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Understand and Prevent Diabetes

(38) Diabetes

Children with diabetes

Care of Children With Diabetes in the School and Day Care Setting

Diabetes38

The child with diabetes

 My 5-year-old son has had diabetes since he was 18 months and he is only 3' 2" (96 cm) tall. I have been told that he is very short for his age. The doctor says that poorly controlled diabetes could be slowing his growth. Is this true?

The average height for a 5-year -old boy is 3' 6" (108 cm), so your son is certainly short for his age. Having high glucose levels for several years could be the cause of this. If you now keep his dia-betes under control and make sure that he has plenty to eat, he should grow rapidly and may even catch up with his normal height. However, his short stature may be due to a growth disorder and may need further investigation.

I have been told not to expect my daughter to be as tall as she would have been had she not had diabetes. Is this true? If so, what can I do to help her reach her maximum height?

Unless your daughter’s diabetes control has been very poor, there is no reason why she should not reach her proper height without any special encouragement. We know of one 16-year-old boy who is 6' 2" (165.8 cm) tall and has had diabetes for 15 years. Diabetes does not have to stunt your growth.

My 6-year-old daughter has had diabetes for 4 years. She is on 12 units of Monotard insulin, once a day. Her urine test in the morning is always 2% and the teatime test 1%. My own doctor is satisfied with her tests and says that negative tests in a child of this age mean a risk of hypos. However, the school doctor says her diabetes is out of control and she should have two injections a day. What do you advice?

Until a few years ago most doctors did not try to achieve close control of diabetes in children. It was considered good enough if the child felt well and was not having a lot of hypos. The feeling nowadays is that good control is important to allow normal growth and prevent long-term complications. In the first place, you should start measuring your daughter’s blood glucose. This will tell you how serious her early morning high glucose actually is, and also whether she is running the risk of a hypo at any other time of the day. It is likely that she will need an evening injection to control her morning blood glucose. It is true that keeping her blood glucose down towards normal may make a hypo more likely. Mild hypos do not cause any harm and even severe reactions do no damage, except to the parent’s confidence! You must not worry about a few days or weeks of poor control and you will never achieve perfection in a little girl whose activities and lifestyle are changing daily.

My son, aged 10, started insulin last year and his dose has gradually dropped. Now he has come off insulin completely and is on diet alone. Will he now be off insulin permanently?

No. There is a 99.9% chance that he will have to go back on insulin. This so-called ‘honeymoon period’ can be very trying as it raises hopes that the diabetes has cleared up. Unfortunately, this very, very rarely happens in young people. Are there any special schools for children with diabetes?

There are no special schools for children with diabetes and they would not be a good idea. It is most important that young people with diabetes grow up in normal surroundings and are not encouraged to regard themselves as ‘different’. These children should go to normal schools and grow up in a normal family atmosphere.

I think my newly diagnosed son is using his insulin injections as a way of avoiding school. I can’t send him to school unless he has his insulin but it sometimes takes ages before I can get him to have his injection. I have two younger children and a husband whom I also have to help to get to school and work. How should I cope with my temperamental son?

You raise several related points. Firstly, you assume that he is using his insulin injections to avoid school. You may be right if he resisted going to school before developing diabetes. In this case you should try the same tactics that you used before. Alternatively, his dislike of school could be related to the diabetes, for example an overprotective attitude by sports instructors, frequent hypos or embarrassment about eating snacks between meals. If you suspect such difficulties, a talk to your son and his form teacher might clear the air. He may in fact be happy about school but actually frightened of his insulin injections so that things get off to a slow start in the morning. Problems with injections have been reduced with the introduction of insulin pens, but some children focus their dislike for diabetes as a whole on the unnatural process of injecting themselves.

Diabetes UK has produced an Information for Schools and Youth Organizations Pack to help parents communicate with the school. It contains information to be given to teachers and those responsible for children with diabetes. You can contact Diabetes UK for a copy of this publication.

When my son starts school, would it be better for him to return home for lunch or let him eat school dinners?

It depends largely on your son’s temperament and attitude to school. Some 4-year-olds skip happily off to their first day at school without a backward glance (much to their mother’s chagrin), while other perfectly normal children make a fuss and have tummy aches at the start of school. Diabetes will tend to add to these problems. You will have to talk to his teachers and it would be worth asking their advice and making sure that someone will take the responsibility of choosing suitable food for your son – you can’t leave that to a 4- or 5-year-old child.

My 10-year-old son has recently been diagnosed with diabetes. What is the best age for him to start doing his own injections?

The fear of injections may loom large in a child’s view of his own diabetes. Many children actually make less fuss if they do their own injections and most diabetes specialist nurses would encourage a 10-year-old to do his own injections right from day one. We know a girl who developed diabetes at the age of 6 and who gave herself her own first injection without any fuss – and has been doing so ever since. Insulin pens take a lot of the horror out of injections. If you do have an injection problem or if you want your son to have a good summer holiday, encourage him to go on a Diabetes UK holiday – you will find details in Balance or contact the care interventions team of Diabetes UK.

When I heard that I was to have a child with diabetes in my class (I am a junior school teacher), I read up all I could about diabetes. Most of my questions were answered but I cannot discover what to do if the child eats too much sugar. Will he go into a coma? If so, what do I do then?

Eating sugar or sweets may make his blood glucose rise in which case he may feel thirsty and generally off-colour. Coma from high blood glucose takes some time to develop and there is only cause for concern if he becomes very drowsy or starts vomiting. If this does happen, you should contact his parents. A child who is vomiting with poor diabetes control probably needs to go to hospital.

The most common sort of coma, which may occur over a matter of 10 minutes, is due to a hypo. In this case the blood glucose level is too low and he needs to be given sugar at once. The causes of hypo are delayed meals, missed snacks or extra exercise.

Can I apply for an allowance to look after my son who has frequent hypos and needs a lot of extra care?

Yes, as the parent of a child with unstable diabetes you can apply for a disability living allowance, which is a non-means-tested benefit. Many people in your position have successfully applied and feel that it provides some recognition of the burden of being responsible for a child with diabetes, especially if hypos are a major problem.

There is an opposing view that diabetes should not be regarded as a disability and that applying for an allowance fosters a feeling that the child is an invalid.

My little boy has diabetes and is always having coughs and colds. These make him very ill and he always becomes very sugary during each illness despite antibiotics from my doctor. Could you please give me some guidelines for coping with his diabetes during these infections?

Yes, of course.

I am headmaster of a school for deaf children and one of my pupils developed diabetes two years ago. Since then his learning ability has deteriorated and I wondered if this had any connection with his diabetes?

No. Diabetes in itself has no effect on learning ability and there are plenty of children with diabetes who excel academically. Poorly controlled diabetes with a very high blood glucose could reduce his powers of concentration. Hypoglycaemic attacks are usually short lasting but he could be missing a few key items while his blood glucose is low and be unable to catch up. At a psychological level, the double handicap of deafness and diabetes could be affecting his morale and self-confidence. Perhaps he would be helped by meeting other boys of his age who also have diabetes. This often helps children to realize that diabetes is compatible with normal life and activities. Contact Diabetes UK who can help you in this area.

My son was recently awarded a scholarship to a well-known public school but when they found he had diabetes, he was refused admission on medical grounds. They can give no positive reason for this and our consultant has tried very hard to make them change their minds. Why should he be so penalized?

This was a disgraceful decision based on old-fashioned prejudice. It looks as if nothing will make the school change its mind but, if Diabetes UK were told, they might have brought more pressure to bear. The Disability Discrimination Act will also cover access to education. You could also consider seeking legal advice.

 Should my son tell his school friends about his diabetes?

It is very important that your son tells his close friends that he has diabetes. He should explain about hypos and tell them that, if he does behave in an odd way, they should make him take sugar and he should show them where he keeps his supplies. If your son shows his friends how he measures his blood glucose, they will almost certainly be interested in diabetes and be keen to help him with it. We know several young people who bring their closest friend to the hospital diabetes clinic with them. As he becomes older and spends more time away from home, your son will come to depend more on his friends.

My 10-year-old son moves on to a large comprehensive school in a few months time. Up until now he has been in a small junior school where all the staff knows about his diabetes. I worry that he will be swamped in the ‘big’ school where he will come across lots of different teachers who know nothing about his condition. Have you any advice on this problem?

Moving up to a big comprehensive school is always a daunting experience and is bound to cause the parents of a child with diabetes extra worry. The important thing is to go and talk to your son’s form teacher, preferably before the first day of term when he or she will have hundreds of new problems to cope with.

Assume that the teacher knows nothing about diabetes and try to get across the following points.

• Make sure that they know your child needs daily insulin injections.

• He may need to eat at certain unusual times.

• Describe how your son behaves when hypo and emphasize the importance of giving him sugar. If he is hypo do not send him to the school office or to home alone.

• Staggered lunch hours may be a problem as he may need to eat at a fixed time each day.

• If he needs a lunchtime injection, then you need to arrange with his teachers how he should store and have access to his insulin, syringe or insulin pen, and blood testing equipment.

• You will need to be told if he is going to be kept in late (e.g. for detention) as parents tend to worry if their children fail to show up.

• Ask the form teacher to make sure all your son’s other teachers know these facts.

Diabetes UK supplies a School Pack, which should help explain diabetes to his teachers and it is especially important to speak personally to his sports and swimming instructors. If there are problems with the school over such things as sports, outings or school meals, your diabetes clinic may have a diabetes specialist nurse or health visitor who could go to the school and explain things. You will probably have to repeat this exercise at the beginning of every school year.

What arrangements can I make with school about my 9-year-old daughter’s special requirements for school dinners?

It is important to go and see the head teacher and preferably the caterer to explain that your daughter must have her dinner on time. Explain that she needs a certain amount of carbohydrate in a form that she will eat and that she should avoid puddings containing sugar. If your diabetes clinic has a diabetes specialist nurse or health visitor, she may be able to go to the school and give advice.

Most parents of children with diabetes get round the whole problem by providing a packed lunch. This means that you have more control over what your daughter eats and you can supply the sort of food she likes and what is good for her. Point out to your daughter that it would be best for her to eat the contents of her own lunch box, and not to swap them with other children! When she goes on to secondary school she may be faced with a cafeteria system. This should allow her to choose suitable food but she may also choose unsuitable items and try to exist on jam doughnuts.

My son has diabetes. Can I allow him to go on school trips?

In general the answer is yes, but for your own peace of mind you would want to be satisfied that one of the staff on the trip would be prepared to take responsibility for your son. Day trips should be no problem as long as someone can be sure that he eats on time and has his second injection if necessary. At junior school level, long trips away from home, especially on the continent, could be more difficult and it really depends on you finding a member of staff that you can trust. They will need to keep an eye on your son and to know how to cope sensibly with problems like a bad hypo. Once in secondary school most children manage to go away on trips with the school, scouts or a youth group. Of course one of the adults in the party should be responsible, but as your son gets older he will be better able to look after himself.

Diabetes UK has the following check list for things to take on school trips and holidays:

• Identification necklace or bracelet

• Glucose

• Insulin, insulin pen (or syringe), needles

• Testing equipment for blood glucose

• Food to cover journeys with extra for unexpected delays

• Hypostop Gel.

My 10-year-old child has heard about Diabetes UK camps from the clinic. I am a bit worried about letting him go off on his own for two weeks. Do you not think that I shouldwait a few years before sending him to a camp?

No, he’s not too young to go. Diabetes UK has been organizing holidays for children since the 1930s and it has become an enormous enterprise. About 500 children take part in these holidays each year, so in one sense your son will not be on his own. Young children love going on group holidays, and the fact of being with other children with diabetes gives them a great sense of confidence – for once they are not the odd ones out. The children learn a great deal from each other and from the staff. Your son will have an exciting holiday and you will have a few weeks off from worrying about his diabetes.

Is it safe to let my little girl go on a Diabetes UK camp?

Perfectly safe. The care interventions team of Diabetes UK has had years of experience in running holidays for children. The average camp consists of 30–35 children who are supervised by the following staff:

• Warden, responsible for planning

• Senior Medical Officer, who is experienced in diabetes

• Junior Medical Officer

• 2–4 Nurses, usually with a special interest in diabetes and/or children

• 3 Dietitians

• 1–2 Deputy Wardens

• 8 Junior Leaders, young adults with diabetes themselves, who give up two weeks to help.

The staff/child ratio is about 1:2 and there is always close supervision on outings and all sports, especially swimming.

COPING WITH DIABETES DURING INFECTIONS

Insulin

• Never stop the insulin even if your son is vomiting. During feverish illnesses the body often needs more insulin, not less.

• During an illness it may be useful to use only clear (short-acting) insulin.

• You may have to give three or four injections a day as this is much more flexible and so you can respond more quickly to changes in the situation.

• Give one-third of the total daily insulin dose in the morning, as clear insulin only.

Food

• Stop solid food but give him sugary drinks, e.g. Lucozade 60 ml (10 g) or orange squash with two teaspoons of sugar (10 g).

• Milk drinks and yoghurt are an acceptable alternative for ill children.

• Aim to give 10–20 g of carbohydrate every hour.

Blood tests

• At midday, check his blood glucose and, if it is 13 mmol/litre or more, give the same dose of clear insulin as in the morning plus an extra 2 units.

• Repeat this process every 4–6 hours, increasing the dose of insulin if the blood glucose remains high.

• Once he is better, cut the insulin back to the original dose.

Ketones

• Check his urine for ketones twice daily. If these are +++, either your son needs more food or his diabetes is going badly out of control.

Vomiting

• Young children who vomit more than two or three times should always be seen by a doctor or specialist nurse to help supervise the illness.

They can become dehydrated in the space of a few hours and if vomiting continues they will need fluid dripped into a vein.

Unfortunately this means a hospital admission.

 

 

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(39) Diabetes

 Care Plan Presentation: Type 2 Diabetes in the Adolescent Population

Diabetes and Teens

Diabetes39

Diabetes and the adolescent

My 16-year-old son is only 5' 2" (157 cm) and very immature. I have heard that children with diabetes reach puberty a year or two later than anyone else. Will he grow later?

If your son is sexually underdeveloped, then he will certainly have a growth spurt when he goes into puberty. However, 5' 2" (157 cm) is undersized for a boy of 16. It could be poor diabetes control that has stunted his growth but there are other possible factors, including the physical stature of his father and yourself. If you are both a normal height, there could be some other medical reason for your son’s short size. It would be worth consulting your doctor or clinic doctor rather than blaming it automatically on his diabetes.

My daughter and I are getting extremely anxious although our doctor tells us there is nothing to worry about. She developed diabetes when she was 14 years old; 1 year after her periods had started. They stopped completely with the diabetes and have never started again, although we have now waited for 2 years. Is our doctor right to be calm and patient, or are we right to be worried?

A major upset to the system such as diabetes may cause periods to stop in a young girl. It is a little unusual for them not to reappear within 2 years and we should like to be certain that your daughter’s diabetes is well controlled and that she is not under-weight. Your doctor will be able to answer these two questions. If her control is good and she is of normal weight, then it would be reasonable to wait 1 or 2 years before embarking on further investigations. There is a very good chance that her periods will return spontaneously. If they do not return, nothing will be lost by waiting for another 2 years.

I am nearly 16 and have not started menstruating yet.  Is this because I have diabetes? Since I was diagnosed, I have put on a lot of weight.

On average, girls with diabetes do tend to start their periods at an older age. We assume from your question that you are now over-weight and this may be another cause for delay in menstruation. Presumably you have begun to notice other signs of puberty such as breast development and the growth of pubic hair. If so, you should make a determined effort to lose weight and control your diabetes carefully. This will involve a reduction in your food intake and probably an adjustment in your dose of insulin. If, after another year, you have still not seen a period then you should discuss the matter with your doctor.

My son has just heard that he will be going to university next year. While we are all delighted and proud of him, I worry because he will be living away from home for the first time. For the 7 years since he was diagnosed, I have accepted most of the anxiety and practical arrangement of his meals and he has done his best to ignore his diabetes. How is he now going to face it alone?

If your son is bright enough to get into university, he should be quite capable of looking after his diabetes. However, you are right to point out that your son’s attitude towards his diabetes is also important. All mothers worry when their children leave home for the first time and it is natural for a child with diabetes to cause extra worry. You can be sure, however, that the training you have given him over the years will bear fruit. Most children like to spread their wings when first leaving home and you can expect a period of adjustment to his new responsibilities. Provided that he realizes why you regard good control of his diabetes as important, he will probably become more responsible in good time. It would also be sensible for your son to contact the diabetes clinic in his university town, so that they can give him support if necessary.

How does diabetes affect my prospects for marriage?

We have never heard a young man or woman complain that diabetes has put off potential marriage partners, although we suppose it could be used as an excuse if someone was looking for a convenient way out of a relationship. If your diabetes has affected your own self-confidence and made you feel a second-class citizen, then you may sell yourself short and lose out in that way.

I have Type 1 diabetes and have recently made friends with a super boy but am frightened that he will be put off if I tell him I have diabetes. What should I do?

The standard answer is that you must tell your new boyfriend at the beginning. However, you have obviously found this a problem or you would not be asking the question. There is no need to broadcast the fact that you have diabetes. It would be possible to conceal diabetes completely from a close companion, although sooner or later he will inevitably discover the truth. Once you get to know him better, your best plan would be to drop a few hints about diabetes without making a song and dance about it, perhaps during a meal together. If the relationship grows, you will want to share each other’s problems – including diabetes. We have never known a serious relationship break up because of diabetes.

My 15-year-old son developed diabetes at the age of 12. Initially he was very sensible about his diabetes but recently he has become resentful saying that he is different from everyone else and blaming us for his disease. What do you suggest?

You must first realize that most people of all ages (and their parents) feel resentful at some stage about this condition, which causes so much inconvenience in someone’s life. Many 12-year-old children conform with their parent’s wishes and generally do as they are told. However, by the age of 15 other important pressures are beginning to bear on a developing young person. In the case of a boy, the most important factors in life are first his friends and secondly girls – or possibly the other way round! While you as parents are prepared to make allowances and provide special meals for example, most young lads want to join the gang and do not wish to appear ‘different’.

At a diabetes camp (which was restricted to hand-picked, well adjusted young adults with diabetes), the organizers were horrified to discover how angry the young people felt about their condition. Of course this anger will often be directed at the parents. We can only give advice in general terms that apply to most adolescent problems.

• Keep lines of communication open.

• Boost his self-esteem by giving praise where praise is due even if your own self-esteem is taking a hammering.

• Allow your son to make his own decisions about diabetes. If you force him to comply, he will simply avoid confrontation by deceiving you.

• Remember that difficult adolescents usually turn into successful adults.

Our 15-year-old daughter has had diabetes for 4 years and until recently has always been well controlled. Now it is very difficult to get her to take an interest in her diabetes and she has stopped doing blood tests. At the last clinic visit, the doctor said that her HbA1c was very high and he thought she was probably missing some of her injections.

I really do not know what to do.

This is a very upsetting situation for all concerned and unfortunately it is not uncommon. Diabetes is difficult because it places great demands and restrictions on people but in the short term they have nothing to show for their efforts. Non-compliance (not following the prescribed treatment) is very common and the reasons for it are very complex. Like most girls of her age, your daughter probably wants to lose weight and she may have discovered that allowing her glucose levels to float up is a very effective way of quickly losing a few pounds in weight. Thus there may be positive gain to your daughter in missing a few insulin injections.

There is no easy solution to this problem especially as many girls in this situation brightly turn up at the clinic and announce that ‘everything is fine’. Simply challenging your daughter and threatening her with the long-term complications of diabetes is unlikely to do much good. It is better to try and get her to realize that you understand that living with diabetes is not easy, and allow her to express her own feelings about it. Of course she may be at a stage of feeling that parents are light-years away from her own experience in which case she is more likely to unburden herself to a close friend, especially someone else with diabetes.

 

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(40) Diabetes

Diabetes, Long Term Complications

Living with Diabetes - Complications

DIABETES COMPLICATIONS

Diabetes40

Long-term complications

 Before insulin was discovered, people with diabetes did not survive long enough to develop diabetic complications as we know them today. In the early days after the great discovery, it was widely believed that insulin cured diabetes. We are now in a better position to realize that, although insulin produced nothing short of miraculous recovery in those on the verge of death and returned them to a full and active life, it is no cure for the condition. However, used properly, insulin results in full health and activity and a long life.

Life expectancy has increased progressively since insulin was first used in 1922 and there are now many thousands of people who have successfully completed more than 50 years of insulin treatment. Increased longevity has brought with it a number of the so-called ‘long-term complications’, some of which (such as heart disease and gangrene of the legs) occur not uncommonly in people who do not have diabetes and are generally considered to be inevitable consequences of the ageing process (we all have to die some time!). Others are not seen in people without diabetes.

These conditions are therefore considered the long-term complications specific to diabetes: the three most important are eye damage (retinopathy), nerve damage (neuropathy) and kidney damage (nephropathy). Diabetic retinopathy can lead to loss of vision and indeed is the commonest cause of blindness registration in people under 65 in the UK. Fortunately it leads to visual loss only in a small proportion of people. Diabetic neuropathy, by leading to loss of feeling, particularly in the feet, makes affected people susceptible to infections and occasionally gangrene, leading to the risk of amputation. It can also cause impotence. Diabetic nephropathy can cause kidney failure and is now the commonest reason for referral for renal dialysis and transplantation in the UK and Europe in young people, although again it occurs only in very small numbers.

It is not surprising that people dread the thought of diabetic complications. In the past they worried but did not ask about them as they were a taboo subject. They were only for discussion between doctors and not between doctor and patient. The world has changed and today people rightly demand to know more about their condition (‘Whose life is it anyway?’) and the majority now find out about the dreaded ‘complications’ soon after they are diagnosed. There are so many old wives’ tales circulating about diabetic complications and it is perhaps the most important area in diabetic counselling where the facts rather than opinions must be stated.

Although medical science has made impressive progress since the discovery of insulin, there is still a long way to go. The scientific evidence from studies of experimental diabetes in animals is strongly in favour of the specific complications of diabetes being directly related to the degree to which the blood glucose is raised. Conversely their prevention is possible by tight control of the blood glucose concentration. We believe that the specific diabetic complications in humans are also a direct result of a raised blood glucose level over many years and that they are all preventable by keeping blood glucose values and HbA1c values normal. This view has been supported by the results of a very large multicentre clinical trial in the USA – the Diabetes Control and Complications Trial (DCCT), and the UK Prospective Diabetes Study (UKPDS) in the UK, which conclusively proved that complications can be avoided by strict blood glucose control.

Some of the questions in this chapter relating to eyes and feet are not strictly questions about complications, but as they do not easily fit in anywhere else in the book they have been included in this chapter under their specific headings.

General questions

 Can someone who is controlled only by diet suffer from diabetic complications?

 Complications may occur with any type of diabetes. The cause of diabetic complications is not completely understood, although bad control of diabetes is the most important predisposing factor. The duration of diabetes (the length of time for which you have had it, diagnosed or not) is also important – complications are rare in the first few years and occur more commonly after many years.

People treated with diet alone are usually diagnosed in middle or later life. At the time of diagnosis, the disease may have been present for a long time, often many years, without the person being aware of it, and therefore without any attempt being made to control it. Thus it is not surprising that complications can occur in some people even when they are treated with diet alone. Good control in these people is clearly just as important as in people who have treatment with tablets or who have Type 1 diabetes.

My child has had diabetes for 3 years and I am trying to find out more about the disease. I recently read a book, which said that some people with diabetes may go blind. I don’t know if this is true and find it very upsetting. Surely they shouldn’t be allowed to write such things in books that young people might read?

You raise a very important matter. Diabetes was almost always fatal within 1 or 2 years of diagnosis until the outlook was revolutionized by the discovery of insulin. None the less, it still required a lot of work and experimental development in the manufacture of insulin before someone with diabetes was able to lead an almost normal life, with the aid of insulin injections, as they do today.

After several years it became obvious to doctors that some people were developing what we now call ‘chronic complications’ or ‘long-term complications’. It was clear that these took many years to develop. This became the object of a massive research drive, requiring the investment of much effort and many years of work by doctors and other scientists. We now understand how some of these complications occur, and we know how to treat them if they occur. We realize that strict control of diabetes is important in their prevention. For this reason, all doctors and other medical personnel treating people with diabetes spend much of their time and effort trying to help them improve their control and keep their blood glucose as near normal as possible. These complications do not occur in all people by any means, although nowadays, with people living longer than ever before, the complications are becoming more important.

You ask whether facts like these should be made available to people with diabetes. The majority of people like to be correctly informed about their condition, its management and its complications. Modern treatment involves increasing frankness between doctors and patients in discussing all aspects of the condition. A survey among our own patients with diabetes showed the majority expected to be told the facts about complications.

What are the complications and what should I keep a lookout for to ensure that they are picked up as soon as possible?

The complications specific to diabetes are known as diabetic retinopathy, neuropathy and nephropathy. Retinopathy means damage to the retina at the back of the eye. Neuropathy means damage to the nerves. This can affect nerves supplying any part of the body but is generally referred to as either ‘peripheral’ when affecting nerves supplying muscles and skin, or as ‘autonomic’ when affecting nerves supplying organs such as the bladder, the bowel and the heart. Nephropathy is damage affecting the kidney, which in the first instance makes them leakier, so that albumin appears in the urine. At a later stage it may affect the function of the kidneys and in severe cases lead to kidney failure.

The best way of detecting complications early is to visit your doctor or clinic for regular review. Regular attendance at the diabetes clinic is important so that complications can be picked up at an early stage and if necessary treated.

Prevention is, however, clearly better than treatment and, if you can control your diabetes properly, you will be less likely to suffer these complications.

I am very worried that I might develop complications after some years of having diabetes. Is it possible to avoid complications in later life? If so, how?

Yes. We believe that all people could avoid complications if they were able to control their diabetes perfectly from the day that they were diagnosed. There are now many people on record who have gone 50 years or more with Type 1 diabetes and are completely free from any signs of complications. The best advice we can give you on how to avoid complications is to take the control of your blood glucose and diabetes seriously from the outset and to attend regularly for review and supervision by somebody experienced in the management of people with diabetes. Focus on learning how to look after yourself in such a way that you can achieve and maintain a normal HbA1c level. If you can do that and keep your HbA1c normal, you can look forward to a life free from the risk of diabetic complications.

To what extent are the complications of diabetes genetically determined?

This is a very difficult question. Most specialists believe that there is a hereditary factor, which predisposes some people to develop complications and makes others relatively immune from them, but so far scientific proof of this is not very strong.

What is the expected lifespan of someone with Type 1 diabetes and why?

The lifespan depends to a very great extent on how old the person is when the diagnosis is made. The older the person at the time of diagnosis the closer their expected lifespan is to that of someone who does not have diabetes. Looking back to the past we know that, when diabetes was diagnosed in early childhood, the lifespan of people with Type 1 diabetes was generally reduced, mainly because of premature deaths from heart attacks and kidney failure. We know, however, that the lifespan has improved with better medical care. We believe that the life expectancy of a child diagnosed with diabetes in the 1990s is longer than ever previously possible and may be nearly as good as an equivalent child who does not have diabetes. We also know that longevity is greatest in people who make regular visits to their clinic and who keep their diabetes under strict control. Those who die prematurely are more likely to be those who do not attend clinic regularly, are not being supervised adequately and do not control themselves well, and who smoke.

My diabetes specialist has said that it does not follow that badly controlled people get all the side effects and ill health in later life; often the reverse is true. Is this really so?

There is an element of truth in this but the word ‘often’ should be replaced by ‘very occasionally’. Well controlled people rarely become ill and develop side effects, whereas people who have unstable and unbalanced diabetes often develop ill health and side effects in later life. This has been confirmed by the results of the Diabetes Control and Complications Trial (DCCT) in the USA, and the UK Prospective Study (UKPDS) in the UK.

For the last two years my cheeks have become increasingly hollow although my weight is static - is this due to diabetes?

Quite a lot of middle-aged and elderly people become slim up top and pear shaped below, whether or not they have diabetes. However, there is a rare form of diabetes called lipoatrophic diabetes and this could possibly be the explanation for the hollowing of your cheeks. This is not a recognized complication of diabetes but a rare form of the condition. Mention it to your doctor the next time you go to your diabetes clinic.

I have had diabetes for the past 10 years and have recently developed an unsightly skin condition on my shins. I was referred to a skin specialist who told me that it was related to my diabetes and would be very difficult to cure. What is it and why does it occur?

Necrobiosis lipoidica diabeticorum (otherwise known as necrobiosis) is a strange non-infective but unsightly condition that most commonly appears on the shins, although it may occasionally appear elsewhere. It may occur in people years before they develop diabetes or at any time thereafter. Nobody knows much about it and treatment can be very disappointing, but achieving good control of diabetes may help. Local steroid injections and freezing with liquid nitrogen (cryotherapy) have been tried without much success. With time the red raised patches quieten down and usually leave transparent scars. Diabetes UK have a necrobiosis network; this enables people with the condition to get in touch with others. You can contact the Diabetes UK Careline for more information.

 

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(41) Diabetes

DIABETES AND EYE DISEASE

Facts About Diabetic Eye Disease

Eye conditions related to Diabetes

Eye Complications

diabetes41

Eyes

 I had a tendency towards short-sightedness before being diagnosed as having diabetes. Is this likely to increase my chances of developing eye complications later on?

Short-sightedness makes not the slightest difference to developing diabetic eye complications – it has been said that those with severe short-sightedness may actually be less, rather than more, prone to retinopathy.

Vision may vary with changes in diabetes control. Severe changes in blood glucose levels can alter the shape of the lens in the eye and thus alter its focusing capacity. It is therefore common for those people with high blood glucose levels (i.e. with poor control) to have difficulty with distance vision - a situation that changes completely when their diabetes is controlled and their blood glucose reduced. When this occurs, vision changes again, so that a person experiences difficulty with near vision and therefore with reading. This can be very frightening, at least until it is understood. After 2 or 3 weeks, vision always returns to thesame state as before diabetes developed.

As someone with diabetes, I know I should have my eyes checked, but how often should this be?

If your diabetes is well controlled and your vision is normal and you have no signs of complications, then once a year is generally sufficient. It is important that you do have your eyes checked once a year by someone trained in this examination, since after many years diabetes can affect the back of the eye (the retina). The routine eye checks are aimed at picking this up at an early stage before it seriously affects your vision and at a stage where it can be effectively treated.

I have just been discovered to have diabetes and the glasses that I have had for several years seem no longer suitable, but my doctor tells me not to get them changed until my diabetes has been brought under control – is this right?

Yes. When the glucose concentration in the body rises, this affects the focusing ability of the eyes, but it is only a temporary effect, and things go back to normal once the glucose has been brought under control. If you change your glasses now you will be able to see better than but as soon as your diabetes is brought under control you will need to change them yet again. It is better to follow your doctor’s advice and wait until your diabetes has been controlled for at least a month before going to the optician again.

Who is the best person to check my eyes once a year?

This can be done by either the specialist in your diabetes clinic, the specialist in the hospital’s eye clinic, your general practitioner or your local ophthalmic optician if they are sufficiently well trained to do this.

You need to undergo two examinations. The first is to test your visual acuity, which is basically your ability to read the letters on the chart down to the correct line. The second is to have the back of your eyes looked at with an ophthalmoscope: this is the more difficult of the two examinations and can be done only by somebody with special training. These days some clinics offer a service to GPs that enables people to have the backs of the eyes photographed: the photographs are then examined by a specialist, and the results are sent to the doctor

.Last time I was having my eyes checked from the chart, the nurse made me look through a small pinhole. Why was this?

The pinhole acts as a universal correcting lens. If your vision was improved when looking through the hole, it indicates that you may need spectacles for distance vision.

When I was last at the optician’s, she put drops in my eyes. Why did she do that?

These drops enlarge the pupil and make it easier for the doctor to examine the back of your eye with an ophthalmoscope. It is sometimes not possible to examine the eye properly without dilating the pupil to get a clearer view. As these drops also paralyse the lens, which allows your sight to focus properly, you should not drive immediately after leaving the clinic. The effect of the drops may last as long as 12 hours. It is worthwhile taking sunglasses with you to the clinic if they are likely to put drops in your eyes, as otherwise bright sunlight can be very uncomfortable until the drops have worn off.

Why does diabetes affect the eyes?

A simple question but difficult to answer. Current research indicates strongly that it is the excess glucose in the bloodstream that directly damages the eyes, mainly by affecting the lining of the small blood vessels that carry blood to the retina. The damage to these vessels seems to be directly proportional to how high the blood glucose is and how long it has been raised. This is the reason why we all believe that it can be avoided by bringing the blood glucose down to normal.

I have had diabetes for 20 years and seem to be quite well. When the doctor looked in my eyes at my last visit he said he could see some mild diabetic changes and referred me to a clinic called the Retinopathy Clinic. Am I about to go blind?

There is no need for alarm. It would be surprising if, after 20 years of diabetes, there were not some changes in your eyes. He probably considers it appropriate that you should be seen by an eye specialist and maybe have some special photographs taken of your eyes in order to examine them in more detail and which will be of use for future reference.

I have been diagnosed with retinopathy. Can you explain more what this is?

Retinopathy is a condition affecting the back of the eye (the retina). It may occur in people with long-standing diabetes, particularly those in whom control has not been very good. There is a gradual change in the blood vessels (arteries and veins) to the back of the eye that can lead to deterioration of vision. This may be due either to deposits in a vital area at the back of the eye or to bleeding into the eye from abnormal blood vessels.

Retinopathy is usually diagnosed by examination of the eye with an ophthalmoscope, and it can usually be picked up a long time before it leads to any disturbance in vision. Treatment at this stage with a laser usually arrests the process and slows or stops further deterioration.

On a recent TV programme it was stated that people with diabetes over 40 years of age were likely to become blind. This has horrified me because my 9-year-old son has diabetes and unfortunately some of his school friends have told him about the programme. What can I say to reassure him?

Some damage to the eyes (retinopathy) occurs quite commonly after more than 20 years of diabetes. Retinopathy is, however, usually slight and does not affect vision. Only a very small proportion of people actually go blind, probably no more than 7% of those who have had diabetes for 30 years or more. Because of the tremendous advances that have occurred in diabetes over the last 20 or 30 years, this proportion will be much less when your son has had diabetes for 30 years. The figure is likely to be smaller in people with well-controlled diabetes and larger in those who are always badly controlled.

Can I wear contact lenses and if so would you recommend hard or soft ones?

The fact that you have diabetes should not interfere with your use of contact lenses or influence the sort of lens that you are given. Of greater importance in the choice of type would be local factors affecting your eyes and vision, and the correct person to advise you would be an ophthalmologist or qualified optician specialising in prescribing and fitting contact lenses. It would be sensible to let him or her know that you have diabetes and you must follow the advice given, particularly to prevent infection-but this applies to everyone, whether or not they have diabetes.

 I get flashes of light and specks across my vision. Are they symptoms of serious eye trouble?

Although people with diabetes do get eye trouble, flashing lights and specks are not usually symptoms of this particular problem. You should discuss it with your own doctor who will want to examine your eyes in case there is any problem.

My father who has diabetes now has developed cataracts. Is this too with his diabetes?

Cataracts occur in people who do not have diabetes as well as in those who do, and as such are not a specific diabetic complication, although they are more common in people with diabetes. There is a very rare form of cataract that can occur in childhood with very badly controlled diabetes, known as a ‘snowstorm’ cataract from its characteristic appearance to the specialist. The normal common variety of cataract seen in diabetes is exactly the same as that occurring in people without diabetes but is found at an earlier age. It is really due to the ageing process affecting the substance that makes up the lens of the eye. It develops wrinkles and becomes less transparent than normal.

Eventually, it becomes so opaque that it becomes difficult to see properly through it. His doctor should arrange for your father to see an eye specialist.

The last time I was tested at the clinic, I was told that I had developed microaneurysms. What on earth are these?

Microaneurysms are little balloon-like dilatations (swellings) in the very small capillaries (blood vessels) supplying the retina at the back of the eye. They are one of the earliest signs that the high blood glucose levels seen in poorly controlled diabetes have damaged the lining to these capillaries. They do not interfere with vision as such but give an early warning that retinopathy has begun to develop. There is some evidence to suggest that these can get better with the introduction of perfect control whereas, at later stages of diabetic retinopathy, reversal is not usually possible. Anyone who has microaneurysms must have regular eye checks so that any serious developments are detected at an early stage. You have picked up early so now is the time to make sure that your glucose level control is impeccable!

I shall be going to have laser treatment soon in my eyes.What will this involve?

Laser treatment is a form of treatment with a narrow beam of intense light used to cause very small burns on the back of the eye (retina). It is used in the treatment of many eye conditions including diabetic retinopathy. The laser burns are made in parts of the retina not used for detailed vision, sparing the important areas required for reading, etc. This form of treatment has been shown to arrest or delay the progress of retinopathy; provided that it is given in adequate amounts at an early stage before useful vision is lost. It is sometimes necessary to give small doses of laser treatment intermittently over many years, although occasionally it can all be dealt with over a relatively short period.

Your eyes will need continuous assessment thereafter, as it is possible that further treatment may be needed at any stage.

My doctor used the term ‘photocoagulation’ the other day. Is this the same as laser treatment? Will it damage my eyes at all?

Photocoagulation is indeed treatment of retinopathy by lasers. The strict answer as to whether it can damage your eyes is yes, but uncommonly. Occasionally the lesion produced by photo-coagulation can spread and involve vital parts of the retina so that vision is affected. Normally treatment is confined to the parts of the retina that have no noticeable effect on vision other than perhaps to narrow the field of view slightly. Photocoagulation can also occasionally result in rupture of a blood vessel and haemorrhage. After a great deal of photocoagulation, there is a slight risk of damage to the lens causing a type of cataract.

I have glaucoma. Is this related to diabetes?

Yes. Although glaucoma can occur quite commonly in people who do not have diabetes, there is a slightly increased risk in those who do. This is usually confined to those who have advanced diabetic eye problems (proliferative retinopathy).

Occasionally the eye drops that are put in your eyes to dilate the pupil to allow a proper view of the retina can precipitate an attack of glaucoma (increased pressure inside the eye). The signs of this would be the pain in the affected eye together with a blurring of vision coming on some hours after the drops have been put in.

Should this occur you must seek urgent medical advice either from your own doctor or from the accident and emergency department of your local hospital. It is reversible with rapid treatment but can cause serious damage if ignored.

Every time I receive my copy of Balance, Diabetes UK’s magazine, I have the impression that the print gets smaller. Is this true or is there something wrong with my eyes?

Eyesight tends to deteriorate with age, whether or not someone has diabetes. First, you should visit your optician and get your eyesight checked to see whether it can be improved with glasses, as this may be all that is required. You should mention the fact that you have diabetes to your optician. For people with severe retinopathy to the degree that reading becomes impossible, there are ways of helping. Balance, for example, is available to members of Diabetes UK as a cassette recording and this service is free of charge although, to satisfy Post Office regulations, you have to have a certificate of blindness before the cassette can be sent to you. Public libraries can also help – most carry a wide selection of books in large type and most also lend books on cassette. Some larger libraries now have Kurtzweil machines, which can translate printed material into speech. So, in effect, they can read to you, although the ‘voice’ sounds a little mechanical. This can be useful for any material that you feel is confidential, such as letters, where you might not want another person to read them to you. Libraries usually have these machines in rooms of their own so, once you have been shown how to use them, you can be quite private.

The Royal National Institute for the Blind also has an excellent talking book service. Diabetes - the ‘at your fingertips’ guide is available as a talking book from the RNIB.

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(42) Diabetes

 Diabetes: Foot care

How to look after your feet if you have diabetes

Diabetic Foot

diabetic-foot

Feet, chiropody and footwear

I have just developed diabetes and have been warned that I am much more likely to get into trouble with my feet and need to take great care of them - what does this mean?

If you keep your diabetes well controlled, have no loss of sensation and good circulation to your feet, and then you are no more at risk than a person without diabetes. In the long term people with diabetes are more likely to develop foot trouble and it pays to get into good habits – inspecting your feet daily, keeping your toenails properly trimmed and avoiding badly fitting shoes from the outset. When you have diabetes you should have access to the local NHS chiropodist (nowadays called a podiatrist), who will check your feet and advise you, free of charge, on any questions that you may have.

I have had diabetes for 10 years and as far as I can see it is quite under control and I am told that I am free from complications, but I cannot help worrying about the possibility of developing gangrene in the feet - can you tell me what it is and what causes it?

Gangrene is the death of tissues in any part of the body. It most commonly occurs in the toes and fingers. Gangrene also occurs in people without diabetes, and people with diabetes develop it only if they have a serious lack of blood supply to their feet or reduced sensation. It can also be caused by smoking, which is the main cause of clogged-up blood vessels. Generally it occurs only in older people and is related to the progressive hardening of the arteries that is part of the ageing process.

The other form of gangrene occurring in people with diabetes is caused by the presence of infection. This usually affects the feet of people who have reduced sensation because of diabetic neuropathy (see the introduction to this chapter). This can occur even in the presence of a good blood supply. Any infected break in the skin of your feet must be treated promptly and seriously. If you are worried about anything to do with your feet, then you should consult your doctor or chiropodist/podiatrist immediately.

As someone with diabetes, do I have to take any special precautions when cutting my toenails?

It is important for everyone to cut their toenails to follow the shape of the end of the toe, and not cut deep into the corners. Your toenails should not be cut too short, and you should not use any sharp instrument to clean down the sides of the nails. All this is to avoid the possibility of ingrowing toenails. If you have problems cutting your toenails consult your NHS chiropodist (podiatrist).

I have a thick callus on the top of one of my toes - can I use a corn plaster on this?

No. Do not use any corn remedies on your feet. They often contain an acid which softens the skin and increases the risk of an infection. Consult a State Registered Chiropodist to have it treated – as you have diabetes you should have access to an NHS chiropodist (podiatrist) who will treat you free of charge.

My son has picked up athlete’s foot. He has diabetes treated with insulin - do I have to take any special precautions about using the powder and cream given to me by my doctor?

No. Athlete’s foot is very common and is due to a fungal infection, which should respond quickly to the treatment with the appropriate antifungal preparation; this can be bought without prescription. Do not forget the usual precautions of making sure he keeps his feet clean, dries them carefully and changes his socks daily.

Will I get bunions because I have diabetes?

No. Bunions are no more common in people who have diabetes than in those who do not.

I have had diabetes for 25 years and I have been warned that the sensation in my feet is not normal. I am troubled with an ingrowing toenail on my big toe, which often gets red but does not hurt - what shall I do about it?

You should seek help and advice urgently in case it is infected. If so, you are at risk of the infection spreading without you being aware of it, because it would hurt less than in someone with normal sensation. This is potentially a serious situation, so see your doctor straight away.

 I am 67 and have had diabetes for 15 years. As far as I can tell my feet are quite healthy but, as my vision is not very good, I find it difficult to inspect my feet properly – what can I do about it?

Do you have a friend or relative who could look at your feet regularly and trim your nails?

If this is not possible, then the sensible thing to do would be to attend a State Registered chiropodist regularly. Ask your GP or diabetes clinic about local arrangements for seeing an NHS chiropodist (podiatrist).

Do I have to pay for chiropody?

Most hospital diabetes departments provide a chiropody (podiatry) service free of charge. Outside the hospital service, chiropody under the NHS is limited to pensioners, pregnant women and school children. Although local rules do vary, most districts consider people with diabetes as a priority group and do offer free chiropody. You should check locally before obtaining treatment. If you are seeing a chiropodist or podiatrist privately, make sure that he or she is State Registered (they will have the letters SRCh after their name).

What are the signs that diabetes may be affecting my feet?

There are two major dangers from diabetes that may affect the feet. The first is due to reduced blood supply from arterial thickening. This leads to poor circulation with cold feet, even in warm weather, and cramps in the calf when you are walking (intermittent claudication). This is not a specific complication of diabetes and often occurs in people who do not have diabetes. The major problem here is arterial sclerosis (hardening of the arteries), and smoking is a more important cause of this than diabetes. In severe cases this can progress to gangrene.

The second way that diabetes can affect the feet is through damage to the nerves (neuropathy), which reduces the feeling of pain and awareness of extremes of temperature. This can be quite difficult to detect unless the feet are examined by an expert.

The danger is that any minor damage to the foot, be it from a cut or abrasion or badly fitting shoe, will not cause the usual painful reaction, so that damage can result from continued injury or infection spreading. It is important that you should know whether the sensation in your feet is normal or reduced. Make sure that you ask your doctor this at your next clinic review.

My daughter has diabetes and often walks barefoot around the house. Should I discourage her from doing this?

It is well known that people with diabetes are prone to problems with their feet which are, for the most part, due to carelessness and can be avoided. The usual reason these problems occur is that, with increasing duration of diabetes, sensation in the feet tends to be reduced. Most people are unaware of this, and so the danger is that damage to the feet may be the first indication of the problem. By then it could be too late!

FOOT CARE RULES

Dos

• Do wash your feet daily with soap and warm water. Do not use hot water - check the temperature of the water with your elbow.

• Do dry your feet well with a soft towel, especially between your toes.

• Do apply a gentle skin cream, such as E45, if your skin is rough and dry.

• Do change your socks or stockings daily.

• Do wear well-fitting shoes. Make sure they are wider, deeper and longer than your foot with a good firm fastening that you have to undo to get your foot in and out. This will prevent your foot from moving inside the shoe.

• Do run your hand around the inside of your shoes each day before putting them on to check that there is nothing that will rub your feet.

• Do wear new shoes for short periods of time and check your feet afterwards.

• Do cut your toenails to follow the shape of the end of your toes, not deep into the corners. This is easier after a bath as your toenails will soften in the warm water.

• Do check your feet daily and see your chiropodist/podiatrist or doctor about any problems.

• Do see a State Registered chiropodist or podiatrist if in any doubt about foot care.

Don’ts

• Do not put your feet on hot-water bottles or sit too close to a fire or radiator, and avoid extremes of cold and heat.

• Do not use corn paints or plasters or attempt to cut your own corns with knives or razors under any circumstances.

• Do not wear tight garters. Wear a suspender belt or tights instead.

• Do not neglect even slight injuries to your feet.

• Do not walk barefoot.

• Do not let your feet get dry and cracked. Use E45 or hand lotion to keep the skin soft.

• Do not cut your toenails too short or dig down the sides of your nails.

• Do not wear socks with holes in them.

• Do not sit with your legs crossed.

• Do not smoke.

Seek advice immediately if you notice any of the following:

• Any colour change in your legs or feet.

• Any discharge from a break or crack in the skin, or from a corn or from beneath a toenail.

• Any swelling, throbbing or signs of inflammation in any part of your foot.

First aid measures

• Minor injuries can be treated at home provided that professional help is sought if the injury does not improve quickly.

• Minor cuts and abrasions should be cleaned gently with cotton wool or gauze and warm salt water. A clean dressing should be lightly bandaged in place.

• If blisters occur, do not prick them. If they burst, dress as for minor cuts.

• Never use strong medicaments such as iodine.

• Never place adhesive strapping directly over a wound: always apply a dressing first.

The dangers to the feet of children with diabetes, however, are really very slight and there is no reason to discourage your daughter from walking about barefoot at an early age.

What special care should I take of my feet during the winter?

In older people with diabetes, the blood supply to the feet may not be as good as in those who do not have diabetes and this will make their feet more vulnerable to damage by severe cold. As winter is cold and wet, we tend to wear warmer thick clothing, and shoes, which are comfortable in the summer, may be unpleasantly tight when worn with thick woolly socks or stockings. This may damage the feet and also make them more sensitive to the cold. It could numb the sensation completely. All these effects will be made worse if your feet become wet. Make sure your shoes are comfortable, fit well, and allow room for you to wear an adequately thick pair of socks, preferably made of wool or other absorbent material. Use weather-proof shoes, overshoes or boots if you are going to be out for any length of time in the rain or snow, and dry your feet carefully if they get wet. Do not put your cold – and slightly numb – feet straight onto a hot-water bottle or near a hot fire because you may find that, when the feeling comes back, the heat is excessive and chilblains may occur. Feet also need protection during the summer as wearing open sandals can cause problems from possible damage by sharp stones, etc.

How can I give continual protection to my feet?

It is extremely difficult. If the sensation in your feet is normal, then generally you have very little need to worry but, if there is even slight numbness of your feet, you should check them daily and seek the advice of someone else to look at the areas that you have difficulty in seeing. If your circulation is poor, try hard to keep your feet warm and well protected.

FEET FACTS

 

  • Minor cuts or abrasions can be covered with sterile gauze after use of a mild antiseptic cream.
  • Avoid using corn plasters – they contain acids which can cause problems.
  • Don’t prick blisters; instead treat as for a minor abrasion.
  • Corns, callouses or ingrowing toenails must always be treated by your chiropodist.
  • When your toenails need cutting, always do this after bathing.
  • Cut the nail edge following the shape of the end of the toe.
  • Don’t cut the corners of your toenails back into the nail grooves.
  • Avoid using a sharp instrument to clean the free nail edge or the nail grooves. If your skin is too dry, apply a small amount of emollient cream (e.g. E45).
  • Check and bathe your feet every day, then pat dry gently, particularly between the toes.
  • If your skin is moist, dab gently with surgical spirit and then dust lightly with talcum powder. Remove hot water bottles before getting into bed, and switch off your electric blanket.
  • If thick woollen bed-socks are worn, they must be loose fitting.
  • Be careful not to sit too close to radiators or fires.
  • Choose shoes which provide good support. They must be broad, long and deep enough. Check that you can wriggle all your toes.
  • Shoes should have a fastening.
  • Check shoes daily for any small objects, such as hairpins, stones or buttons.
  • If socks have ridges or seams, wear them inside out. Loose fitting ones are best. Avoid very hot baths.
  • Always dry your feet carefully after bathing.
  • Remove hot water bottles before getting into bed, and switch off your electric blanket.
  • If thick woollen bed-socks are worn, they must be loose fitting.
  • Be careful not to sit too close to radiators or fires.
  • Choose shoes which provide good support. They must be broad, long and deep enough.
  • Check that you can wriggle all your toes.
  • Shoes should have a fastening.
  • Check shoes daily for any small objects, such as hairpins, stones or buttons.
  • If socks have ridges or seams, wear them inside out. Loose fitting ones are best.

 

I have suffered from foot ulcers for many years and would be grateful if you could suggest something to help my problem.

You should not attempt treatment of this yourself but you should seek medical advice and expert chiropody. Foot ulcers in people with diabetes are usually caused by reduced sensation in the feet (neuropathy) and you should have your feet examined by your specialist to find out whether this is the case. If so, you need to attend for regular chiropody and to learn all the ways of avoid-ing trouble once sensation is reduced. You may need special shoes made by a shoe fitter (an orthotist), which your consultant or podiatrist can arrange.

I have so many other things to remember - can you give me a simple list of rules for foot care?

The list of foot rules that we have given is aimed specifically for those who have abnormalities of either blood supply (ischaemia) or nerve damage (neuropathy). If you have poor sight then you should get somebody else with good eyesight to help you inspect and care for your feet.

 

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