Diabetes Medications

Foot Care

Urine Testing for Ketones

Annual Health Checks

You need to be confident about…

 

Overview

The Joslin Diabetes Centre have a check list so you can see what sort of things you need to know to look after yourself with diabetes. This list covers type one and type two diabetes. For each heading I will list what we have already covered on this course and what we will be covering in more depth in the Type One Section *

There is a considerable overlap between both types of diabetes. To start with most people with insulin dependent diabetes diagnosed in childhood or young adulthood are  not overweight or insulin resistant. As time goes on this may change so Type Ones would benefit from reading the earlier sections to see if any of it applies to them. The majority of the carb counting methods have also already been covered in the Metabolic and Type 2 section.

For type twos who start off on diet or oral medications they may find that after  a while this is no longer sufficient to maintain normal blood sugars. You may benefit by reading on to find out how to deal with insulin now or in the future.

If you don’t feel really confident about any of the things I have listed please take advantage of some of the books and internet resources in the help sections. It is important that you know what to do ahead of any emergency developing so please contact your diabetes support team for further personal training.

 

MEAL PLANNING

Your own meal plan
know how carbs, proteins* and fats affect the body
special foods and occasions
dining out
portion control
label reading
how to fit in treats*
alcohol*

 

SELF MONITORING OF BLOOD SUGAR

blood glucose goals
how to use the meter
monitoring schedule*
storing supplies*
interpreting blood glucose values and making decisions in diabetes treatment plan*

USE OF INSULIN AND DIABETES MEDICATIONS

Action and side effects of medication*
timing and schedule*
insulin injection techniques*
storage, refrigeration and disposal of supplies*
what to do if you miss a dose*

EXERCISE

What type, how long, how hard, how often and when.*
snacking adjustments*
preventing high and low blood sugars*

KNOWLEDGE OF HIGH AND LOW BLOOD GLUCOSE

Factors that cause high and low blood glucose*
symptoms*
how to treat*
when to call a healthcare provider*
how to prevent*

FOOT CARE

daily foot care*
emergency treatment for cuts, sores and abrasions.
how to do a proper foot exam*
proper footwear

URINE TESTING FOR KETONES

When and how to check for ketones*
What ketones mean*
When to call a doctor*

YOUR HEALTH TEAM WILL DO THESE ANNUAL CHECKS AND TESTS

A1C ( 2-4 times a year)*
kidney function*
cholesterol, ldl, hdl, triglycerides*
foot exam*
eye exam*
blood pressure*
general health check eg thyroid, tests for coeliac disease and anything relevant to you*

YOU NEED TO BE VERY CONFIDENT ABOUT…

Your own meal plan
The medication you are taking
Your glucose monitoring system
The treatment of high and low blood sugars
How to manage your sick days
Your risk factors for developing other health problems
Your foot care

 

Quick Quiz:
1. A test type twos should have done every six months is…
a Liver function and creatine kinase.
b Hbaic.
c Fasting lipids.
d Sex hormone binding globulin.

Have you got it?
1. You must have your hbaic checked every 3-6 months. If statins are being taken, fasting blood lipids, liver and creatine kinase levels may be taken episodically.

Where to Next?
Please all proceed to the How To: Safely Dispose of Needles and Other Sharps section.

 

How To: Give Your Feet a Pedicure

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This section is for all of you. If you want to treat your ten little tootsies this is how.

Its lovely to have nice looking, comfortable, happy feet.  After you’ve been doing all that exercising your feet could do with a little pampering.  The more you can make this part of your daily routine the happier your feet will be. You may soak your feet for up to five minutes if you intend to cut your nails.

Fill a basin or bath with some warm water.
Test it with your hand to see its not too hot.
Add a good sprinkle of salt.
Add some bath gel, liquid soap or use a bar of soap.
Add a favourite aromatherapy oil – just a few drops – if you like.
Put your feet in and give them a gentle wash.
You may leave them to soak for up to five minutes.

Take your feet out and put them on a towel.
Give them a thorough dry particularly between the toes.
Place your feet where you can see them and if you are not flexible enough to see the sole of your foot use a mirror.

Are there any rough areas, unusually reddened areas?
Any sores? Any cuts? Any blisters?
How are your nails?
Any breaks in the skin between your toes?

If any problems are apparent you may need to deal with them yourself, see your podiatrist within the week or even see a doctor as an emergency if you suspect you have an infection.

Do your nails need cut?
To cut them use nail clippers or scissors. Be sure to look exactly where you are going with the scissors. Cut the big nail straight across so the nail edge does not cut into your skin.

Now for a massage.
Bring out your container of vegetable or animal oil. Pour some into your palms and then stroke it all over your feet.
Rub it into the nails, between the toes, and on the sole of your foot.
Give the ball of your foot which takes a lot of pressure a good massage.

You can extend the massage up your leg to your knee. Sweep your hand upwards towards the heart. The shin area and round the ankle area can be affected by poor circulation in later years so keeping the skin supple here is helpful.

To finish off gently use the towel to absorb any excess oil on your legs or feet.
Put on a fresh pair of socks for a while. This will keep your carpets, bedcovers and shoes from becoming oily.

Make a date with your feet to have the same loving experience very soon.

Quick Quiz:
There is no quiz in this section. The only thing you need to ask your tootsies is what soaps and oils they like best.

Reference Info:
Acknowlegements to my ten little friends and to my podiatrist Simon Littlejohn.

Where to Next?
Did you enjoy that? I hope you did. Your happy feet can now toddle along to the next section How To: Know What Things Beyond Food Can Affect My Blood Sugar.

How To: Eat from a Hospital Menu

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This section is for everyone. It could happen to you!

Ironically one of the most risky places for a diabetic to eat is as an inpatient in a hospital.

Because you are a diabetic you will be told by nursing and dietetic staff that you must choose from the “Healthy Eating” section of the menu. This “Healthy Eating” section is specifically designed to be high in carbs, lowish in protein and very low in fat. I’m not at all sure what kind of metabolism is suitable for this sort of diet but it it’s certainly not a good idea if you have the sort of metabolism that cannot handle sugar and starch.  This is the situation for all those people with glucose intolerance or diabetes. Yes. You!

It is necessary for you and your relatives to be very firm at the outset that you must be able to choose from the whole menu, be able to choose large or small portions as you desire and to bring in supplementary food items if necessary.  This could include olive oil and vinegar to dress your salads, fresh temperate grown fruits, cheese, cooked meats, oatcakes and diet drinks.

For breakfast ignore the toast and cereals and porridge and go for the cooked breakfast and eggs in a large portion. Supplement this with a small portion of fresh fruit. Grapefruit and mandarin orange segments are often offered on hospital menus but they are usually tinned and sweetened with sugar so are best avoided.

Instead of digestive biscuits as a midmorning and midafternoon snack try some cheese and oatcake with butter.  Many hospitals routinely offer diabetics snacks as this used to be necessary with twice daily insulin regimes. You may not really need  a snack however. If you are hungry at a snack time you may not have eaten as much protein and fat as you really needed to at the previous meal. If you are insulin dependent you will need to have lucozade or gatorade or snacks available for low blood sugar treatment. A longer acting carb and some protein can work well provided you are not too low.

For lunch and dinner pick large portions of meat, fish, poultry, cheese and egg dishes with vegetables or salad. Ignore any potatoes, chips, rice, pasta or bread items. Avoid deep fried battered food if possible due to the high hydrogenated fat content and carb content of the batter.

Before bedtime toast and biscuits are about the only thing that is offered in hospital. These are likely to be too high glycaemic for you and cheese and cold meat or cheese and oatcakes usually work better to prevent a blood sugar spike or nightime lows.

Despite the difficulties in getting fed properly in hospital it is well worth the effort  to keep your sugars normal. Your infection rate is decreased and your recovery will be faster.

 

Quick Quiz:
1. Maintaining normal blood sugars by following a low carb diet in hospital results in three of these. What won’t happen?
a Less post operative infection.
b More chance of surviving a life threatening illness.
c Faster discharge from hospital.
d Getting on the dietetic staff’s Christmas card list.

 

2. In hospital suitable breakfasts for a diabetic are…
a Whatever the nurse thinks looks good from the healty eating section of the menu.
b Porridge, skimmed milk, fresh orange juice with cholesterol lowering margarine.
c Toast, butter, boiled eggs, tinned grapefruit and mandarin oranges.
d Bacon, scrambled eggs, tomato, half a grapefruit.

3. The most risky eating situation for a diabetic is…
a As an inpatient in hospital.
b As a passenger in an aeroplane.
c From a roadside snack shack.
d As a guest at a dinner party that includes Miss Marple, Hercule Poirot, Ellery Queen, Lord Peter Whimsey and Detective Columbo.

Have you got it?
1. ABC have been proven to result from good glycaemic control in hospital. Sadly D is something that is not as likely from low carbing in hospital. Well there is a first time for everything and sooner or later dieticians will come on board. If you are the first patient to get a card in these circumstances we MUST hear about it!

2. D is correct. The others are too high in sugar and starch. At least with option C you could eat the boiled eggs. Unfortunately the “Healthy Eating Menu in hospitals usually entails LOW FAT. The sugar content is usually high and the protein content is usually low. Most hospital dieticians and nurses will automatically dragoon you into choosing from this menu unless you make it very clear that you object.

3. These are all very risky eating situations. How do you choose between them? In hospitals and aeroplanes you have a very restricted choice of meal. Snack shacks may not be as hygeinic as you would wish. And someone always get poisoned when these super sleuths are near. The only way to deal with these risky situations is to plan ahead and that often means bringing your own meal.

Reference Info:
Acknowlegements for this section to John Gibson the first of my patients who stood up up to the dietetic staff in the hospital I work in. I am also grateful to hospital administrative staff who did their absolute best to bully me into backing down. I would never have believed what was necessary to secure a guarantee of freedom from the “Healthy Eating Plan.” To cut to the chase YOU MUST THREATEN TO SUE THEM. If they don’t back down. It’s okay. Call your lawyer and sue the pants off them.

Where to Next?
All of you need to know about the next topic. March this way to the How To: Take Care of Your Feet section.

How To: Cook and Bake the Low Carb Way

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This section is for everyone.

Overview

Looking at Ingredients: Carbohydrate

Foods to Eat Regularly

Eat in Moderation

Eat Sparingly 

What Fats Should I Use?

What Protein Should I Use? 

How do I successfully substitute ingredients?

Sugar Conversions

Recipe Books

Internet Sites

Overview

There are two ways of cooking and baking the low carb way.

By far the easiest way is simply to use ingredients that are naturally low in total carbohydrate and in glycaemic index and cook the way you usually do. For example many meat, fish, poultry and egg dishes can be made just the same as usual and served with plenty of low starch vegetables and butter or olive oil instead of rice, pastry, pasta, bread or potatoes.

The more tricky way is to substitute lower carb ingredients for the higher glycaemic, high carb items such as sugar, flour, potatoes, rice and bread. This tends to be a lot more expensive and there is often some compromise regarding the texture and flavour of these dishes.

Learning how to cook and bake low carb well is a pleasure not only for the cook but for those who get to eat the end result. You need not give up old favourites entirely. You simply enjoy them in a different way.

Before my son was diagnosed with type one diabetes I often bought entire meals from the cook chill cabinets at the supermarket. My son loves  cakes and desserts and to maintain excellence in blood sugar control without an apparent restriction in these food items I now make time to have  a regular cooking and baking slot about twice a week.

LOOKING AT INGREDIENTS: CARBOHYDRATE

What carbs raise your blood sugar very little and what ones raise it rapidly and a lot?

I have listed some of the commoner ingredients which Dr Atkins has listed according to how generous or restricted you should be with them.

FOODS TO EAT REGULARLY

Asparagus, green beans, bok choy, broccoli, brussels sprouts, butter beans, cabbage, cauliflower, celery, chard, collards, cucumber, aubergine, fennel, lettuce, mushrooms, okra, onion, mangetout, snow peas, peppers, radishes, rutabaga, saukerkraut, spinach, sprouts, courgettes, tomato, water chestnuts.

Cottage cheese,ricotta.

Almonds, brazil nuts, coconut, hazelnuts, macadamias, pecans, pine nuts, pistachios, pumpkin seeds, sesame seeds, sunflower seeds, walnuts.

Chickpeas, hummus, kidney beans, lentils, lentil soup, minestrone soup, peas dried or split, soybeans, unsweetened soy milk, tofu.

Apple, blackberries, blueberries, cherries, cranberries, grapefruit, unsweetened grapefruit juice, oranges, peach, pear, plum, raspberries, strawberries, tangerine.

All bran, cooked barley, low carb bread and muffins, low carb pasta, old fashioned oatmeal, wheat bran.

EAT IN MODERATION (ie infrequently or in small portions)

Carrots, green peas, mashed pumpkin, buttenut squash, tomato juice, tomato soup.

Whole milk, unsweetened yoghurt.

Cashew nuts, peanuts.

Black eyed beans.

Apricots, grapes, kiwifruit, mango, melon, papaya, pineapple.

Bran flakes, 100% wholegrain bread, pumpernickel bread, rye bread, sourdough, buckwheat, bulgur, whole wheat couscous, egg fettucine, melba toast, no sugar added muesli, pasta, popcorn, raisin bran, brown rice, taco shell.

EAT VERY SPARINGLY (these are the “bad guys”)

Sweet corn, parsnips, pea soup, potato

Full fat ice cream with sugar

Baked beans

Apple juice, bananas, cranberry juice, tinned fruit cocktail, grape juice, orange juice, prunes, raisins.

White bread, wholewheat supermarket brand breads, cornflakes, couscous, semolina, crackers, croissants, pita bread, pizza, pretzels, most breakfast cereals, all white rice, shredded wheat.

WHAT FATS SHOULD I USE ?

Use lard, butter and macadamia nut oil in  preference to refined vegetable cooking oil  and margarine for frying and in baked goods.

Use extra virgin olive oil, unrefined flax oil, hazelnut oil, walnut oil and macadamia nut oil for dressing salads.

Use grapeseed oil and canola oil for cooking at higher temperatures but stir fry instead when you can.

WHAT PROTEIN SHOULD I USE?

Free range meat, poultry, fish and eggs are best as they usually contain healthier fats and have less hormones and antibiotics added.

Cold and cured meats may contain added sugar and preservatives that are not beneficial.

Lightly grill meats and fish and avoid getting them black.

Partly cook your barbeque meats in the oven to minimise the black on the outside and raw on the inside health risks.

Use marinades to tenderise meat. Marinades with reduced levels of oil can reduce flaming that burns the meat. Trimming fatty meat can reduce this too.

If you eat about the palm of your hand size minus the fingers of lean protein three times a day your are having about the right amount for you.

HOW DO I SUCCESSFULLY SUBSTITUTE INGREDIENTS?

Some things lend themselves to substitution better than others.

Rice
Grate cauliflower and then gently fry it to simulate fried rice or steam it briefly to simulate boiled rice.

Mashed potatoes
Steam or boil the cauliflower cauliflower for at least 7 minutes till it is tender and then mash with butter and cream. You can add grated cheese or fried shallots or finely cut onions to taste. This can also be used to top cottage pie and moussaka.

Pasta
Low carb pasta can be purchased in certain specialist stores. It usually has  a high gluten content.  It seems to become high glycaemic again when it is overcooked or reheated so just cook lightly and once.

Spaghetti squash can be baked and then used in pasta dishes to mimic spaghetti.

Sauces
Instead of using flour to thicken sauces use cream instead of milk for white sauces.  Very small quantities of xanthan powder can also be used to thicken sauces.

Bread
For a traditional loaf which is low in carbs you could make Graeme’s version which is in the downloads section of this site. He even includes a photograph.

For a microwave bread which is faster to prepare see the recipe section at our sister site www.diabetes-normalsugars.com. Mandy, a fellow “Bernie” has spent a lot of time perfecting this recipe (requires login) and has some variants you may wish to try.

Pancakes
Instead of using flour use ground almonds and instead of sugar use a substitute.

Muffins
Instead of flour use such items as flaxseed meal, whey protein powder, soya flour, ground almonds.

Cheesecakes
These are very easy to low carb because the texture depends on the fat rather than the sugar.  They can have no base or a low carb pastry base can be made.

Chocolate
Dark chocolate is a very versatile and healthy ingredient when a high cocoa content, 70% or above , version is used.

Cakes and Shortcrust Pastry
Such items as  courgettes, almonds, ground hazelnuts,  soya flour and  whey protein powder are used in various combinations as flour substitutes.

Because of oxidative damage caused by an excess of omega six vegetable oils and margarines it is better to use unsalted butter, lard and macadamia nut oil for many baked goods. Hydrogenated fats have the advantage of being cheaper and they produce lighter textured baked goods with a longer shelf life. On the long run though we are aiming at not only improving your blood sugars but also your general health. As hydrogenated vegetable fat consumption is related to higher obesity, diabetes, heart disease and cancer risks it is better to avoid them. As my friend Rosie puts it, “If bacteria are smart enough to know not to eat hydrogenated fats I’m certainly not going to either.”  Baked goods may be heavier than you would like as a result. Beating egg whites separately till they peak and then adding them in ito the cake mix is a technique that can help.

If you have a favourite family recipe that you can’t de carb successfully it is  often possible to compromise and use half the high glycaemic flour or sugar and substitute the rest.  It is the texture that is more commonly affected than the taste by going full low carb.

Sugar
All of the sugar substitutes are more expensive than sugar. There is not the same caramelisation and texture benefits or the range of sugar substitute types.  To mimic brown sugar you can add a small quantity eg a teaspoon of black treacle or black strap mollasses to eg a carrot, passion cake or gingerbread recipe along with the sugar substitute.

To mimic white granulated sugar I have found the best one to be Steviva Blend.

To mimic icing sugar I have found Splenda to be the best. This is also more available and cheaper than Steviva Blend.  I find this sweeter than sugar and would recommend you use about half a cup or half the weight of the amount of granulated sugar you would normally use in a recipe.

SUGAR CONVERSIONS

I packet of sucralose (eg Splenda) = 2 teaspoons sugar in  bulk but = 4 teaspoons in sugar of sweetness.

24 packets of sucralose (eg Splenda) = one cup splenda = 2 cups in sweetness

Use half the usual bulk of sugar that you would normally use when using Splenda for your first go. You can increase or decrease the amount according to taste at your next baking session.

Two tablespoons of Stevia Plus  = one cup sugar

One cup of Steviva Blend = one cup sugar

One and a half tablespoons of Sweet and Slender = one cup of sugar

*any other sugar substitute conversions would be very welcome here*

RECIPE BOOKS

These are my personal selection of books that I cook from regularly.

344 Pages of Low Carb Recipes

500 Low-Carb Recipes  Dana Carpender

500 More Low-Carb Recipes  Dana Carpender

The Low-Carb Gourmet Karen Barnaby

Low Carb Italian Cooking Francis Anthony

Low-carb Vegetarian Celia Brooks Brown

The Illustrated Atkins New Diet Cookbook  Robert Atkins

Extreme Lo-Carb Meals On The Go  Sharron Long

Low Carb Sinfully Delicious Desserts  Victor Kline

George Stella’s Livin’ Low Carb George Stella

Eating Stella Style George Stella

INTERNET LOW CARB COOKING SITES

I have listed some helpful sites for you in the metabolic section. My favourite is:

www.carb-lite.com

The Bernies have been experimenting for years and have a very varied selection of recipies for you.

Bernie Forum Recipes (requires registration)

Quick Quiz:
There is no quiz for this section. I hope you now know that almost anything can be lower carbed with a bit of effort. As Dr Atkin’s was fond of saying. “This is not deprivation diet.”

Reference Info:
Much of this section is from Atkins for Life.

Where to Next?
“From the sublime to the ridiculous” is another saying. No matter how healthy you think you are, you never know when. In the next section we all need to get to grips with that most chilling of subjects,  How To: Eat from a Hospital Menu.

 

 

 

How To: Monitor My Blood Sugar Appropriately

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This section is for everyone.  It is somewhat more applicable to type one diabetics but type twos need to know some of this too.

Normal blood sugars for fit young non diabetics are 4.7 on waking and prior to meals and bedtime provided no snacks have been eaten.  Two hours after a meal such a persons blood sugar will be down to five or six. Blood sugars should not normally go below 4.0 even if a person has not eaten or has been exercising. A healthy young person can expect to have a hbaic of less than 5.0 although the range given in laboratories takes the not so fit into consideration and often gives an upper limit of normal as 6.0.

What we are trying to achieve with type one and type two diabetes is a replication of normal blood sugar patterns as much of the time as is achievable for you.

In the non diabetic person the pancreas secretes a small amount of insulin all the time. This small amount stops the liver from converting body proteins such as the muscles and vital organs such as the heart into sugar. This is called basal insulin. About the only time this is switched off completely is during very vigorous exercise.

When a meal is eaten an immediate surge of stored insulin enters the blood stream and tells the cells to grab hold of any glucose molecules that are circulating. This is called a first phase insulin response.

As eating continues the pancreas makes as much insulin as it needs to keep the blood sugar normal and it makes this insulin to order as it goes along. This is called the phase two insulin response.

There have been some advances recently in drugs and transplants that will help diabetics of both types one and two get better control or even cure the disease. Meanwhile, unless you are a mouse with a very good health insurance policy, you are best to  take charge of your diet and glucose monitoring. Lower carbohydrate diets particularly can help you keep damage from high or swinging bood sugars minimal.

What you want to get from a tight food plan and monitoring schedule

  • Normal blood sugar levels – or as near as you can get.
  • Improvements in hbaic, lipids and kidney tests.
  • Achieve a suitable weight for you.
  • Reverse at least some diabetic complications
  • Reduce the frequency and severity of low blood sugars.
  • Relief from mild neurological problems associated with high blood sugars such as chronic fatigue and short term memory impairment.
  • Blood pressure reduction.
  • Reduced demand on pancreatic beta cells – this is important for type 2s and type ones in honeymoon or earlier in the disease process.
  • Increased strength, stamina and sense of well being.
  • Sleep better.
  • Have fewer infections.
  • Have healthier skin.

 

When do I test my blood sugars?

In order to find out how well your body is dealing with your diet and any medication you are taking blood sugars need to be taken:

  • On waking
  • Immediately before breakfast
  • Before each meal
  • Two hours after each meal
  • At bedtime

When you are testing out new foods to see how they affect you testing every half hour or alternately at one hour after eating, two hours after eating and three hours after eating.  This gives you a good idea of what types and dosages of insulin may be needed to cover that food successfully. See the “Eat to Meter” section in the type two diabetes section of this course for more information on this.

You also need to check blood sugars before, during and after exercising till you know how that particular sport, duration and intensity of exercise affects you.

Shopping and running errands can drop your blood sugar so have your meter and glucose handy.

It is extremely important to check your sugars before you drive and after every hour of driving.

Intense brain work such as sitting an exam can use up glucose but adrenaline can also raise it.  Better check before the exam when you can correct a little or eat something.

Whenever you are hungry or suspect your blood sugars are running higher or lower than expected you should check.

It is useful to teach a toddler a nursery rhyme or song and get them to repeat it often.  If you suspect a low blood sugar get them to repeat the song. If they get muddled up they may well have a low blood sugar. Test to check this system works for you a few times and if it is reliable for you you may omit the fingerstick.

If your vision for small print starts to go this can be a sign of low blood sugars so check.

For new college students or those in new or different jobs from usual increased walking to different places and different work schedules can put your sugars way out.  You need to check your blood sugars more frequently than usual if your work pattern changes.

Shift work is a whole big problem area for diabetics. Your patterns will change with each type of shift and the transition periods will be particularly difficult as lack of sleep can seriously affect blood sugars too.

Women’s blood sugar patterns shift a lot in relation to their menstrual cycle, some hormonal methods of contraception and of course in pregnancy. You will need to check more frequently during these periods.

If you drink alcohol always eat along with it and be moderate. Alcohol can cause low blood sugars but sugary mixes can raise your blood sugar.  You must again test more frequently and  of course before you go to sleep no matter how late or early you get in.

Tell people you see regularly that you can get quite crabbit with high and low blood sugars and ask them not to take it personally. Make a deal to check your blood sugar if they ask you to.

Finger prick testing is more accurate than arms pricks if your blood sugar is falling rapidly or if you are very low. If you think you are low test the finger tips or base of the thumb. If you think you are high test wherever you fancy.

 

How to I monitor my blood sugars in hospital?

Apart from times that your are under an anaesthetic or extremely unwell the person who should take responsibility for your blood sugar monitoring in hospital is YOU.

You must bring in all your kit and continue to look after yourself as if you were at home.

You must have your kit by your bedside or with you if you go off on a hospital trolley for any tests and do not allow it to be disposed of or hidden by the nursing staff.

To reduce the number of finger pricks you need get the nurses to check your figures against theirs. As long as the first few are reasonably similar they should give their agreement to accept your figures.

It is NOT SAFE to assume that the medical or nursing staff know more about your diabetes than you. Given the wide range of medications, insulins and delivery devices it is indeed unfair to expect them to know better than you do.

For insulin dependants it is very important indeed that you administer your own insulin if you are at all able to do this. There have been deaths from staff making mistakes with this.

For people on insulin that should be administered prior to food it may be best to wait till the trolley arrives on the ward or at your bedside before you inject. You may not get it delivered at the time you are expecting and you may also have to count the carbs and estimate the protein before injecting. You may need the food to be kept warm for you to get the optimal time for eating or for allowing a high blood sugar to drop if you need to.

What laboratory test may I need to have regularly?

Thyroid function tests
Type one diabetics are prone to the development of other autoimmune diseases so this test should be done every so often and particularly if you begin to feel particularly cold, tired, you gain weight unexpectedly, you have more hypos than usual or your cholesterol suddenly rockets.

Lipids and Liver Tests
All diabetics in the UK over the age of 40 are routinely put on drugs called statins whether they have a raised lipid level or not. Recent guidance is that this should be extended to all type ones over 18 who have one or more complications from their diabetes.

Statins work because they reduce inflammation in the lining of blood vessels and reduce atheroma and clot formation which damage blood vessels and blood supply.  Statins can upset liver function and creatine kinase so these are tested routinely.

It is accepted by most doctors that there is a benefit in taking statins for people with diabetes and those with ischaemic heart disease. The problem is that a group benefit may not transfer into a personal benefit for YOU. One in 20 people get liver enzyme rises, muscle pain or general malaise and need to stop statins. They are dangerous to take if a woman is pregnant or at risk of becoming pregnant so women in their childbearing years need to think very carefully about them.

Kidney Tests
The albumin-creatinine ratio is as test that can detect early signs of kidney damage. If this or microalbumen tests in the urine are positive you may be asked for 24 hour samples and blood tests to clarify the extent of any problem.

The estimated glomerular filtration rate or eGFR is a new blood test done at the same time as the Urea and Electrolyte test. It gives an idea of what stage of kidney impairment may be going on.

ACE inhibitors or ARBs are new drugs that can reduce the rate of kidney deterioration. They  end in “pril” or “sartan” respectively.  They are also effective in reducing high blood pressure. If you start them for the first time you need a blood test after two weeks to see that they are not worsening kidney function. This can happen in some people who have a condition called renal artery stenosis which is hard to detect otherwise.

Coeliac Disease Tests
Coeliac disease is an autoimmune disease of gluten sensitivity. It can occur at any age.  The symptoms can be very vague and it can take a very long time to develop the raised enzyme tests of endomysial antibody and tissue transglutamase and obvious anaemia.  Tiredness and abdominal pains are probably the main symptoms. An easy and less expensive test to do is the ferritin level in the blood. This is the amount of stored iron and low levels occur frequently in coeliac disease.

CRP
The C reactive protein test is a non specific tests that indicates inflammation.  It is often raised in metabolic syndrome and type 2 diabetes.

In the absence of any inflammatory condition or infection you could have high levels of this if you are a type one who is getting quite tubby round the middle and you seem to need a lot of insulin to get your sugars down.  In other words it is a marker that you are getting both kinds of diabetes at once. A good exercise regime and lower carb diet is what you need to deal with this problem.  High insulin levels cause damage to blood vessels too. Getting insulin and blood sugar levels reduces cardiovascular deterioration.

HbAIC
The hbaic must be the diabetologists favourite blood test. It is also known as the haemoglobin AIC or the glycosylated haemoglobin. It is a test of your average blood sugar over the last 3 months. A truly normal level is less than 5.0 and more accurately 4.2-4.8%.

The average UK figures for 10-18 year old diabetics is a whopping 9.5%

The American Association of Endocrinologists have set a target of 6.5 % or less for diabetics and the UK National Institute for Clinical Excellence are going to recommend that level quite soon. Diabetes UK have set the level at 7.4% or less for children and teenagers but less than one in 7 meet this target at present.

Control of 8.0 or over is considered to be poor and can be an indication that insulin is necessary in type 2s who are struggling on maximal oral therapy.

Diabetic complications can come on in people who have never been diagnosed with diabetes but who have had hbaics of 5.5 or more for many years.  Type 2 diabetics are often discovered to have complications at the time of their diabetes diagnosis because of the slow and stealthy development of problems.  Visual troubles, breathlessness on exertion and subtle coordination problems are often seen as something to do with middle age or complications can entirely asymptomatic as in kidney disease.

The American Diabetes Association have decided that from next year they will provide patients with a measure of their average blood sugar to help them understand more about what the hbaic test really means.

Here is a chart to help you:

hbaic   =   average blood glucose value UK / US

5 = 5 / 90

6 = 6.6 / 119

7 = 8.3 / 149

8 = 10 / 180

9 = 11.6 / 209

10 = 13.3 /239

11 = 15 / 270

12 = 16.6 / 299

13 = 18.3 / 329

14 = 20 / 360

It is in your best interest to keep as low as you can towards normal without risking severe hypoglycaemia. Fortunately this is achievable with a low carbohydrate diet.

Why not find out what tests you have been getting done by your doctor ?
If you keep a record of them you will be in a much better position to understand more about how the diabetes has been affecting you. This can help if you need to see a different doctor from usual or you take ill on holiday.

 

Quick Quiz:
There is no quiz for this section. Type ones however will be getting questions on it later!

Reference Info:

Where to Next?
Please move on to the How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar section next.

How To: Safely Dispose of Needles and Other Sharps

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This section is for everyone.

Sharps are a problem because they can stick into other people legitimately handling your waste or animals who are raiding your garbage.

The worry that someone will get AIDs from being pricked by a used sharp is greatly in excess of the likelihood of this happening. But you never can tell. Hep C and B can also be transmitted from sharps and hepatitis C is the most transferable of these.

To treat a contaminated sharp injury in time a person has to get appropriate antiviral drugs within an hour. These are highly toxic and need to be taken for a month.

Please take the safest measures you can to dispose of your sharps. Here are the best ways:

Use a specially designed container. This is usually hard plastic with a lid that cannot be opened once it is locked.  They can often be obtained from pharmacies or your diabetic clinic.

Some pharmacies and hospitals provide a sharp box swap system. You may have to pay towards this service.

You can clip off the needle or lancet tip with a needle clipping device that stores the needles inside. This can then be thrown away when full. If you do this dispose of your syringes appropriately too.

A “cin bin” or sharps box is easiest to use because the whole syringe and needle can be disposed of at once. They can be bulky so having a needle clipper for use outside the house can be a great help.

If you have to dispose of sharps in your garbage as a last resort you can use a heavy opaque plastic bottle  eg a bleach bottle. When it is 3/4 full screw the lid back on and securely tape it down.

Keep your sharps and disposal box away from younger children or pets.

Reference Info:
Thanks to the BC (British Columbia) Children’s Hospital . They have a great selection of leaflets particularly aimed at younger type ones.

Where to Next?
Please all proceed to the  How To: Monitor My Blood Sugar Appropriately section.

How To: Know What Oral Medications I May Be Offered for Diabetes

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This section is for type twos and type ones with any degree of insulin resistance.  If you are a slim type one you may skip over to the How To: Use Bolus Insulins Effectively section.

For many years there were only two types of drugs offered to people with type two diabetes, metformin and sulphonureas.  More recently the glitazones and the meglitinides have been prescribed.  Last year several other medications such as januvia and byetta have come along too.

As the number of people with type one diabetes who have also developed insulin resistance has increased there has been more experimentation with oral drugs as well as insulin.  The insulin resistance is usually related to weight gain and high amounts of injected insulin which are necessary  to cover  a high carbohydrate diet.

As the number of people with type two diabetes who have not been able control their blood sugars on oral drugs increases there are more type twos on combinations of oral drugs and insulins. This rise is  related to worsening insulin resistance at least partly due to high amounts of ingested refined carbohydrate and beta cell failure partly due to the toxicity of high blood sugars on beta cells over a long period of time.

In this section I will be discussing some points about the older oral drugs for diabetes. As users of the newer drugs gain experience with them I would hope more information on this expanding area of prescribing can be given.

Sulphonureas

Sulphonureas work by making your pancreas release more insulin.  Although sulphonureas sometimes don’t work when first given they almost always stop working later on. Every year secondary sulphonurea failure occurs in 5-10 per cent of people taking them.  50% of people taking a sulphonurea will have beta cell failure by six years.

Going on this drug may seem like a good way of avoiding insulin injections to start with.  But it really just delays the point at which most people are likely to need an alternative treatment or insulin. Remember that your pancreas is smarter than you are when it comes to fine tuning your blood sugars.  Even a little bit of useful pancreatic function could make a big bit of difference later on.

There are also worries about increased cardiac mortalilty with sulphonurea use. An epidemiological association between hyperinsulinaemia and cardiovascular disease has raised concerns about the safety of sulphonureas.

Sulphonureas are popular with physicians and patients because they tend to be well tolerated. They do cause significant weight gain in many patients but this is not apparent right away.

The fear of injections in patients and the burden of patient education about insulin use in doctors seem to keep the prescriptions for this drug flowing along.  Before you start this drug however there are some things it may be helpful to ask both yourself and the doctor.

1. Is there any alternative medication or supplement that could help to get my blood sugars down?

2. Would a low carb diet be a better alternative course of action for me?

3. Would an exercise programme be a better alternative for me?

4. How much pain is involved with injections? Could I try one to see?

5. Have I a particularly reduced life expectancy that could make a sulphonurea a more favourable alternative to insulin injections?

6. How expensive is the insulin versus the sulphonurea?

Once you have asked these questions and  given realistic answers you will be in a much better position to make a well informed decision that your future self will be happy with.

Meglitinides :The Prandial Glucose Regulators

Repaglinide (Novonorm) and Nateglinide (Starlix) are chemically unrelated to sulphonureas. But again they work by squeezing more insulin out of the pancreas. They are taken just before meals to stimulate insulin for just that meal. They are usually taken three times a day. They are not used with sulphonureas but can be used with metformin. They can cause gut upset and hypoglycaemia.

At the moment we don’t know the long term effects that these drugs have in the way we do about sulphonureas.  Because they have a similar action on the pancreas they may also be expected to lead to premature beta cell failure but we just don’t know. They are active for a shorter time than sulphonureas and that may influence things.

Pragmatically it would be worth asking yourself and your physician the sulphonurea questions.  If you are leaning towards sulphonureas a meglitinide may be a better longer term option.  We just don’t know.

Metformin

Metformin does not tend to cause weight gain which is important for many people with type two diabetes. It is particularly useful when fasting hyperglycaemia is present. It causes some beneficial effects on blood lipids. It lowers blood glucose mainly by reducing the production of glucose from the liver. It may increase the sensitivity of the muscle cells to insulin and slow the uptake of glucose from the intestine. It does not depend on stimulating insulin secretion as the sulphonureas do. About ten percent of patients fail to respond to it when it is first used and the secondary failure rate is 5-10 per cent a year.

Metformin therapy in the prediabetic patient reduces the onset of type two diabetes mellitus by 31%. Visceral fat is reduced in metformin therapy.  Visceral fat is more metabolically active and produces adipocytokines which contribute to insulin resistance.

Metformin has benefits outwith the lowered hbaic compared to sulphonureas and insulin.

Gastrointestinal side effects can be minimised by starting with a single dose of 500mg after the evening meal. The maximum glucsose lowering dose is 2g daily.  A long acting version of this drug can be particularly helpful for those with gastric side effects on the regular medication and also can be given in the evening  to reduce the high morning blood sugars caused by the dawn phenomenon.

Important though uncommon side effects include lactic acidosis, especially if renal failure is present, and B12 deficiency.

Glitazones

The glitazones are the first group of drugs for diabetics that directly reverse insulin resistance. Rosiglitazone and pioglitazone were released in Europe in 2000. Neither drug has been linked to liver damage. They cause changes in the muscle and fat cells where the insulin resistance resides. They also enhance the actions of insulin in the liver.

The glitazones have their greatest effect on blood sugar after eating rather than the first morning glucose.

Glitazones are insulin sparing meaning that the body does not have to make as much insulin to control the blood sugar when a glitazone has been given.

So far secondary failure does not seem to be a problem.

Glitazones take 12 weeks to give the maximum benefit.  You should only be given a glitazone in combination with a sulphonurea if you can’t tolerate metformin or there is some other reason why you can’t take it.

You can be offered a glitazone in addition to metformin and a sulphonurea if your blood sugars aren’t well controlled enough as an alternative to starting on insulin.

Glitazones can cause hypoglycaemia if used with a sulphonurea or insulin.

Glitazones have demonstrated beta cell preservation which delays or prevents  insulin therapy.  This has not been seen in patients treated with sulphonureas or metformin.

Glitazones directly improve insulin resistance and reduce hyperinsulinaemia. They also raise HDL and give less dense LDL, give improved endothelial function and slightly reduce diastolic blood pressure.

The glitazones become less effective as the duration of diabetes goes on and endogenous insulin production from the pancreas lessens.

The data for beta cell preservation is good and makes glitazones a favourable choice early in the course of type two diabetes.  Problems are fluid accumulation and the effect of precipitating  heart failure.

Glitazones have been shown to give increased osteoporosis at unusual sites such as the upper limb. In addition Rosiglitazone may increase the risk of cardiac death. Until more is known about the effects of Rosiglitazone it may be best to use Pioglitazone if this class of drug is being considered. Pioglitazone has been shown to have a favourable effect on cardiac risk.

Both metformin and the glitazones have been used in insulin resistant type ones. Metformin seems to be a very helpful add on medication for this group but the glitazones have been disappointing.

 

Quick Quiz:
There is no quiz for this section.

 

Reference Info:
Acknowlegements to Dr. Bernstein’s Diabetes Solution and Sarah Jarvis and Alan Rubin’s book “Diabetes for Dummies, UK Edition / Diabetes for Dummies

Where to Next:
Please all continue to the How To: Use Bolus Insulins Effectively section.

How To: Look after yourself with Type 2 diabetes

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This section is for all type twos and any type ones who think they are developing insulin resistance. This is often recognisable by an increasing waist line, blood pressure and need for high doses of insulin relative to your thinner years.

Slim type ones may proceed to the How To: “Eat to Meter” section.

When you eat carbohydrate it gets broken down by the digestive system and appears in the blood stream as glucose.  Insulin is immediately released by the pancreatic beta cells.  Insulin is the hormone that tells certain types of cell in the body to take up glucose in the bloodstream.  In this way the glucose level in the blood stays within a narrow range.

In insulin resistant states such as metabolic syndrome and type 2 diabetes the cell wall insulin receptors are less sensitive to insulin and in an effort to keep blood sugar levels normal the pancreas releases more insulin.

High insulin levels causes inflammation and stiffening of the lining of your blood vessels. This lining is called the endothelium. This stiffening causes high blood pressure.

The pancreatic cells can initially make plenty of extra insulin to compensate for the weakened effect of the insulin but eventually become exhausted and start to die off. This causes higher blood sugars.  Unfortunately blood sugars higher than 6.1 are toxic to beta cells and they start to die off with higher and higher blood sugars. The whole thing is a vicious circle.

Type two diabetes is often thought of as being less serious in some ways than type one diabetes. It is certainly true that a type two will not die as rapidly if they don’t get insulin as in type ones. On the long term however type two diabetes causes all the same complications as type one and can be just as fatal. Instead of it being obvious that something is drastically wrong with your health as in type one, those with type two can have it creep up on them over many years, slowly causing damage to the blood vessels, eyes, kidneys and nerves and not even know about it.

In type two diabetes there is initially more insulin produced to try to overcome the effect of insulin resistance. In early type two diabetes there can even be episodes of low blood sugars when the pancreas releases too much insulin at the wrong time. As time goes on the beta cells become exhausted and produce less and less insulin and  die off. In many people insulin injections are eventually needed to give anything like normal blood sugar control.

Type two diabetics store less immediately available insulin than normal people. In addition they also need to produce more than normal because their cells are less sensitive to insulin. As their ability to produce insulin on demand declines they get higher blood sugars after eating and this persists for much longer than in non diabetic people.

High blood sugars after eating can be minimised by eating fats, protein and carbohydrates that release sugar gradually so that their pancreatic insulin factory (phase two insulin response) can keep up. This effectively means eating non starchy vegetables as the main source of carbohydrates.

For type two diabetics who do not need insulin they may get better results from eating  4 or 5 small meals a day rather than sticking to three bigger meals a day.

Many people have inherited their tendency to insulin resistance.  If your parents or grandparents had heart disease, high blood pressure, fat round the middle, high cholesterol, high triglycerides, type two diabetes or swollen ankles you are more at risk.

The diabetes tendency becomes noticed at times such as pregnancy, ageing and if the person tends to eat a high sugar or starch diet.  Lack of exercise also affects how rapidly the tendency will appear.

Insulin primarily affects blood sugar but also affects blood pressure, cholesterol and triglycerides and the storage of fat. No medications can reduce excess insulin production: only a low carb diet. A low carb diet works by reducing the oversecretion of insulin and helps restore balance.

Beta blockers and diuretics which are often used to control blood pressure also increase insulin resistance and are best avoided in some people.

Although there are cut off points in blood sugar tests to say who is normal, who has metabolic syndrome and who has diabetes, the condition is really a continuum.  Someone who has metabolic syndrome can get retinopathy, kidney disease and cardiovascular disease just the same as a diabetic.

The worse your sugar control is the worse your cardiovascular and complication risk.  A popular test to do is the hbaic. This is the percentage of sugar attached to your red cells in the blood. Although a normal range of 4-6 is often given for instance it has been found that your risk goes up progressively from levels of just 4.6.  It therefore makes sense to have as good blood sugar control as you can, particularly if you have a moderate to long life expectancy.

Tests that you can have done to find out your risk or severity of metabolic syndrome and type two diabetes include measuring your waist/hip ratio, hbaic, glucose tolerance test, fasting lipids and blood pressure.

There is a progression in how type two diabetes is treated:

Low carbohydrate diet
Appropriate weight loss
Exercise
Drugs that enhance insulin sensitivity or insulin action
Insulin injections with or without oral drugs.

People who have lived with high blood glucose levels for years can feel shakey or ill at normal blood sugar levels.  They also can have blurred vision. A gradual adjustment of the target blood range and progressive reduction in carbohydrates can help these symptoms settle down.

Quick Quiz:
1. One of these is true for type two diabetics…
a They get less serious complications than type ones.
b They can have slowly developing damage to tissues without realising it.
c They need the same level of daily monitoring as insulin using type ones.
d Those not on insulin get on best with three meals a day.

Have you got it?
1. B is correct. Unfortunately the myth that type twos get less serious complications than type ones persists. Diabetes is certainly not as dramatic in onset as in type ones. It’s insidious nature makes it harder to detect and so damage goes unchecked. It is the case that monitoring of blood sugars needs to be done a lot less often than in insulin dependants but dietary habits must be just as good. If reasonable amounts of a person’s own insulin are being made type two diabetics may have better sugar results with smaller and more frequent meals than the 3 or 4 a day advocated for type one diabetics.

Reference Info:
Most of the information in this section is from Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars.
Where to Next?
You are now ready to proceed to the How To: “Eat to Meter” section.