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(24) Diabetes

 Diabetes Research Institute helps save American soldier from life of brittle diabetes

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Brittle diabetes

What is brittle diabetes and what treatment does it require?

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(25) Diabetes

 Young Voices: Allison's Life with Diabetes

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Life with diabetes

 These papers are meant to answer all the questions that affect daily living when you have diabetes. It covers a broad sweep from sport to holidays to surgical operations and illness. After reading all papers, you will realize that there are very few activities that are barred to people with diabetes.

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(26) Diabetes

 World Diabetes Day: Understand Diabetes, Get Involved

University of Michigan

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Eating out

My wife and I entertain a great deal and we often go out for meals with friends or in a restaurant. I have recently been started on insulin for diabetes. How am I going to cope with eating out?

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(27) Diabetes

 How does insulin work in the body?

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Work

 Can I undertake employment involving shift work?

Yes, certainly. Many people combine shift work with good control of their blood glucose. Shift work does, however, need a little extra care as most insulin regimens are designed round a 24-hour day. Shift workers usually complain that they are just settling into one routine when everything changes and they have to start again. It is hard to generalize about shift work as there are so many different patterns but, if you follow these rules, things should work out all right:

• Aim at an injection of short- and intermediate-acting insulin every 12-16 hours, or use a basal + bolus regimen. This way of giving insulin makes it much simpler to plan for shift work.

• Try to eat a good meal after each injection.

• Eat your normal snacks between meals every 3 hours or so, unless you are asleep.

• If there is a gap of 6 to 8 hours when you are changing from one shift to another, have some short-acting insulin on its own followed by a meal.

• Because your pattern of insulin and food is constantly changing, you will have to do more blood glucose measurements than normal, as you cannot assume that one day is very much like another.

• If your blood glucose results are not good, be prepared to make changes in your dose of insulin.

You will soon know more about your diabetes than anyone else! How can I cope with my diabetes if I work irregular hours as a sales rep?

Just as in shift work many people manage to combine an irregular lifestyle with good diabetes control. People who lead an erratic lifestyle usually find that the basal + bolus regimen gives them the freedom they require.

If you have had an injection of insulin in the morning and normally have fairly low blood glucose before lunch, then you will go hypo unless you eat at the right time. So a well-controlled person cannot afford the luxury of missing meals completely.

However, it is always possible for you to have a few biscuits or even a sweet drink if you are getting past your normal eating time.

The occupational hazard of all sales reps, with diabetes or otherwise, is the mileage that they clock up each year on the roads. The dangers of hypoglycaemia while driving cannot be overemphasized and there is really no excuse for this now that instant blood glucose measurement is available.

Remember:

• If driving before a meal, check your blood glucose.

• If it is low, eat before driving.

• Always carry food in your car and have some immediately if you feel warning of a hypo.

Should I warn fellow employees that I might be subject to hypos?

Definitely. Hypos unfortunately can happen, especially when a person first starts using insulin. Warn your workmates that, if they find you acting in a peculiar way, they must get you to take some sugar. Warn them also that you may not be very cooperative at the time and may even resist their attempts to help you.

Some people find it difficult to admit to their colleagues that they have diabetes but, if you keep it a secret, you run the risk of causing a scare by having a bad hypo and being taken to hospital byambulance for treatment. A needless trip to hospital should be avoided.

My husband’s hours of work can be very erratic. Sometimes he only gets 3 or 4 hours sleep instead of his normal 8 hours. Can you tell me what effect lack of sleep has on diabetes?

Lack of sleep in itself will not affect diabetes although, if your husband is under great pressure, his blood glucose may be affected. The real problem with working under a strain is the tendency to ignore diabetes completely and assume that it will look after itself. Unfortunately a few minutes of each day has to be spent checking blood glucose, eating a snack or giving insulin. These minutes are well spent.

I developed diabetes 5 months ago, 1 week after I had started a new job. I am coming to the end of my 6-month probation period and have been given two weeks’ notice because of my diabetes. They said I could not do shift work because of my diabetes. Could you help?

This is a sad story and a good example of ignorant prejudice against people with diabetes. Of course there are many people on shift work who maintain good control - although it does require a bit of extra thought. You may well have a case under the Disability Discrimination Act and you should seek advice from your local Citizen’s Advice Bureau.

I am a pub manager and have had diabetes for the past 19 years but my employers are now making me redundant. Apparently, their insurers cannot accept me for a permanent position owing to my diabetes. Who can help strengthen my case?

We know of several publicans with diabetes who run good pubs and still keep their diabetes under good control. However, people who work in licensed premises are at greater risk of drinkingmore alcohol than average and heavy drinkers are in danger from hypos (see the section on Alcohol later in this chapter). We wonder if you have been having frequent hypos, which has made it difficult to continue in your present occupation. Ask your clinic doctor and Diabetes UK to lobby on your behalf and seek legal advice from your local Citizen’s Advice Bureau.

I have been refused a job with a large company because of my diabetes. Have I sufficient grounds to take proceedings against them for discrimination?

The Disability Discrimination Act covers people with diabetes but it can be difficult taking a company to court. We know this sort of discrimination does sometimes happen, especially in large organizations, although, of course, it is very difficult to prove. It may be possible for your case to go to an industrial tribunal to see if there are grounds for unfair dismissal but, as it sounds as if you have been refused a new job rather than dismissed from an existing job, then this could be difficult. The support of your own diabetes team will be important if you wish to take proceedings under the Disability Discrimination Act.

Diabetes UK has had discussions with medical officers responsible for occupational health in several large organizations. These have resulted in an employment handbook, which is circulated to diabetes clinics and occupational health doctors.

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(28) Diabetes

Type 2 Diabetes

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Other illnesses

 I have recently had a severe cough and cold and have been given ‘diabetic’ cough medicine by the doctor. Since then my blood glucose has been very high. Could this be due to the medicine?

This is a good example of the effect that any infection or serious illness has on diabetes – it nearly always causes a rise in blood glucose. Unfortunately, many people often do not start to feelunwell until the glucose reaches danger level. People on insulin usually need more insulin when they are ill and yet they are sometimes advised to stop insulin completely if they do not feel like eating. This advice can be fatal.

 The rules when you are ill are as follows:

• Test blood/urine at least 4 times a day.

• If tests are high take extra doses of short-acting insulin.

• Never stop insulin.

It is of course possible to get over a bad cold by carrying on with your normal dose of insulin and accepting bad control for a few days. However, this means that your mouth and nose will be slightly dehydrated and it will take a few extra days before you feel back to normal. So you will probably feel better more quickly if you adjust your insulin and try to keep the blood glucose near normal.

Antibiotic syrup and cough linctus are often blamed for making diabetes worse during an illness such as ’flu or chest infection. In fact a dose of antibiotic syrup only contains about 5 g of sugar and is not going to make any real difference. It is the illness itself that unbalances the diabetes. In general, medication from your doctor will not upset your diabetes.

I have noticed that my son suffers from more colds since developing diabetes. Could this be due to his diabetes?

Many parents make this observation, but there is no real reason why the common cold should be more common in diabetes. However, a relatively minor cold may upset his diabetes control and lead to several days of illness (see previous answer). This may make it a more memorable event. To repeat the previous advice, never stop insulin.

My daughter keeps getting infections and has been rushed to hospital on several occasions with high ketones and requiring a drip. How can I prevent these infections? Will vitamins help?

It sounds as though your daughter has so-called ‘brittle’ diabetes and this must be very alarming for you. There are really two types of people with brittle diabetes. The first type includes those who are really very well controlled and can prove this by frequent blood glucose measurements below 7 mmol/litre and a normal HbA1c, but who quickly become very ill and ‘sugary’ at the first sniff of a cold or the beginning of an infection. The other sorts are those who are normally poorly controlled with blood glucose results all over the place and who therefore have no leeway when they become ill.

In the case of the first type it should be possible to increase the dose of insulin rapidly, giving extra doses every few hours depending on the blood glucose. The second type are more of a problem as it is the overall control that needs to be improved and this can be very difficult. Of course, if an infection (e.g. cystitis) starts off the trouble, this must be treated immediately with antibiotics. Provided that your daughter has a reasonable diet, vitamins will not help.

My 6-year-old daughter who is on insulin is troubled with frequent vomiting that occurs suddenly. She has ended up in hospital on several occasions as she becomes dehydrated. What can I do to avoid this?

Vomiting in a young child with diabetes has to be taken seriously and the hospital admissions are probably necessary to put fluid back into your daughter by means of a drip. If the vomiting is associated with high blood glucose levels and ketones, then it may be possible to avoid these problems, if extra doses of short-acting insulin are given as soon as the blood glucose levels start to rise before vomiting occurs. As she gets older these attacks of sickness will improve.

What is the best treatment for someone suffering from hay fever?

I understand that some products can cause drowsiness, which could affect my balance and be confused with a hypo. You can use exactly the same treatment for your hay fever as people without diabetes, as it does not affect your control. Anti-histamines are often used for hay fever and these may make you feel sleepy, but this should be easy to distinguish from a hypo. Remember that, if you are on antihistamines, you should take alcohol with great caution. Hay fever can also be alleviated by sniffing capsules, which reduce the sensitivity of the membranes in the nose.

I have just been in hospital with anaphylactic shock from a bee sting. I have diabetes controlled with tablets and wondered if this had anything to do with the severity of my reaction?

There is no connection between diabetes and allergy to bees.

What should I do if my son has an intercurrent illness while on tablets?

This can be a really difficult problem. Of course if your son is ill enough to need hospital admission, he will often be given insulin while his sugars are running high. At home, this is not as simple because there is no way of knowing what dose of insulin he may require, and an inadequate dose of insulin may even make matters worse. So, although in a perfect world he would have insulin for the duration of his illness, in reality it is acceptable for him to run high sugars for a day or so, in the expectation that they will soon settle down spontaneously. In a longer lasting illness, there is of course time to adjust the insulin dose in response to the results of blood glucose measurements.

What is the effect of other illnesses on diabetes? Is my son likely to suffer more illness than other children of his age?

Illnesses usually make diabetes worse in the sense that people on insulin need to increase the dose to keep blood glucose controlled. People on tablets or diet alone often find that a bad cold will upset their control. In the case of a prolonged illness or one needing hospital admission, a person with Type 2 diabetes may need to have insulin injections for a time.

Diabetes itself does not necessarily make people prone to other illnesses. In fact a survey in a large American company reveals that people with diabetes had no more absences from work than those without. Most children with diabetes grow up without any more illness than their friends.

Since I was diagnosed I have been very depressed. Is there any link between depression and diabetes?

People vary greatly in their mental response to developing diabetes. Some lucky ones accept their new condition easily, while others find the whole thing very depressing. The depression seems to take two forms: at first, shock, and even anger at the very onset, coupled with fear of injections and the unspoken fear of complications; a few weeks later comes the depressing realization that diabetes is for life, and not just a temporary disease that can be ‘cured’. This type of depression seems to affect young people who are worried and are insecure about the future.

A few people with diabetes feel that, in some way, they are flawed, especially if they have previously been very body conscious. The best way round this feeling of inadequacy is to throw you into sporting activities with extra enthusiasm. Exercise is good for us all and people with diabetes have managed to reach the top in most forms of sport from ocean racing or rowing to international football.

If you treat your diabetes in a positive way rather than letting the condition control you, the depression will gradually lift. However, if your low mood is interfering with your normal work and relationships, you should tell your doctor about it.

 How does stress and worry affect diabetes? I spend many hours studying and find that, if I study too long, I feel weak and shaky. Are there any side effects to pressure that may affect my diabetes?

In general, stress and worry tend to increase the blood glucose. A Scottish student told us that in the run up to her final examination, she had to double her insulin dose to keep perfect blood glucose control, even though she did not appear to be particularly anxious to her friends. Stress causes a release of adrenaline and other hormones, which antagonize the effect of insulin. During periods of stress it may be difficult to keep to strict meal times, so you could be going hypo. You should check your blood glucose and, if it is not below normal, then you are simply experiencing the tiredness that we all feel after studying hard. Don’t blame it on your diabetes but have an evening off from your studies.

 Hospital operations

Recently, when I was in hospital to have my appendix removed, I was put on a ‘sliding scale’. Please could you explain this, especially as it might save other people in a similar position from worrying?

We agree that the expression ‘sliding scale’ does sound rather alarming - but it is nothing to worry about. It can be difficult to predict exactly how much insulin someone will need during and after an operation. The way round this is to use a ‘sliding scale’ so that more insulin is given if the glucose in the blood is high. This is usually monitored every 1-4 hours and the insulin adjusted accordingly. Nowadays, during an operation, insulin is often given straight into a vein using a slow infusion pump. Most surgicalwards have machines for measuring blood glucose and by doing this regularly the dose of insulin can be adjusted according to the result. In this way, diabetes control can be carefully regulated throughout the operation and until the person is eating again. At this stage the insulin may be given by 3 or 4 injections a day, the dose given at each injection being determined from the amount of insulin according to the ‘sliding scale’.

Are there any problems with surgery for a child with diabetes?

Surgical operations on children usually involve a general anaesthetic and it is advisable to have nothing to eat or drink (nil by mouth) for 6 hours before the anaesthetic is given. Any difficulties caused by this period of fasting can be overcome by a glucose drip into the vein. The normal insulin injection is not given on the day of operation but small regular doses are either injected under the skin or pumped continuously into the vein.

The dose of insulin is adjusted according to the blood glucose level. In minor operations where people are expected to be eating an hour or so later, these elaborate procedures may not be necessary and insulin may simply be delayed until the next meal is due. If an emergency operation is necessary, it is important that the doctors know that you have diabetes. This is another good reason for wearing an identification bracelet or necklace.

Must I tell my dentist that I have diabetes and will this affect my treatment in any way?

Having diabetes will not affect your dental treatment at all. However, it is important to remove all possibility of a hypo while you are in the dentist’s chair. If you are on insulin, warn your dentist that you cannot run over a snack or mealtime. It is less embarrassing to mention this before the start of a session than to have to munch glucose tablets while the dentist is trying to administer treatment.

Obviously you must warn your dentist if he plans to give youdental treatment needing a general anaesthetic, this is usually done in hospital.

Is someone with diabetes more likely to suffer from tooth decay or gum trouble?

 There is an increased risk of infection in people who are poorly controlled. The gums may become infected and this in turn may lead to tooth decay. However, someone who is well controlled is not prone to any particular dental problem – in fact, there is a positive advantage to avoiding sweets, which cause dental caries (tooth decay).

I have been told that, as I have diabetes, I don’t have to pay for dental treatment. Is this true?

No. Dental treatment is not free to people who have diabetes. If you are entitled to benefits such as Income Support, you may be entitled to some help with the cost of treatment. any form of heavy sedation. If someone on insulin is to have

 

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