Type 2 DIABETES TREATMENT food Lifestyle WHAT YOU NEED TO KNOW Working in partnership with PACK SOME PEACE OF MIND... Diabetes UK Insurance Services provides comprehensive travel insurance, covering pre-existing medical conditions, with no upper age limit on single trip policies. What’s more, Diabetes UK receives a donation for every policy sold, at no extra cost to you. So what are you waiting for? Choose to protect yourself and your loved ones with the help of Diabetes UK Insurance Services. • • • • • • • • TRAVEL INSURANCE LIFE ASSURANCE HOME INSURANCE MOTOR INSURANCE RETIREMENT ESTATE PLANNING FUNERAL PLANNING HEALTH CASH PLAN Call 0800 731 7431 for a quote or more information. Quoting: TT2. Alternatively, visit www.diabetes.org.uk/services now for more information and a 10% discount off your travel insurance policy. Diabetes UK Insurance Services is a trading name of Heath Lambert Limited which is authorised and regulated by the Financial Services Authority. Registered Office: 9 Alie Street, London E1 8DE. Registered No.: 1199129 England & Wales. www.gallagherheath.com Gallagher Risk & Reward Limited is authorised and regulated by the Financial Services Authority. Registered Office: 9 Alie Street, London, E1 8DE. Registered No. 3265272 England & Wales. www.riskandreward.com Funeral plan is provided by Dignity Pre Arrangement Limited. A company registered in England No.: 1862158. VAT registered No.: 486 6081 14. 4 King Edwards Court, King Edwards Square, Sutton Coldfield, West Midlands B73 6AP Telephone No.: 0121 354 1557. Fax No.: 0121 355 8081. Part of Dignity plc. A British company. Registered with the Funeral Planning Authority. Key Retirement Solutions Limited. Registered in England No. 2457440. Registered Office: Harbour House, Portway, Preston, Lancashire, PR2 2PR. Telephone 08451 655955 Facsimile 0845 12 555 13. Key Retirement Solutions is authorised and regulated by the Financial Services Authority. All benefits payable are subject to BHSF Limited policy terms: Copies available on request. BHSF Limited is authorised and regulated by the Financial Services Authority. SD3890_A/18032013 Testing Hypos & hypers 14 Education Eating in Eating out 46 30 18 Welcome Welcome to What You Need to Know – Type 2 Diabetes. This is an introductory guide for adults who’ve recently been diagnosed with Type 2 diabetes. It also serves as a handy refresher for those who have had the condition for some time. Following diagnosis, it’s perfectly understandable that you may be experiencing a wide range of emotions. You may feel upset, angry, confused and even guilty. You may be asking yourself the question, �Why me?’ – and wondering how you will cope. This guide will answer a lot of your questions and address your doubts and concerns by giving you the facts. It takes you through diabetes care and living your day-to-day life – from work and illness, to socialising and travel. It also sheds light on some complications that you need to be aware of and the steps you can take to prevent them. It will also tell you where you need to go for more information. Plus, there’s lots of information about how Diabetes UK can support you as you continue to live your life to the full. 44 what’s inside... INTRODUCTION 5 Debunking the myths 6 What is diabetes? DIABETES CARE 8Medications 12 Moving to insulin 14Testing 18 Hypos & hypers 22 Long-term testing 24 The care to expect 30Education 31 Health information online FOOD 32 A healthy balance 34 Top tips for eating well 36Carbohydrates 40 Food labelling 44 Eating in 46 Eating out 50Alcohol 52 Religious fasting 53 Questions & answers 2013 Type 2 diabetes 3 Physical activityPregnancy Work 62 LIVING WITH DIABETES 55 Weight management 60 Calorie swaps 62 Physical activity 66 Accepting diagnosis 68 Telling people 70 Love life 72 Contraception 74 Pregnancy & labour 78 Illness & infections 80 Work & discrimination 82Travel 84Festivals 86Driving 88 Smoking & drugs ARTICLES & ADVERTISEMENTS Products and services advertised in this guide are not necessarily recommended by Diabetes UK. Although the utmost care is taken to ensure products and services advertised are accurately represented, it is only possible to thoroughly check specialist diabetes equipment. Please exercise your own discretion about whether or not an item or service advertised is likely to help you personally and, where appropriate, take professional advice from your medical advisor. Please note also that prices are applicable only to British buyers and may vary for overseas purchases. Diabetes UK policy statements are always clearly identified as such. ©Diabetes UK 2013 A charity registered in England and Wales (no. 215199) and in Scotland (no. SC039136). With thanks to all the contributors and advisors, and the volunteers who participated in photoshoots. Type 2 diabetes 2013 Driving 86 80 74 4 Travel 82 complications 90Cardiovascular disease (CVD) 92Retinopathy 94Neuropathy 96Nephropathy FURTHER INFORMATION 98 About Diabetes UK debunking the myths INTRODUCTION diabetes my   ths Myth: Eating lots of sugar causes diabetes Having lots of sugar has no direct effect on your risk of diabetes. Sugary foods are high in calories which can mean taking in more calories (energy) than your body needs, leading to weight gain. This increases the risk of Type 2 diabetes. Myth: It’s not safe to drive if you have diabetes Myth: People with diabetes cannot have sugar Having diabetes doesn’t mean having to have a sugar-free diet. People with diabetes should follow a healthy, balanced diet low in fat, salt and sugar, but they should still be able to enjoy a wide variety of foods, including some with sugar. If people with diabetes are responsible and have good control of their blood glucose levels they are just as safe on the roads as everyone else. Nevertheless, the myth persists that people with diabetes are unsafe to drive. i F or more on driving, see p86. Myth: People with diabetes should eat �diabetic’ foods Myth: People with diabetes can’t play sport People with diabetes are encouraged to exercise as part of a healthy lifestyle. Keeping active can help reduce the risk of complications such as heart disease. Sir Steve Redgrave, Olympic gold medal-winning rower, is an example of someone who has achieved great sporting achievements while living with diabetes. i For more on exercise, see p62. �Diabetic’ labelling tends to be used on sweets, chocolate, biscuits and similar foods that are generally high-calorie and often have lots of fat. Diabetes UK doesn’t recommend �diabetic’ foods for people with diabetes because these foods still affect blood glucose levels, are expensive and can cause diarrhoea. If people want to treat themselves occasionally then they should go for the real thing. i F or more on food, see p32. 2013 Type 2 diabetes 5 Introduction what is diabetes? Type 2 diabetes explained You may hear a lot of different and sometimes conflicting information about diabetes and how it affects people, which can be confusing. It’s important to get the right information from a trusted source, so here are some of the facts gullet liver stomach pancreas 6 Type 2 diabetes 2013 What is diabetes? Diabetes is a condition where your body can’t produce insulin, it doesn’t produce enough, or where your insulin doesn’t work properly. If you don’t have the right amount of insulin, or if your insulin isn’t doing its job properly, you can become very ill. What is insulin? It is a hormone that helps your body use the glucose in your blood to give you energy. Insulin is made by an organ called the pancreas, which lies just behind the stomach. It acts as the �key’ that �unlocks’ the body’s cells to let glucose in, which is then converted into energy. Where does glucose come from? Glucose enters the bloodstream when we digest carbohydrate from various kinds of food and drink, including starchy foods (such as bread, rice, potatoes), fruit, some dairy products, sugar and other sweet foods. The liver also produces glucose. In people without diabetes, insulin carefully controls the amount of glucose in the blood. What happens in someone with Type 2 diabetes? Type 2 diabetes develops when what is diabetes? the pancreas doesn’t produce enough insulin or when the insulin it produces doesn’t work properly (known as insulin resistance). As a result, glucose remains in the bloodstream and is unable to enter the cells where it can be converted into energy. This is why some people with untreated diabetes often feel tired. The body then gets rid of the excess glucose via the urine. This can make you pass more urine than usual and become dehydrated, which may lead to extreme thirst. What are the symptoms? The symptoms of undiagnosed Type 2 diabetes are the same as those you may experience if your blood glucose levels are higher than normal. These may include: • passing urine more often, especially at night • increased thirst • extreme tiredness • genital itching or regular episodes of thrush • wounds and cuts that take a long time to heal • blurred vision • losing weight without trying. What are the risk factors? Although you already have diabetes, you might want to encourage your family and friends to see if they are at risk and to look out for the signs of Type 2 diabetes. The earlier they take action, the sooner they can get the right care. People who are most at risk of Type 2 diabetes are: • aged over 40 years old (or over 25 if South Asian) • from a Black African, Caribbean or South Asian origin • those who have a parent, brother or sister with diabetes INTRODUCTION • overweight • women with a waistline bigger than 80cm (31.5in) • men with a waistline bigger than 94cm (37in), or 90cm (35in) for South Asian men • those who have ever had high blood pressure, a heart attack or a stroke • people taking anti-psychotic medication to treat a mental health condition • women who have polycystic ovary syndrome or have had gestational diabetes or had a baby weighing more than 4.5kg (9.9lb) • known to have pre-diabetes, impaired glucose tolerance or impaired fasting glucose. The more risk factors a person has, the greater their risk of developing Type 2 diabetes. How is Type 2 diabetes treated? There are three main treatments: • h ealthy eating and being physically active, or • healthy eating, being physically active and medication, or • healthy eating, being active, medication and insulin injections. Your diabetes healthcare team will talk to you about how to manage your diabetes. You may need to make lifestyle changes, such as eating more healthily and being more active, and – if necessary – losing weight. You may also need to take diabetes medication or have insulin injections – or both. Everybody is different and it can sometimes take a while to find out what works best for your diabetes. As Type 2 is progressive, your treatment may need to change over time – either the dose or the type of medication. Your doctor or nurse will work with you to find the treatment that’s right for you. Some people refer to Type 2 diabetes as �mild’ depending on how it is treated. Type 2 diabetes is not mild, it is a serious medical condition that won’t go away, but with the right treatment it shouldn’t stop you living a full life. It’s important that you understand what you need to do. 2013 Type 2 diabetes 7 Diabetes care MEDICATIONS your medication Alongside a healthy diet and physical activity, medication may also be used to control your diabetes K eeping good control of your blood glucose levels (as well as your blood pressure and blood fats) is the best way of avoiding the long-term complications associated with diabetes. Diabetes medications help to lower blood glucose levels, and they work in a number of different ways (see overleaf). When you are first diagnosed with Type 2 diabetes, your doctor may ask you to look at what you are eating, lose weight if necessary and be more active as a way of getting your blood glucose levels under control. This is because excess weight makes the insulin you are still producing work less effectively. These lifestyle changes work for some people and they are able to control their diabetes as a result. But others find their blood glucose levels stay high or start to rise again despite a period of time where lifestyle changes were controlling their levels. Doctors will then add in some form of medication. This is not used instead of a healthy lifestyle – you still need to eat healthily and be physically active. For some people, even this won’t be enough; Type 2 diabetes is a progressive condition and more than one type of treatment is likely 8 Type 2 diabetes 2013 to be needed over your lifetime. Some people who can initially keep control with one type of medication may, over time, need to change that medication or need to take several different types, or need to take insulin. This doesn’t mean they have done anything wrong – it’s just that the body needs more help to control diabetes and keep complications at bay. Your diabetes healthcare team will help you decide when (and if) your treatment needs to change. Which diabetes medication is best for me? This will depend on your own needs and situation, so you should discuss the types of medication available and the ones best suited to you with your healthcare team. Whichever medication you are prescribed, it will only work if you take it properly and regularly. Make sure your doctor or pharmacist explains how much to take, when to take it and discusses possible side effects with you. Know your medication When you’re given your prescription, it is important to know the name of your medication, what dose you should take and when. Diabetes medications are safe drugs but, like all medication, they can have side effects or react with other medicines you are taking. There are several different types of medication, which work in slightly different ways, and can have particular side effects. Ask your doctor, nurse or pharmacist about the medication you’re taking. types of medication There are several different groups (or types) of diabetes medication: • Biguanides • Sulphonylureas • Alpha-glucosidase inhibitors • Prandial glucose regulators • Thiazolidinediones (glitazones) • Incretin mimetics • DPP-4 inhibitors (gliptins) • SGLT2 inhibitors. These groups may contain more than one medication. Most medicines have two different names. One is the generic (proper) name. The other is the brand (trade) name given by the manufacturer. MEDICATIONS The important name to remember is the generic name. If you are unsure about whether you have the right medication, check with your pharmacist. If you feel you need more information on your medication(s) speak to your doctor, nurse or pharmacist. The Patient Information Leaflet (PIL) also has more information. This is produced by the manufacturer and is dispensed with your medication. combination medication The aim of any treatment is to keep blood glucose levels as close to normal as possible. As this is individual to each person, the target levels must be agreed between you and your diabetes team. To stay within your range you may need to take a combination of tablets, such as a sulphonylurea and metformin, or a combination of tablets and an injection. diabetes care Q& A What if I forget to take a tablet or a dose? You need to keep taking your tablets regularly to keep your diabetes under control. But if you do forget a dose, don’t double the amount when you come to take your next dose. If it is only an hour or two since your normal time for taking the tablet, just take it as soon as you remember. If it’s more than a few hours after, miss the dose out and take the next one at the usual time. If you frequently forget to take your tablets, discuss this with your doctor. It may be possible to simplify your treatment. Do I still need my medications when I’m ill and not eating? Yes. If you cannot eat your ordinary meals, try to have some snacks or soup, milk or fruit juice instead. Your doctor may suggest you test your glucose levels at least four times a day and keep a record of your results. If you are being sick and cannot keep anything down, contact your GP or diabetes clinic straight away. Read more about managing your diabetes when you are ill on p78. Side effects All medication has potential side effects and you should check the information leaflet supplied to see which side effects you might experience. Some side effects are just temporary while your body gets used to the treatment. Remember that you are unlikely to experience all side effects that are listed, and you may not experience any at all. If you do, speak to your doctor as there may be another type of diabetes medication you could try instead. Ask your doctor for advice if you notice an adverse change in your symptoms after moving to a new drug or any new side effects you think you have. You can also report unwanted side effects (not already included in the patient information leaflet) using the yellow card scheme, which is used is to collect information from on suspected side effects. Visit www.yellowcard.mhra.gov.uk, call 0808 100 3352 or pick up a card from your GP. 2013 Type 2 diabetes 9 Diabetes care MEDICATIONS Prandial glucose regulators Examples include repaglinide and nateglinide. Sulphonylureas Different sulphonylureas are available, examples include gliclazide, glipizide and glibenclamide. How they work Like the sulphonylureas, these stimulate the cells in the pancreas to make more insulin. However, unlike the sulphonylureas, they work very quickly but only last for a short time. There is also a risk of hypoglycaemia (low blood glucose levels). How they work They stimulate the cells in the pancreas to make more insulin. They also help the insulin to work more effectively. There is a risk of hypoglycaemia (low blood glucose levels). When to take them They should be taken within half an hour prior to each meal. If you miss a meal, the dose is not required. When to take them They are taken once or twice a day, with or shortly before, meals. Biguanides Metformin is the only biguanide used in the UK. How it works Metformin helps stop the liver producing new glucose and enables the body’s insulin to carry glucose into muscle and fat cells. It can also aid weight loss. When to take it Metformin is usually used as the first line of treatment, especially for people who are overweight. Metformin is taken two or three times a day, with a meal – to help the insulin work at the correct time. It is available as tablets for immediate release (up to three times a day) or prolonged release (usually once a day), and oral solution and powder for immediate release. Thiazolidinediones (glitazones) The only one in this group is pioglitazone. How it works Pioglitazone helps the body to overcome insulin resistance, enabling it 10 Type 2 diabetes 2013 to use its own natural insulin more effectively. When to take them Once or twice a day. It’s useful for overweight people and helps to prevent heart problems. muscle liver pancreas MEDICATIONS diabetes care Alpha-glucosidase inhibitors There is only one tablet of this type currently used in the UK, called acarbose. How it works It slows down the absorption of starchy foods from the intestine, slowing down the rise in blood glucose after meals. When to take it It should be chewed with the first mouthful of food or swallowed whole with a little liquid immediately before food. Incretin mimetics This is a non-insulin medication given by injection, examples include exenatide and liraglutide. How they work They increase levels of hormones called �incretins’. These hormones help your body produce more insulin as it is needed; reduce the amount of glucose being produced by the liver when it is not needed; reduce the rate at which your stomach digests food and reduce appetite. When to take them There are three types of incretin mimetics. The once-daily version (Victoza) can be given any time, but the twice-daily (Byetta) should be given within 60 minutes of the morning and evening meal – not after a meal. There is also a once weekly version called Bydureon. stomach kidney (located behind) DPP-4 inhibitors (gliptins) Examples in this group include sitagliptin, vildagliptin and saxagliptin. How they work They block the action of the enzyme DPP-4, which destroys the hormone incretin. Incretins help the body produce more SGLT2 inhibitors The only one in this group is Dapagliflozin. How it works It works by reducing the amount of glucose being absorbed in the kidneys so that it is passed out in the urine, reducing the amount of glucose in your blood. When to take it Once a day. Because of the way it works, your urine will test positive for glucose while you are on this medication. How effective it is depends on your kidney function. There is a risk of genital infections and urinary tract infections. insulin when it is needed – and reduce levels of glucose being produced by the liver when it is not needed. These hormones are released throughout the day and levels are increased at meal times. When to take them Depending on the type, they are taken once or twice a day with or without food. 2013 Type 2 diabetes 11 Diabetes care Moving to insulin Some people with Type 2 diabetes may find that over time they’re taking more than one medication, and that insulin may be an option. It sounds daunting, but with time it will become part of your daily routine treatment changes I f the medication you are taking is no longer able to control your diabetes on its own, insulin may be another option. This is because your pancreas is becoming less efficient in producing its own insulin. This often happens after several years on tablets. This problem may be eased by changing to a different type or a higher dose of medication or by taking several different types of medication together. But, if the problem persists, your doctor may recommend insulin instead of, or as well as, the tablets you’re taking. In some cases, you might only need insulin temporarily during an operation, for instance, to control blood glucose levels. Similarly, you may be advised to use insulin if you are pregnant or breastfeeding. In these cases, you may be able to go back to your original medication, but, for some, this will no longer be as effective and they’ll need to stay on insulin. If you need insulin, it will be explained what you need to do. 12 Type 2 diabetes 2013 Coping with starting insulin You may feel like you’ve done something wrong or you haven’t achieved all that was expected of you, but it’s not your fault that you have to take insulin. Diabetes is a progressive condition and over time it is unlikely that the treatment you were first given will continue to work as well. Using insulin just means that your body needs a bit more help to keep you healthy and minimise the risk of developing complications. Most people who change to insulin say that they feel much fitter and wish they had changed earlier. Talk to your diabetes healthcare team if you are worried. Once you’ve got over the initial fear of injecting, you will hopefully feel much better. Some of the symptoms of high blood glucose levels you may be experiencing will get better, too, eg you may feel less tired and less thirsty Starting insulin injections Insulin is a protein, so it can’t be taken in tablet form – otherwise it would be digested in the stomach and wouldn’t be able to work. This is why it needs to be injected via a small syringe or pen injector. Your diabetes healthcare team will show you how to inject insulin, work out which insulin is best for you and tell you when you will need to inject. You’ve probably been given a �pen’ injector device – pens are fairly easy to use and there is a whole range to suit different types of insulin. The needles used are very small because the insulin only needs to be injected under the skin (subcutaneously) – not into a muscle or vein. Once injected, it’s absorbed into small blood vessels and passes into the bloodstream Starting insulin injections doesn’t mean that you’ve developed Type 1 diabetes. You still have Type 2 diabetes but it is treated with insulin – changing treatment doesn’t change your condition. Moving to insulin Where to inject There are four main places: Arms* Stomach Stomach Bottom Bottom Thighs Thighs How to inject 1 2 ake sure your hands and the area you’re M injecting are clean. Eject two units of insulin into the air to make sure the tip of the needle is filled with insulin (called an �air shot’). 3 4 Choose an area where there is plenty of fatty tissue, eg tops of thighs or the bottom. If you have been advised to, lift a fold of skin (the lifted skin fold should not be squeezed so tightly that it causes skin blanching or pain) and insert the needle at a 90° angle. With short needles you don’t need to pinch up, unless you are very thin. Check with your diabetes healthcare team. * check with your diabetes healthcare team as arms aren’t suitable for everyone. where it gets to work. Most insulin prescribed today is genetically engineered �human’ insulin, which doesn’t involve the use of any animal – or indeed human – products. If you find your injections a little painful or uncomfortable, especially the first few, it may be because you are tense and anxious. But, as your confidence grows, they’ll get easier and become second nature. Keep on moving It’s vital that you rotate or change injection sites. If you keep injecting into the same site small lumps can build up under the skin. These won’t diabetes care 5 ut the needle in quickly. If you continue to find P injections painful, try numbing an area of skin by rubbing a piece of ice on the site for 15–20 seconds before injecting. 6 Inject the insulin, ensuring the plunger (syringe) or thumb button (pen) is fully pressed down and count to 10 before removing the needle. 7 8 elease the skin fold and dispose of the R used needle safely. Remember to use a new needle every time. Reusing a needle will make it blunt and can make injecting painful. look or feel very nice, and also mean that the insulin doesn’t work properly because it’s harder to absorb through the lumps. Also, don’t inject in the same spot within each site – change the spot that you use each time. By rotating injection sites and spots you can help avoid getting lumps (any that may have occurred will slowly disappear). This also applies if you are prescribed the non-insulin injection. 2013 Type 2 diabetes 13 Diabetes care TESTING time to test Some people with Type 2 diabetes test their blood glucose levels, so what does it involve? It is recommended to prick the side, rather than the middle of your finger Y ou may need to do some form of testing – either blood or urine – to understand more about how your diabetes is being managed. Whether or not you need to test should be assessed by your diabetes healthcare team; they should talk with you to decide if it’s right for you. If you go ahead with testing, your healthcare team should assess how you monitor your blood glucose levels every year (or more often if it’s needed) as well as checking that you know what to do with your results. Two ways to test The different ways you can test your blood glucose at home are: • Urine testing This involves holding a special strip under a stream of urine for a few seconds and comparing the colour change 14 Type 2 diabetes 2013 on the strip after a set amount of time (check the manufacturer’s instructions) with the chart on the strip container. This shows whether there is any glucose in the urine – a result of �none’ is the ideal. Urine testing gives a less accurate picture of your blood glucose level than blood testing, but your doctor may still feel that it’s suitable for you. It is less accurate because there is usually no glucose in your urine unless your blood glucose levels have been persistently over 10mmol/l. Also, it doesn’t give you an indication of what your blood glucose level is at the time you test, because the urine may have been produced several hours before. Urine tests also can’t tell you if your blood glucose is too low – which is important for people on insulin or certain diabetes medication. Since the amount of glucose in the urine is dependent on a person’s kidney function and this varies from person to person, urine tests aren’t always reliable and can cause confusion. • Blood testing To test your blood glucose, you prick the side (as opposed to the pad) of your finger with a special device and put a drop of blood on a testing strip, which is then read by a blood glucose meter. The strips for meters can only be read by the meter itself. Blood testing gives you an accurate �real time’ picture of your blood glucose levels. It can help you to maintain day-to-day control, find out if you are hypo (hypoglycaemia – low blood glucose levels), and also helps to provide information that can be used to prevent long-term TESTING complications. Your diabetes healthcare team will teach you how to do the test properly so that you can be sure your results are as accurate as possible and you know how to respond to these results. When to test Your diabetes healthcare team will help you to understand testing and together you will agree how many and what types of tests are best for you. Sometimes you may be advised to do a few tests at different times to get an overall picture of your diabetes control and show where changes in your treatment may be needed. You may also need to test more if you’re unwell, driving or doing physical activity. See p78, 86, and 62. Keeping control Good control means keeping your blood glucose levels as near normal as possible. Research has shown that good control of blood glucose levels as well as blood fats (including cholesterol) and blood pressure greatly reduces the chances of developing the long-term complications of diabetes. Testing and responding to the results appropriately can help you reduce the risk of these complications. If you test your blood, you should agree your individual target blood glucose range with your healthcare team. This usually means between 4–7mmol/l before meals and under 8.5mmol/l two hours after meals. Don’t panic if you have the odd result above the upper limit – this happens to everyone. If you’re testing your urine, you’re aiming for a negative result – but, again, don’t worry if you occasionally get a positive result. Good control also means understanding how your medication, food and activity affects your blood glucose. This will give you the confidence to adjust your Q& A My doctor always does a blood test, even though I take my results book with me to check-ups. Doesn’t he trust my records? The test that your doctor does measures your overall control for the last few weeks – it is not the same test as the ones you do at home. There are different types of this test. The HbA1c test is the most common and gives your average blood glucose level for the previous 8–12 weeks. This, along with the tests you do at home, help your doctor to see how well your treatment is working and to make any changes necessary. See p22 for more on the HbA1c test. diabetes care How to test blood glucose 1 Wash your hands rather than using wet wipes (these contain glycerine that could alter the result). 2 3 Make sure your hands are warm – if they are really cold it’s hard to draw blood, and fingerpricking will hurt more. rick the side of a P finger (not the index finger or thumb) – don’t prick the middle, or too close to a nail, because this can really hurt. 4 Use a different finger each time and a different part – this will hurt less. 5 Keep a diary of your results. This will help your helathcare team suggest adjustments to your treatment, if needed. Try the Diabetes UK smartphone app to keep track. www.diabetes.org.uk/ tracker-app 2013 Type 2 diabetes 15 Diabetes care TESTING “Quote” Your target range Target ranges are agreed between you and your diabetes healthcare team. For guidance, the general blood glucose target ranges for people with Type 2 diabetes are: – 4–7mmol/l before meals – less than 8.5mmol/l two hours after meals. treatment, activity, and what and when you eat, and avoid high or low blood glucose levels. Then you can fit diabetes into your life, rather than planning your life around it. Also, good control means taking the complications of diabetes seriously, doing your best to keep yourself healthy and minimising your risks – you need to make sure you are receiving all the essential health checks (see 15 healthcare essentials on p29). Choosing a meter Your diabetes healthcare team will usually provide you with a meter if a decision has been made that blood glucose testing is definitely for you. To monitor your blood glucose levels, not all people will be given a meter. Testing strips for the meter will be prescribed for you, depending 16 Type 2 diabetes 2013 on the amount you need. If you are choosing a blood glucose meter, it can be complex as new products come out all the time. Some manufacturers also produce computer software to enable you to look at trends in your levels. However, if you buy your own meter, you may not always get a prescription for testing strips – you’ll need to speak to your healthcare team about this. The Medical Devices Agency evaluates all blood glucose meters that are available in the UK and ensures that they meet international standards. If you’re at all unsure about the most suitable equipment for your needs, contact your healthcare team. They should help you to understand blood glucose monitoring, support you in using a meter that meets your needs and devise a care plan that suits you (see p24). ACTION POINTS • If you are testing your blood glucose, ask your diabetes healthcare team what targets you should be aiming for and what you should do about high/low results. • Make sure you know how to quality-check your blood glucose meter and how often you should do this. you’re not alone with TESTING diabetes bECome a member Join us today Diabetes UK is the leading charity that cares for, connects with and campaigns on behalf of all people affected by and at risk of diabetes. Over 300,000 supporters are the bedrock of the work we do at Diabetes UK to: • Help people manage their diabetes effectively by providing information, advice and support. • Campaign with people with diabetes and with healthcare professionals to improve the quality of care across the UK’s health services. • Fund pioneering research into care, cure and prevention for all types of diabetes. Every supporter makes a difference to the lives of those affected by diabetes. Members also receive balance every two months, with the latest information about living with diabetes. Join today. Call 0800 138 5605 and quote Tesco2 or visit www.diabetes.org.uk/Tesco2 Diabetes care hypos & hYpers managing highs & lows People who take certain medications or insulin may be at risk of hypos and once diagnosed you are still at risk of hypers. Understanding them will help you to manage them T he key to controlling diabetes is to balance your food, activity and medication. But it’s not always easy. When the balance isn’t right, you may develop hypoglycaemia (hypo – when blood glucose drops too low) or hyperglycaemia (hyper – when blood glucose rises too high). Hypos Hypoglycaemia (or hypo) means low blood glucose levels, ie when the blood glucose level drops below 4mmol/l. In people without diabetes, low blood glucose levels trigger the body to stop producing insulin and to release stored glucose to keep the body going. But, in people with diabetes, while this mechanism still works, it’s not so effective. Some people with Type 2 diabetes may need tablets or insulin injections to increase the amount of insulin circulating in the bloodstream. Insulin produced in this way can’t be �switched off’ so it will continue to work, even though blood glucose is too low. If your Type 2 diabetes is controlled by diet and physical activity alone or by diet and metformin or acarbose tablets, there is no risk of hypos. But if you are treating your diabetes with insulin, sulphonylureas or prandial glucose regulators, you are at risk of hypos (see p8). 18 Type 2 diabetes 2013 Explaining what hypos are all about to your friends and loved ones is a good idea Spotting the symptoms Hypos can come on quickly and you will tend to develop symptoms that will indicate that your blood glucose levels are dropping too low. Everyone has different symptoms, but common ones are: • feeling hungry • trembling or shakiness • sweating • anxiety or irritability • going pale • fast pulse or palpitations • tingling of the lips • blurred vision. Why do hypos happen? There’s no hard and fast rule why they happen, and sometimes there’s just no obvious cause. But some things that can mean it’s more likely include: • too much insulin • a delayed or missed meal or snack hypos & hYpers • not enough carbohydrate • unplanned physical activity (see p62) • drinking large quantities of alcohol or drinking alcohol without food (see p50). treating a hypo There are a series of steps to take when treating a hypo: Immediate treatment If you have tested your blood glucose and it is low, or you notice your hypo warnings, take action quickly or it’s likely to become more severe, and you may become confused, drowsy or possibly even unconscious or have a fit. Immediately treat with 15–20g of a fast-acting carbohydrate such as: • a sugary/non-diet drink • glucose tablets • sweets, eg Jelly Babies • fruit juice • glucose gel – this can be useful if you’re feeling drowsy and someone can help you, but should not be used if you are unconscious (glucose gel is available on prescription if you are treated with insulin). Hypo treatments vary, and the quantities vary from person to person. Choose the treatment that works best for you. But avoid food and drinks containing fat (eg chocolate, biscuits, milk). This is because fat delays the absorption of sugar, so won’t treat the hypo quickly enough. Retest Check your blood glucose after 15–20 minutes and, if it’s still low, repeat with the same treatment. Follow-on treatment To prevent your blood glucose levels dropping again, you may need to follow with 15–20g of a longer-acting carbohydrate, diabetes care such as: • half a sandwich • fruit • a small bowl of cereal • biscuits and milk • the next meal, if due. Explaining hypos to others Some people find explaining hypos to family, friends and work colleagues tricky, but it’s better to let them know in advance what might happen so that if and when you have a hypo, they can help you deal with it. Explain why they’ll sometimes see you eating or drinking sugary things, and tell them what to do if you can’t manage on your own. Some people find that they get irritable or stubborn when they go hypo, so you’ll need to let people know what to do to get you to eat or drink something. Severe hypos A severe hypo is when you need help from another person to treat it. If a hypo is untreated there is a risk that you may become unconscious. While this is not common, it’s important that you know what to do so you can be prepared: Hypos & everyday life There are a few things that you need to be aware of: Driving Hypos are most dangerous when you need all your concentration and co-ordination, such as driving a car. Even a mild hypo, because of its effects on the brain, can seriously impair your ability to drive (see p86 for details). Exercise Exercise will generally lower blood glucose levels. If your diabetes is treated with certain tablets or insulin, then you may be at risk of a hypo if you do intense exercise for a period of over an hour. So it’s sensible to check your glucose levels before and during the exercise and to keep some fast-acting glucose such as a non-diet drink close by. See p62 for more on physical activity. 2013 Type 2 diabetes 19 Diabetes care hypos & hYpers tops tip • If possible, you should be placed in the recovery position (on your side with your head tilted back) • If you have been given a glucagon injection kit (available as GlucaGen HypoKit), someone else can help you by injecting it, but only if the person you are with has been trained to use it. If you don’t have a glucagon kit available or you have not recovered within 10 minutes of receiving the glucagon injection, the person you are with should put you in the recovery position and call an ambulance immediately. • If you are unable to swallow or are unconscious, you should not be given anything by mouth and ambulance staff should be called straight away. Make sure your family and friends are aware. • Always tell your diabetes healthcare team if you have had a severe hypo as your treatment may need to be altered. Hypos 1 2 Keep hypo treatments with you at all times. 3 Make sure you carry some form of ID, an identity card, bracelet or necklace, so that if you ever become unwell or if you are unable to communicate in an emergency, people are aware that you have diabetes and can help. If you’re having nighttime hypos, test your glucose levels before you go to bed and during the night – ask your healthcare team about the time to test. ACTION POINTS • Try to understand the main causes of hypos and hypers and take steps to keep yourself safe. • Familiarise yourself with your warning signs and symptoms that a hypo or hyper is taking place and try to have your treatment available at all times. 20 Type 2 diabetes 2013 Hypers At the other end of the scale are hypers (hyperglycaemia), which happen when blood glucose levels go too high. Some of the reasons are: • a missed dose of medication • too little medication • eating too much carbohydrate food • over-treating a hypo • stress • being unwell with an infection. Symptoms include: • increased thirst • frequent urination • headaches • extreme tiredness. Treatment If your blood glucose level is high for just a short time, emergency treatment won’t be necessary. But if it stays high you need to take action: • M ake sure you drink plenty of sugar-free fluids. • If you are on insulin, you may need to take extra insulin. • If you are feeling unwell, especially if you are vomiting, you must contact your diabetes healthcare team for advice. hypos & hYpers diabetes care better to let people “It’s know in advance what might happen ” Q& A Should I keep my blood glucose levels high to avoid hypos? No. It can be harmful for you if you try to run your blood glucose levels consistently very high in order to avoid hypos. You may start to feel thirsty, go to the loo a lot and feel tired – basically you will feel like you did before you were diagnosed. Long-term high blood glucose levels can lead to complications (see p90 onwards). What are the main reasons for hypos? The most frequent cause is missing or delaying a meal, but occasionally it might be a mistake in your medication dose or unplanned exercise. Stress, or very hot or cold weather, also causes some people to have hypos. If there’s a simple explanation for the odd hypo, there’s no need to adjust your treatment. It’s only if you have frequent hypos at similar times or if you have a severe hypo that you may have to look at what you eat or your medication doses. Speak to your diabetes healthcare team for advice or if you have any concerns. You may also find that it helps to do more blood glucose tests. That way, you’ll be able to spot when your levels are likely to drop and take action, without running your levels too high all the time. How do hypos affect my blood glucose levels? After you’ve had a hypo, your blood glucose level may actually rise. If you are on insulin don’t be tempted to increase your dose. The rise may happen because you felt incredibly hungry during the hypo and ate to correct this. Your levels may also rise because hypos cause the body to mobilise its own glucose stores. Will hypos affect my quality of life? Unfortunately, occasional hypos may happen. But they should not be frequent or severe. If they are, contact your diabetes healthcare team. Try to build a picture of any hypos you have to see if there is a pattern in their occurrence. If there is, you may wish to alter your diabetes treatment with the help of your healthcare team. Why do some people have severe hypos without any warnings? Research suggests that people who keep their diabetes very tightly controlled may have problems in recognising hypo warnings. Research also shows that if you have one severe hypo without warnings, you’re more likely to have repeated episodes. And once you’ve had one severe hypo, you are at risk of further severe hypos, so you should take particular care. There is also some evidence that people who’ve had diabetes for a long while may have lost their hypo warnings. However, they can often regain them by adjusting their diabetes treatment. If you’re having problems, talk them through with your diabetes healthcare team. They’ll be able to give you individually tailored advice. 2013 Type 2 diabetes 21 Diabetes care long-term testing long-term control You’ll be invited for various tests at least once a year to check on your overall health now that you have diabetes. There will be particular targets to aim for M onitoring your health when you have diabetes is crucial to prevent some of the complications associated with the condition. This involves knowing your blood glucose, blood pressure and blood fat levels, and there are targets you should be aiming for. As well as day-to-day blood glucose testing, the HbA1c test (usually done from a fingertip blood test) measures your diabetes control over two to three months. This target and the others are: • H bA1c: below 48mmol/mol but 58mmol/l or below for those at risk of severe hypoglycaemia • Blood pressure: 130/80mm Hg or less • Blood fats: – total cholesterol: below 4mmol/l – LDL (bad fat): below 2mmol/l – HDL (good fat): 1mmol/l or above for men, 1.2mmol/l or above for women – triglycerides: 1.7mmol/l or below. Remember, target ranges are individual and your diabetes healthcare team may suggest a different target to you. • See p29 for 15 healthcare essentials. For more on complications, see p90. 22 Type 2 diabetes 2013 Q& A I have sickle cell anaemia and my doctor has said that he can’t do the HbA1c test on me. Why is this? HbA1c measures the amount of glucose that is being carried by the red blood cells in the body. But red blood cells are affected if you are anaemic, or have a condition like sickle cell anaemia or thalassaemia (all of which involve a lack of, or abnormal type of, haemoglobin – the �oxygen carrying’ part of the blood). So this means that the test will give a false result. DIABETES ? W O N K O T D E NE ? K L A T O T D NEE Our CARELINE is staffed by professional counsellors who have extensive knowledge of diabetes. They can provide information about diabetes, take the time to talk things through and explore emotional, social, psychological or practical difficulties you may be experiencing. The telephone service: • is available during working hours on all weekdays • provides access to a translation service for people who do not want to speak English • welcomes calls via Text Relay for people with a hearing impairment • offers recorded information on the most popular diabetes-related subjects out of hours. You can contact us directly any time between 9am and 5pm, Monday to Friday. EMAIL [email protected] CALL 0845 123 2399* WRITE TO Diabetes UK Careline, 10 Parkway, London NW1 7AA *The cost of calling 0845 numbers can vary according to the provider. Please check with your own provider for details, particularly about mobile phones as they can cost considerably more than landline calls. Or call 020 7424 1030 and your call will be connected directly to the Careline. A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2013 2013 Type 2 diabetes 23 Diabetes care THE care to expect YOUR CARE EXPLAINED It takes a team of professionals to provide the best possible diabetes care. Find out who’s in your team and what care and services to expect Y our diabetes healthcare team is made up of all the healthcare professionals who are involved in your care, but you won’t see them all together at the same time. Your diabetes care may be provided in different places depending on your specific needs, but most likely at your GP surgery. It is best to discuss with your GP the roles and responsibilities of those providing your diabetes care. It is important to identify the key members of your diabetes healthcare team and agree the name of the key contact, who you are likely to see most often. You may see some members of your team more often than others and they may change over time. To achieve the best possible diabetes care, it is essential for you to work in partnership with your diabetes healthcare team and use your combined experience and expertise to agree what care and support you need. Remember, the most important person in the team is you – because the decisions made will affect you. (See �Planning your diabetes care’, right). Your healthcare team will have a wealth of experience Planning your diabetes care The partnership between you and your diabetes healthcare team, where you are actively involved in deciding how your diabetes will be managed, is a process called �care planning’. During your appointments, you should: • discuss your concerns and questions with members of your diabetes healthcare team • work together to set realistic goals • decide how you are going to achieve these goals. Your healthcare team will have The goals you agree during a wealth of your discussionsexperience will form the basis of your care plan, which is the written summary of what you and your diabetes healthcare team are both going to do to help you to manage your diabetes. A paper copy of your care plan should be given to you by a member of your diabetes healthcare team. If not, ask for one. 24 Type 2 diabetes 2013 THE care to expect most important “The person in your diabetes team is you ” What care to expect It is important that you understand your diabetes and the healthcare you can expect so that you are an effective member of your own diabetes healthcare team. There are different stages that your care will go through: When you have just been diagnosed with diabetes, you should: • Have a full medical examination and discuss with a member of your diabetes healthcare team any immediate treatment you need; your concerns and unanswered questions; your feelings and reaction to being diagnosed. • Receive an explanation of what’s on offer for you to learn more about diabetes and keeping well. This includes diabetes education and self-management courses (see p30), as well as other sources of information and support. • See a registered dietitian to talk about what you usually eat, how this relates to your condition, and what other information and support will help you manage your food and diabetes. Once you have received initial information and treatment, your ongoing care includes: • A yearly formal care planning review with a doctor or nurse experienced in diabetes. This should include a discussion of your test results and examinations, as well as your experiences of living with diabetes and any other concerns, needs or anxieties. • Full review every year to check for complications (see the 15 healthcare essentials p29). diabetes care tops tip Appointments Before • decide what you need to know • write down the points you want to raise • bring your blood glucose meter and results record with you • bring any news features/stories or research that you have any questions about. During • listen actively – ask questions, give feedback and ask for clarification if you’re unsure of anything • make notes to help you remember what has been said • check you’ve covered your list. After • review what’s been said and agreed • make a note of anything you need to do before your next appointment. • Regular access to your healthcare team to assess your diabetes control. This could be every four to six months, or as agreed in your care plan. You should have the time to ask questions and to discuss your care. • Access to a member of your healthcare team for specific support and advice when you need it. This could be in person or by phone, email or text, depending on what is used in your area. 2013 Type 2 diabetes 25 Diabetes care THE care to expect As part of your ongoing care your healthcare team is there to support you to manage your diabetes. They will: • P rovide continuity of care, ideally from the same doctors and nurses, or if this isn’t possible, doctors or nurses who are fully aware of your medical history and background and are experienced in diabetes. They’ll work with you to continually review and update your care plan, including your diabetes management goals. • M ake sure that you understand and are involved in the decisions about your treatment or care. This means having access to your results with information about what they mean, so you can ask questions and make sure your personal goals are reflected in copies of any letters written about your diabetes. • A sk you how you are feeling and give you information on available emotional and psychological support. • If you need it, organise pre- and post-pregnancy advice together with your obstetric team. • E ncourage you to gain support from your friends, partner and/or relatives and from other people with diabetes. • Provide you with ongoing education sessions, appointments and information on different ways you can learn about diabetes, eg websites, books, support groups, courses and conferences. • Offer you a review of your medicines, which may be via your pharmacist. 26 Type 2 diabetes 2013 • G ive you information on the effects of diabetes and treatments when you are ill or taking other medication. • Give you information about how to dispose of your used sharps (injection needles and/or blood glucose monitoring lancets) and local arrangements for collection of sharps disposal boxes. • Help you access specialist services when you need them, for example specialist foot services. If your diabetes is treated by insulin or non-insulin injections your care should also include: • Contact (face-to-face, telephone, email or text messages) with your diabetes healthcare team. This will be frequent at first, as you learn how to inject, look after your insulin or non-insulin medication, syringes, injection pen and how to dispose of needles (sharps). • Being shown how to test your blood glucose and be informed what the results mean and what to do about them. • Being given supplies of, or a prescription for, the medication and equipment you need. • A discussion about hypo- and hyperglycaemia episodes, when and why they may happen and how to deal with them. • An examination of your injection sites to check insulin can be absorbed properly. • How illness can affect blood glucose levels and how to manage episodes of illness. If your diabetes is treated by other medication or by healthy eating and physical activity, your care should include: • information about testing your blood or urine glucose at home and a discussion of what the results mean and what to do about them • supplies of, or a prescription for, the medication and equipment you need (see below about �prescriptions’) • a discussion about hypoglycaemia (hypos) episodes if relevant to your treatment, when and why they may happen and how to deal with them. Prescriptions In the UK, people with diabetes who take diabetes medications are entitled to free prescriptions, but you’ll need a prescription exemption certificate. Talk to your GP, diabetes nurse or pharmacist about how to apply for one. Equipment such as test strips, lancets, syringes, insulin pens, pen needles and sharps boxes are all available on prescription. Your diabetes specialist nurse will usually provide you with a blood glucose meter and fingerpricking device. THE care to expect Hospital stay If you are admitted to hospital for any reason (diabetes related or not), here are a few tips to bear in mind: • If you are having a planned operation or examination, discuss a plan for your diabetes care in hospital at your preassessment appointment. The plan should include information about what will happen before, during or after your procedure. • If you wish to manage your diabetes care during your stay in hospital, you should have access to your own medication, hypo treatment and equipment (including blood glucose monitoring equipment) – if you don’t have everything to manage your diabetes, the appropriate hospital staff should be able to provide you with what you need. • If you’re admitted unexpectedly and you would prefer to use your own diabetes equipment, you could ask a friend, carer or relative to bring it in for you. • If you have any concerns about your diabetes care, speak to the hospital staff – they can contact the diabetes healthcare team if necessary. • After your stay in hospital, if any changes have been made to your treatment, you and your usual diabetes healthcare team should be informed of them and receive information about ongoing management. diabetes care Q& A I’m not happy with my healthcare. What can I do? If you are unhappy or dissatisfied with the care you are receiving, try to deal with minor irritations at the time and with the person involved. Look carefully and honestly at what happened. Persistent problems should be taken up with the person in charge of the surgery or clinic. If you are still unhappy, you can take your complaint further. There are a different series of steps to follow in each country within the UK. For more details, visit www.diabetes.org.uk/ your-concerns are entitled to “You free prescriptions if you treat your diabetes with medication ” ACTION POINTS • Discuss the roles and responsibilities of those providing your diabetes care with your GP so you know who to contact as and when. • Find out who the key members of your diabetes healthcare team are and agree the name of the person you’ll see most often. They will become your main contact. 2013 Type 2 diabetes 27 Diabetes care THE care to expect Meet your team It’s important to identify the key members of your diabetes healthcare team and agree the name of the key contact. This is the person you are likely to see the most often. You may see some members of your team more often than others and the individuals involved may change over time. It is best to discuss with your consultant or GP the roles and responsibilities of those providing your diabetes care. Your GP has overall responsibility for the care you receive at your local surgery. Some may play a central role in monitoring your diabetes and prescribing treatment. But others, who are not diabetes experts, may refer you to a clinic (either hospital or community) or a special diabetes centre. Practice nurses are based at your surgery and may provide your diabetes care. Some may 28 Type 2 diabetes 2013 have specialist knowledge of diabetes. Diabetes specialist nurses (DSNs) have special expertise in diabetes. They will usually provide telephone advice between your appointments. Some may advise on how to alter your medication. Most hospitals and community clinics have DSNs and some GP surgeries have DSNs visiting during diabetes clinics. Diabetologists are consultants who specialise in diabetes. They are usually based at a hospital clinic or specialist diabetes centre, although some areas have community diabetologists who provide diabetes care and support in community clinics. Registered dietitians work with you to assess your eating habits and help you make lifestyle and food choices in order to manage your diabetes. Everyone with diabetes should see a registered dietitian for individual dietary advice. Registered podiatrists manage foot problems related to diabetes. They advise on shoes, and check and treat conditions of the foot and lower limb. You should be referred from your hospital clinic or GP surgery, if necessary. Ophthalmologists are doctors with specialist training in the diagnosis and treatment of conditions that affect the eye. You should be referred from your hospital clinic or GP surgery. Pharmacists are based in all pharmacies and chemists. They give you supplies of medication when you provide them with a prescription from your GP. Many also provide lifestyle advice and medication reviews. Psychologists help you to cope with the impact that your diabetes has on your life. You should be referred from your hospital clinic or GP surgery, if necessary. THE care to expect diabetes care 15 healthcare essentials Having the right care is essential for the wellbeing of all people with diabetes. There is a minimum level of healthcare that every person with diabetes deserves and should expect. Here are the 15 essential checks and services you should receive. If you aren’t getting all the care you need, take this checklist to your diabetes healthcare team and discuss it with them 1 10 2 3 11 4 12 Get your blood glucose levels measured at least once a year. An HbA1c blood test will measure your overall blood glucose control and help you and your diabetes healthcare team set your own target. Have your blood pressure measured and recorded at least once a year, and set a personal target that is right for you. Have your blood fats (cholesterol) measured every year. Like blood glucose levels and blood pressure, you should have your own target that is realistic and achievable. Have your eyes screened for signs of retinopathy every year. Using a specialised digital camera, a photo of each eye will be taken and examined by a specialist who will look for any changes to your retina (the seeing part at the back of your eye). Have your feet checked – the skin, circulation and nerve supply of your feet should be examined annually. You should be told if you have any risk of foot problems, how serious they are and if you will be referred to a specialist podiatrist or foot clinic. Have your kidney function monitored annually. You should have two tests for your kidneys: urine test for protein (a sign of possible kidney problems) and a blood test to measure kidney function. Have your weight checked and have your waist measured to see if you need to lose weight. Get support if you are a smoker including advice and support on how to quit. Having diabetes already puts people at increased risk of heart disease and stroke, and smoking further increases this risk. Receive care planning to meet your individual needs – you live with diabetes every day so you should have a say in every aspect of your care. Your yearly care plan should be agreed as a result of a discussion between you and your diabetes healthcare team, where you talk about your individual needs and set targets. If you live in Northern Ireland care planning is different. 5 6 7 8 9  Attend an education course to help you understand and manage your diabetes. You should be offered and have the opportunity to attend courses in your local area. Receive paediatric care if you are a child or young person. You should receive care from specialist diabetes paediatric healthcare professionals. When the time comes to leave paediatric care, you should know exactly what to expect so you have a smooth change over to adult health services. Receive high-quality care if admitted to hospital. If you have to stay in hospital, you should still continue to receive high-quality diabetes care from specialist diabetes healthcare professionals, regardless of whether you have been admitted due to your diabetes or not.    Get information and specialist care if you are planning to have a baby as your diabetes control has to be a lot tighter and monitored very closely. You should expect care and support from specialist healthcare professionals at every stage from preconception to post-natal care. See specialist diabetes healthcare professionals to help you manage your diabetes. Diabetes affects different parts of the body and you should have the opportunity to see specialist professionals such as an ophthalmologist, podiatrist or dietitian. Get emotional and psychological support. Being diagnosed with diabetes and living with a long-term condition can be difficult. You should be able to talk about your issues and concerns with specialist healthcare professionals. 13 14 15 To find out how the 15 healthcare essentials are provided in your local area, visit www.diabetes.org.uk/Diabetes-Watch-online-tool 2013 Type 2 diabetes 29 Diabetes care EDUCATION Following the right course Courses may be taught in person (face-to-face or in groups) or online D iabetes UK advocates that all people with diabetes, should receive the education and support they need to enable them to manage their own condition. It is also part of the 15 healthcare essentials (see p29). Diabetes is a lifelong condition and having the understanding, knowledge and skills to effectively manage it can make a big difference to your life. This is why education is very important and should be offered to you. There are lots of different education courses available for people with diabetes and they vary in length and the types of things covered. They should include information about how to manage your diabetes through diet, physical activity and medication. The courses can take place in groups, one-to-one sessions or even online. 30 Type 2 diabetes 2013 There are a broad range of educational courses available for people with diabetes, to help you learn about and manage your condition, so it’s important to pick the one that is right for you Q& A When choosing an education course you should ask the following questions. • Is the programme relevant to my type of diabetes? • Can I commit enough time to complete the programme in full? • Is the programme run by qualified healthcare professionals? • Do I meet the requirements set out by the programme? • Am I happy to take a more involved and proactive role in my diabetes care? It is important that the course suits you, talk to your nurse and/or dietitian about what is available. What is structured education? It is a course that meets the criteria set by the National Institute for Health and Clinical Excellence (NICE). What are the criteria that the course should have? • a patient-centred philosophy • a structured, written curriculum • trained educators • be quality assured • be audited. ACTION POINTS i For more information and examples of the types of courses available, visit: www.diabetes.org.uk/ structured-education • Speak with your diabetes healthcare team about what local courses are available. health information online diabetes care caught in the web? Not all the information found on the internet is 100 per cent accurate. Here are some tips that will help you sift out the quality advice Ask your healthcare team to recommend some good websites A s we rely more and more on the internet for information, it’s tempting to accept that everything we discover is truthful. But when it comes to health information it always pays to be cautious. Following some simple guidelines will help you to steer clear of any unscrupulous traders and ditch out-of-date information and advice. • If there’s any health-related articles online that interest you, talk them through with your healthcare team. Remember to take a copy with you. • Ask your healthcare team to recommend good, relevant sites. • Be cautious about buying medical products via the internet. In most countries, selling and buying medical products online is an illegal activity. You’re far better getting your medical products at pharmacies or through your healthcare team. • Beware of sites offering a cure for diabetes. Research advances every day, but there’s no cure. • C heck that links on the site are still �live’. �Dead’ links tend to indicate that other information on the site will also be out of date. • B e critical. Remember that if it sounds unbelievable – it probably is. • D on’t be fooled by the use of high-tech websites. Just because a site looks good, doesn’t necessarily mean that the content will be high quality. • If you’re unable to check online information with your GP or member of your diabetes healthcare team, Diabetes UK Careline may be able to help you – call 0845 123 2399 or email [email protected]. • D on’t rely on search engines to find information and use a reliable source instead. See right for some recommended sites. There are also several good online diabetes forums. Generally the advice, shared knowledge and experience you’ll receive is very useful, but don’t change treatments or make any alterations to your lifestyle until you have discussed them with your healthcare team. Sites you can trust Diabetes UK www.diabetes.org.uk Diabetes Support Forum www.diabetessupport.co.uk NHS Direct www.nhsdirect.nhs.uk NHS Choices www.nhs.uk National Institute for Health and Clinical Excellence www.nice.org.uk Health Protection Agency www.hpa.org.uk/HPA 2013 Type 2 diabetes 31 FOOD a healthy balance Getting the balance right We know we’re meant to eat a healthy, balanced diet, whether we have diabetes or not. Here’s how to get it right E veryone needs to make sure they get enough fruit and vegetables, milk and dairy, carbohydrate and protein every day. And no food is off limits when you have diabetes – it’s fine to have a treat every now and again, just don’t overindulge. The foods you choose are an important part of your diabetes treatment, just like taking your medication, testing blood glucose and being active. Food can be divided into five groups: 32 Type 2 diabetes 2013 1 2 5 3 4 1Starchy foods Bread, rice, potatoes and pasta contain the all-important nutrient carbohydrate, which is broken down into glucose and used by the body’s cells as fuel. Try to choose those that are more slowly absorbed (have a lower Glycaemic Index, see p40), as these won’t affect your blood glucose levels as much. Starchy foods are naturally low in fat, and the high-fibre varieties are good for keeping your bowels regular and preventing digestive disorders. How much per day? 5–14 portions. One-third of your diet should be made up of these foods, so try to include them in all meals. What’s a portion? One portion is equal to: 2–4 tbsp cereal; 1 slice of bread; 2–3 tbsp rice, pasta, couscous, noodles or mashed potato; 2 new potatoes or half a baked potato; half small chapatti; 2–3 crispbreads or crackers. a healthy balance 2 Fruit & vegetables All of these foods are low in fat and calories, and packed with vitamins, minerals and fibre, which are vital for good health. They can help protect against stroke, heart disease, high blood pressure and certain cancers. How much per day? Aim for at least 5 portions. Fresh, frozen, dried and tinned fruit and veg all count. What’s a portion? Roughly what you can fit into the palm of your hand. It’s best to mix and match fruit and veg to get as wide a range of vitamins and minerals as possible. See p34, point 4 for some examples. 3 Dairy products Milk, cheese and yogurt contain calcium, which helps to keep your bones and teeth strong. They are also a good source of protein, but some can be high in fat, so choose lower-fat alternatives where you can. How much per day? Aim for 3 portions. What’s a portion? ¹/3 pint of milk; a small pot of yogurt; 2 tbsp cottage cheese; or a matchbox-sized portion of cheese (40–45g/1½oz). 4 Foods high in fat and sugaR Technically, your body doesn’t need any foods in this group, but eating them in moderation will still mean you are following a healthy, balanced diet. Sugary foods will raise your blood glucose, as will sugary drinks, so bear this in mind and choose diet or low-calorie soft drinks instead. It’s also worth remembering that fat contains a lot of calories, so try to reduce the amount of oil you use in your cooking and choose lower-fat alternatives where possible. FOOD How much per day? 0–4 portions (the fewer the better). What’s a portion? One portion is equal to: 2 tsp spread, butter, oil, salad dressing, sugar, jam or honey; 1 tbsp Bombay mix; rasher of bacon; ¹/3 of a vegetable samosa; 1 mini chocolate bar; 1 scoop of ice cream or 1 tbsp cream. 5 Meat, fish, eggs & pulses These foods are high in protein, which is needed for building and replacing muscle cells in the body. They also contain minerals, such as iron, which are needed for producing red blood cells. Omega-3 fish oils, found in oily fish such as mackerel, salmon and sardines, can help to protect the heart. Good sources of protein for vegetarians are beans, pulses, lentils, soya and tofu. How much per day? Aim to have 2–3 portions. What’s a portion? One portion is equal to: 60–85g (2–3oz) meat, poultry or vegetarian alternative; 120–140g (4–5oz) fish; 2 eggs; 2 tbsp nuts; 3 tbsp beans, lentils or dahl. The number of portions people need varies, and these are given as a guide. Your dietitian will be able to tell you how much you should eat. Seasoning Eating too much salt (6g/0.2oz or more per day) can raise your blood pressure, which can lead to stroke and heart disease, so limit the amount of processed foods you eat and try flavouring foods with herbs and spices instead. 2013 Type 2 diabetes 33 FOOD Top Tips TOP TIPS FOR EATING WELL There are many ways you can enjoy eating well. Small, simple changes all go a long way to improving your diet and help to protect your long-term health. Here are our top 10 tips… 1Eat regular meals 2INCLUDE CARBS It’s important not to skip your meals. Try to space them evenly throughout the day as this will help control your appetite and blood glucose levels – especially if you are on twice-daily insulin. 3 CUT THE FAT Eat less fat – particularly saturated fat – as a low-fat diet is healthier for you. So try: • unsaturated fats and oils, especially mono-unsaturated fats like olive oil and rapeseed oil, as these types of fat are better for your heart • using skimmed or semi-skimmed milk and other low-fat dairy products • grilling, steaming or baking foods instead of frying. Include starchy carbohydrate foods in your diet. Carbohydrate (carbs) affects blood glucose levels, so be conscious of how much you eat (see p36). The best carbs are those our bodies absorb slowly. Try: • pasta, basmati or easy-cook rice • granary, pumpernickel or rye breads • new potatoes, sweet potatoes and yams • oat-based cereals, such as porridge or natural muesli. ’T BE MEAN 5 DON WITH THE BEANS 4 34 TRY THE �FIVE A DAY’ RULE Aim for at least five portions of fruit or vegetables a day to give our bodies all the vitamins and minerals and fibre we need. A portion is: • 1 piece of fruit, like a banana or apple • 1 handful of grapes • 1 tbsp dried fruit • 1 small glass of fruit juice or fruit smoothie • 3 heaped tbsp vegetables. Type 2 diabetes 2013 rilliant beans, lovely lentils B and perfect pulses. They’re all low in fat, high in fibre, cheap to buy and packed with nutrition. They don’t have a big impact on blood glucose and may help to control blood fats (eg cholesterol). And there are so many to choose from: kidney beans, chickpeas, green lentils, and even baked beans. Try them: • hot in soups and casseroles, or cold in salads • in baked falafel, bean burgers and low-fat hummus and dahls. TOP TIPS FOOD AY �YES’ TO 7SLESS SUGAR 6 DISH UP THE FISH All types of fish are healthy, but top choices are oily fish like mackerel, sardines, salmon and trout. These contain polyunsaturated fat, called omega-3, which helps protect against heart disease. Aim to eat 2 portions of oily fish a week, ideally from a sustainable source. This doesn’t mean you need to eat a sugar-free diet. You can include some sugar in foods and baking as part of a healthy diet, just aim to have less of it. You can use sweeteners as an alternative to sugar, too. Some easy ways to cut back on your sugar intake are: • choosing sugar-free, no-added sugar or diet fizzy drinks and squashes • buying canned fruit in juice rather than syrup • reducing or cutting out sugar in tea and coffee. LOW 8 SDOWN ON THE SALT Reduce salt in your diet to 6g or less a day. Too much salt can raise your blood pressure, which increases your risk of heart disease and stroke. • 70 per cent of our salt intake comes from processed foods, so cut back on these types of food where you can. • Try flavouring foods with herbs and spices instead of reaching for the salt cellar. Remember, sugary drinks are an excellent treatment for hypos. 9 THINK BEFORE YOU DRINK The recommended daily alcohol limit for women is 2–3 units and 3–4 units for men. • 1 unit is a single measure (25ml) of spirits • half a pint (284ml) of lager, beer or cider has 1 to 1½ units, and a 175ml glass of wine up to 2 units. • Alcohol is high in calories. To lose weight, think about cutting back. • Never drink on an empty stomach as alcohol can make hypos (hypoglycaemia – low blood glucose level) more likely to happen if you are at risk of hypos. See p52 for more on alcohol. 10 DITCH �DIABETIC’ FOODS These products offer no benefit to people with diabetes and may still affect your blood glucose levels. They contain as much fat and calories as ordinary versions, they are expensive and can have a laxative effect. 2013 Type 2 diabetes 35 FOOD CarbohydraTes THE CARB CONNECTION Carbohydrates are often in the spotlight and there are conflicting stories about why we need them, what they really do, which ones are best and how much we should eat or not (in the case of lowand no-carb diets). So let’s go back to basics… WHAT ARE CARBOHYDRATES? There are two main types of carbohydrate – starchy carbohydrates and sugars. Starchy carbohydrates: These include bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. Sugars: These can be divided into naturally occurring sugar and added sugar. Natural sugars are found in fruit (fructose) and some dairy products (lactose). Added sugars are found in table sugar, glucose syrup, invert syrup and honey. Sugars can often be identified on food labels as those ingredients ending in �ose’, eg sucrose, glucose, lactose, fructose. Why do we need carbohydrate? Carbohydrate is a nutrient and is an important source of energy. All carbohydrates that you eat and drink are broken down into glucose, which is 36 Type 2 diabetes 2013 the body’s essential fuel that keeps us functioning – especially the brain. High-fibre varieties are important for keeping your bowels regular and preventing digestive disorders. How much do we need? It depends on your age, weight and activity levels. In �Getting the balance right’ (p32), we looked at carbohydrate portions – what they are and how much is needed. Remember that all carbohydrates break down into glucose, and the total amount you eat and drink will have an effect on your blood glucose levels, so being aware of how much carbohydrate you are eating could help you to achieve your optimal glucose control. If you’re taking fixed amounts of insulin, you may find it beneficial to have consistent amounts of carbohydrates on a day-to-day basis. Your dietitian will help you find the balance that suits you. FOOD Run towards a future without diabetes Run for team Diabetes UK It’s a great way to help you get fit and healthy, and help manage your diabetes. To sign up for a Bupa Great Run: CLICK www.diabetes.org.uk/bupa CALL 0845 123 2399 EMAIL [email protected] 2013 Type 2 diabetes 37 FOOD CarbohydraTes GI CONCEPT EXPLAINED You may have heard about the Glycaemic Index (GI), which is a ranking of carbohydratecontaining foods based on their overall effect on blood glucose levels. Here’s how you can take this into account when it comes to your diabetes F oods are given a GI number according to their effect on blood glucose levels. Glucose is used as a standard reference (GI 100) and other foods are measured against this. Slowly absorbed foods have a low GI rating, while foods that are more quickly absorbed have a higher rating. This is important because, when you have diabetes, choosing slowly absorbed carbohydrates instead of quickly absorbed carbohydrates, can help even out blood glucose levels. Research into low-GI diets has shown some benefits in HbA1c levels in people with Type 2 diabetes. They have also been linked with improved levels of �good’ cholesterol and a lower rate of heart disease. Does anything affect GI? Factors may include: • Cooking methods: frying, boiling and baking. 38 Type 2 diabetes 2013 • Processing and the ripeness of fruit and certain vegetables. • Wholegrains and high-fibre foods act as a physical barrier that slows down the absorption of carbohydrate. This is not the same as �wholemeal’, where, even though the whole of the grain is included, it has been ground up instead of left whole, eg some mixed grain breads that include wholegrains have a lower GI than wholemeal or white bread. • Fat lowers the GI of a food. For example, chocolate has a medium GI because of its fat content and crisps will actually have a lower GI than potatoes cooked without fat. • Protein lowers the GI of food. Milk and other dairy products have a low GI because they are high in protein and contain fat. If you only ate low-GI foods, your diet could be unbalanced and high in fat and calories, which could lead to weight gain (making it harder to control your blood glucose levels) and increase your risk of heart disease. So, it’s important not to focus exclusively on GI and to think about the balance of your meals, which should be low in fat, salt and sugar, and contain plenty of fruit and vegetables. How do I find out the GI values of all food? There are books that give a long list of GI values for many different foods, though this does have its limitations. The GI value relates to the food eaten on its own and we usually eat foods in combination as meals. How can I get the benefit of GI? You can maximise the benefit of GI by switching to a low-GI option food with each meal or snack. A few suggestions are given in the table, right. CarbohydraTes How strict should I be with applying the GI concept? Eating to control your diabetes isn’t just about GI ratings and shouldn’t be used in isolation. Choosing foods solely on the basis of their GI, without regard to their content of energy, saturated fat or salt, is unlikely to be a healthy diet. Although some research has shown that low-GI diets help in controlling blood glucose levels, the amount of carbohydrate you eat has the biggest influence on your blood glucose levels after meals. FOOD of the “Allcarbohydrate that you eat and drink are broken down into glucose ” Making the most of low-GI foods u BREAKFAST Lunch Try an oat-based breakfast cereal, eg porridge. u Add sliced fruit to wholegrain breakfast cereals. u A dd baked beans to your jacket potato and serve with a large green salad. u Try a bean-based or vegetable soup. u Eat a variety of grainy or pumpernickel bread, instead of white or wholemeal bread. u Consider boiled potato or sweet potato instead of mashed potato with your meal. Evening meal u Choose basmati or easy-cook rice instead of long-grain rice. u Include plenty of vegetables with your meals. u Include more beans and lentils in your meal; try adding them to casseroles and curries. u Get into the habit of eating fruit. Snacks u Low-fat yogurt. u Popcorn. u Go easy on lower-GI foods like chocolate and nuts, which are high in fat and calories, especially if you are trying to lose weight, so save them for occasional treats. 2013 Type 2 diabetes 39 FOOD food labelling looking at labels The first step to eating more healthily is understanding what is in your food M ost supermarkets and large food and drink manufacturers display �traffic light’ and/or Guideline Daily Amount (GDA) food labels on the front of their products to help you make informed (and healthier) choices. Here are the different systems explained: Traffic light labelling These tell you if the product has low (green), medium (amber) or high (red) amounts of fat, saturated fat, sugars, salt and calories per portion (see Table 1, below, for a guide). So the healthier the food, the more green lights it will have. Most foods will have a mixture of different-coloured lights, so try to choose products with more green and amber lights than red. light and/or GDA “Traffic food labels help you to make informed choices Table 1: What is �high’, �medium’ and �low’ per 100g? 40 per 100g Low Medium High Sugars 5g or less 5.1g–15g More than 15g Fat 3g or less 3.1g–20g More than 20g Saturates 1.5g or less 1.6g–5g More than 5g Salt 0.3g or less 0.31g–1.5g More than 1.5g Type 2 diabetes 2013 ” With both labelling systems, check the manufacturer’s idea of a portion size (given in grams), as it may be different to yours. food labelling top GDA labelling tips Guideline Daily Amounts are what an average adult of normal healthy weight should eat per day. How much we need depends on age, weight and activity levels (see Table 2, below, for recommendations). GDA labelling shows the amount of calories, sugar, fat, saturated fat and salt per portion of the product, and then expresses it as a percentage of the total amount of nutrient that is recommended each day as a healthy, balanced diet (see Table 3, below). This is useful for helping you decide how a particular food fits into your overall diet. In 2013 the government will be recommending a consistent system of food labelling, including traffic light colours, text and percentage GDA. Sugars Fat Saturates Salt Women 2000 90g 70g 20g 6g Men 2500 120g 95g 30g 6g Table 3: Example of GDA labelling 116 6 % 11g 12 % Saturates 1 2 % Amount in product help you decide whether the product contains �a little’ or �a lot’ of fat, sugar, salt and fibre. • Use the �per 100g’ a guide as to how much nutrient is in your food or drink per 100g. Use this to check against your actual serving size. • The figures for sugar don’t tell you how much of the sugar comes from natural sugars, eg fruit sugar (fructose) and how much comes from added sugars (sucrose). • To see whether a product Fat 0.9g • Looking at the label can • Table 3 (bottom) gives Calories Sugars Reading food labels column on the label to compare the make-up of similar food and the �per serving’ for different foods. Table 2: Guideline Daily Amounts (GDAs) of calories and nutrients recommended for a healthy, balanced diet Calories FOOD 0.5g % Salt 0.3g 6% % of adult Guideline Daily Amount is high in added sugar, look at the ingredients list, which always starts with the biggest ingredient first. • Remember that you don’t need to avoid all food and drink that contain a lot of fat, sugar or salt. It’s the overall balance of your diet that counts. 2013 Type 2 diabetes 41 FOOD food labelling decoding FOOD LABELS The following key words will feature on your food label. Let’s look at them in more detail: Energy • The amount of calories (Kcal) that a food or drink provides. • To keep to a healthy weight, the energy provided by your food and drink must be in balance with the energy you use. Fat • There are two main types of fat: saturated and unsaturated (polyunsaturated and monounsaturated) fats. • Reduce your total fat intake – particularly saturated fat as it is linked to heart disease. Choose unsaturated fats and oils, especially monounsaturated fat, as these fats are better for your heart (see p34, point 3, for examples). • Eating less fat helps you lose weight. Being a healthy weight helps your diabetes control. Carbohydrate • The figure for total carbohydrate includes carbohydrate from sugary and starchy food and drink. • Carbohydrate (of which sugars) tells you how much sugar is present and includes both added sugar and natural sugar. • Added sugars include sugars such as sucrose, glucose, glucose syrup, 42 Type 2 diabetes 2013 invert syrup, maltose and honey. The nearer they are to the top of the ingredients list, the more likely the food or drink is high in added sugars. • All carbohydrate increases your blood glucose levels. • Intense low-calorie sweeteners such as Splenda, Canderel and Hermesetas can be a useful alternative to sugar. • Regular meals, which include some starchy food, will help to control your blood glucose levels. Fibre • Also known as �roughage’ (plant matter that your body can’t digest). • There are two types of fibre, soluble and insoluble – both are beneficial to your health. • Soluble fibre, found in beans, pulses, oats, fruit and vegetables, helps to regulate your blood glucose and cholesterol levels. • Insoluble fibre, found in wholegrain cereals and breads, beans, fruit and vegetables, helps to keep your digestive system healthy. What to look out for 1 Salt You may see �sodium’ listed on the label, rather than salt. To convert sodium into salt you need to multiply the measurement on the label by 2.5. 2   Reduced and low fat It’s important to realise these don’t mean the same thing. Low fat means a product has 3g or less fat per 100g, while reduced fat means a product is 25 per cent lower in fat than the standard product. Often these foods are high to start with, for example mayonnaise, cheese and crisps. You still need to limit how much you eat, as the reduced version is likely to still be high in fat. 3   Portion sizes A manufacturer’s idea of a portion size might be smaller than yours. A product may look healthy, but even with healthier choices – if you eat large portions – you may end up consuming more calories than you need. 4   Hidden sugars Sugar isn’t always listed in the ingredients as �sugar’. Look out for the following terms: sucrose, glucose, fructose, maltose, honey, palm sugar, hydrolysed starch, syrup and inverts sugar. Remember the higher up sugar is on the ingredient list, the more added sugar the product has. Ready STEADY Shop! A selection of items from Diabetes UK. All funds raised come to the charity. new balance trainers Exciting range of New Balance trainers. For information on size, colour and width, please call 0800 585 088. Alternatively, go to http://shop.diabetes.org.uk Carbs & Cals An easy-to-understand visual guide to carb and calorie counting in diabetes management. Contains more than 1,700 photos of popular food and drink items, with the carbohydrate and calorie values clearly displayed above each photo. £14.99+p&p (code 4352) Quick cooking for Diabetes This book contains more than 60 recipes that can be cooked in 30 minutes or less. Also includes information on the Glycaemic Index rating and day-to-day menus. £5.99+p&p (code 3020) badges Beautifully crafted badges – choose from two different fastenings: Broach fastening £1+p&p (code 4202a) Butterfly fastening £1+p&p (code 4202) Order these and other Diabetes UK items at http://shop.diabetes.org.uk or freephone 0800 585 088, Monday to Friday, 8am to 6pm. Please quote TT2 when placing your order. (Postage is charged on some items.) 2013 Type 2 diabetes 43 FOOD EATING IN RECHARGE YOUR RECIPES There’s no need to throw out recipes that you know and love... But making some small changes will have you cooking up a healthier version in no time W hether it’s your favourite home-made pudding or a comforting casserole, you may have some tried-andtested recipes that you still want to enjoy – but there may be simple ways to make them healthier. And, by following these tips you can cut down on the sugar, fat and salt in your cooking, yet still keep the flavour. Remember that you don’t need to change your recipes when eating for special occasions. Sugar • xperiment by using less sugar in your baking recipes. Most E cakes will work even if the sugar in the recipe is cut by a half. Recipes such as fruit cakes, fruit scones or teabreads can be made without added sugar, as they don’t need sugar for bulk and the dried fruit will provide sweetness. Recipes using a reduced amount of sugar won’t keep as long as traditional recipes, as sugar is a natural preservative. To avoid wastage, freeze in portions – remember to check that the recipe is suitable for freezing. When making jams and marmalades, ordinary sugar will do, but try to reduce the ratio to 1lb fruit to ½lb sugar. Use sweeteners to add extra sweetness. • • • 44 Type 2 diabetes 2013 EATING IN healthier AFRICAN & CARIBBEAN cooking Fat • • • • • • FOOD se low-fat dairy products U where possible, such as skimmed milk, reduced-fat cheeses and low-fat yogurts. Try using stronger cheese for cooking. You’ll find that you won’t have to use as much to get a good flavour. Grated cheese tends to go further, too. You can also try reduced-fat varieties. Use pulses such as peas, beans or lentils in soups and salads or to replace some of the meat in shepherd’s pie, casseroles and lasagne. They’re low in fat and high in fibre. Choose lean meat, poultry and fish as lower-fat alternatives to fatty meats. Remove any visible fat and skin from poultry before cooking and throw it away. Grill, bake, poach, steam or boil foods, rather than cooking with added fat. Reduce the amount of oil you use – measure it out properly and don’t just pour. Avoid foods sticking to the pan by cooking on a low heat and stirring often, using a nonstick pan and a low-fat spray, or using a splash of water. • • • • • • kim the fat from the top of S curries, casseroles and stews. Watch out for creamy sauces and dressings and swap for tomato-based sauces. Light crème fraiche is not heat sensitive and so is ideal for use in savoury sauces. It’s also delicious served on hot or cold puddings instead of double cream. Fromage frais is fresh skimmed milk cheese, but is more like a natural yogurt. It’s sensitive to heat, so is best used in cold desserts and dips in place of cream or Greek yogurt. When you feel nothing but cream will do, spoon extra-thick single cream on to fruit or puddings and use whipping cream for filling cream buns or cakes instead of double cream. Try using filo pastry instead of normal pastry and spread with beaten egg in-between the sheets instead of butter. Salt • educe the amount of salt R and try spices and herbs for added flavour. • U se less saturated fat, such as palm oil, coconut oil and butter. • Grill, steam or oven bake foods such as jerk chicken, jerk beef, corn and pineapple fritters. • Cutting down on foods such as sugar cake, sweet potato pie, duckunoo, pudding and condensed milk can be an easy way to reduce the sugar in your diet. • Choose healthier ways of cooking plantains, fish, breadfruit, yams or dumplings, such as baking, grilling, boiling or poaching. • Avoid refrying leftovers. healthier South asian cooking • A dd millet or chickpea flour to chapatti flour to make it lower in GI. • Avoid adding (or reduce the amount of) fat or oil when making chapatti dough. • Try using unsaturated fats, such as rapeseed or sunflower oil instead of ghee. • You can make low-fat paneer using skimmed or semi-skimmed milk. • Use less coconut cream or coconut milk, or try a reduced-fat version. • Limit pickles with your meals. • Cut back on snacks, such as chevda and try plain popcorn or roasted corn instead. • Roast your poppadoms instead of frying them. 2013 Type 2 diabetes 45 FOOD EATING OUT Out & about When you’re on the go, eating out is a great option. But if you do this a lot, it’s worth thinking about healthier choices W e live in a convenience culture where it’s relatively easy to find ready-made meals and takeaways. And a large part of socialising revolves around food, such as dinner parties and eating out. These meals may be higher in fat, sugar and salt and you may enjoy portions larger than you would normally eat at home. But eating out should be enjoyable. Taking time for your meal, whether eating on the go or in a restaurant will make you more aware of what you are eating and drinking (and therefore less likely to overindulge). This section is aimed at people who eat out regularly and are interested in finding some ways to do so more healthily – especially if there is no nutritional information available. Eating out doesn’t need to be at the expense of your health. 46 Type 2 diabetes 2013 MEAL DEAL, NO DEAL Try to avoid offers that encourage you to buy fattening crisps or sugary drinks. Likewise, resist the temptation to �supersize’ unless you know that your lifestyle allows the extra calories, as most triple-decker sandwiches contain 500– 600 calories – around a quarter of your GDA. BURGER CHAINS Burgers are a quick and easy option when you’re on the go, but you could cut down the fat by asking for no mayonnaise and going easy on the cheese. Cut the calories by choosing a �bun-less’ burger and order extra salad – but keep an eye on the dressing. CURRY DISHES These are high in fat, but tandoori and tikka options are baked and tend to be lower in fat. Dahls are good providers of fibre because of the lentils and pulses, but can still be quite oily. Choose boiled or steamed rice, rather than pilau or fried rice. Watch out for the extras you order, such as poppadoms and naan breads. EATING OUT FISH AND CHIPS Try and order a smaller portion, or even remove some of the batter. Thicker-cut chips tend to be a little lower in fat as the thicker the chip, the less fat it absorbs during cooking. DRINK WELL If you’re watching your weight, remember that some �healthy’ fruit smoothies contain added sugar, honey, yogurt or milk that can bump up the calories, fat and sugar content. Even some fruit juices contain added sugar, so check the label before you buy. CHINESE, THaI AND MALAYSIAN These dishes are often high in calories, fat, salt and sometimes sugar. Soups are often preferable starters over prawn crackers and spring rolls, and choose boiled or steamed rice and noodles as the accompaniment for your main meal. CHECK YOUR SALADS You may think choosing a salad is a safe bet, but many are swimming in high-fat dressings that bump up the calorie and fat content considerably. Ask for the dressing on the side so that you can decide how much to add. Take a look at the ingredients and remember that they are listed from the highest-quantity ingredient first to the lowest-quantity. FOOD Sometimes my blood glucose levels are higher than normal when I’ve eaten out. Why is this? At some point, whether you’re eating more than usual or different foods at a restaurant, from a takeaway or over festive periods, you may find that your blood glucose levels are higher than normal. Being less active, overindulging or changing your routine could be the reason. The odd one or two high glucose readings shouldn’t affect your long-term diabetes control or health. Q& A Do I need to make changes to my diabetes medication when eating out or eating at a later time than normal? A change in your usual routine and diet when eating out needn’t have an effect on your diabetes control. For example, if you are on twice-daily insulin injections and eating lunch later than usual, you may need to have an extra snack before your meal. Doing this will help to prevent a hypo. If it’s an evening meal that you are having later than usual, it may be possible to simply delay the timing of your evening insulin to when you start your meal. If you are on a basal bolus insulin regimen, it can be easier to vary the timing of all meals – you take your bolus insulin when you eat. Your diabetes team will be able to give you specific information on how to adjust the timing of your medication and/or insulin and how much to take. Is it a good idea to do some sort of exercise after eating? Some form of activity after a meal will help to use up the extra energy you have eaten and help to control your blood glucose levels. A brisk stroll after lunch and dinner will make all the difference and get rid of that sluggish feeling you may have after a heavy meal. Ask your friends and family to join you, as they’ll benefit too – not just those with diabetes. 2013 Type 2 diabetes 47 FOOD EATING OUT PIZZA This can be very high in fat and salt, so choose your portion sizes and toppings carefully. Ordering thin bases and extra side salad could help to reduce some of the calories. SLIMLINE SANDWICHES These are healthier lunch options with low-fat spreads and dressings replacing high-fat mayonnaise, margarines and coleslaw. Healthier fillings include: lean ham, chicken, turkey, fish or egg instead of fatty bacon, cheese, sausage or stuffing. Choose grainy breads and sandwiches or wraps with salad to help bump up your fibre intake and help you feel fuller for longer. HEALTHIER SNACKS Choosing vegetable crudités and fruit for snacks can help you to meet your �five a day’ target. Low-fat yogurts are also a good choice and an easy way to add bone-strengthening calcium to your diet. We all know that regular crisps are high in fat, so instead of going for these, choose oven-baked or lower-fat varieties, or individual packs of air-popped popcorn – though be aware that these are still relatively high in fat, salt and calories. Individual cake bars, although tempting, are full of calories, fat and sugar. Even �skinny’ muffins and cakes contain 300–400 calories, which is more than many chocolate bars. Individual slices of malt loaf, fruit loaf and tea cakes are healthier alternatives. 48 Type 2 diabetes 2013 DIABETES PEER SUPPORT Connecting people with diabetes to share experience and support LIVING WITH DIABETES? NEED TO TALK? We all have questions. Your calls and emails are answered by trained volunteers with first-hand experience of diabetes. Our service is for everyone living with diabetes. Wednesday Thursday Friday Sunday 12–3pm and 7–10pm 7–10pm 9–12 midday and 7–10pm 7–10pm 0843 353 8600 quoting PSTES1 www.diabetes.org.uk/peer-support A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2013 Get involved Become a member 0845 123 2399 Join our 300,000 supporters who help us care for, connect with and campaign on behalf of all people affected by and at risk of diabetes. Raise Your Voice www.diabetes.org.uk/ diabetesvoices Join Diabetes Voices and make a difference to services and care by working alongside us to campaign and influence for change. Volunteer www.diabetes.org.uk/ volunteering Whether you can spare an hour a month or a day a week, there are many ways that you can make a difference at Diabetes UK. Raise funds www.diabetes.org.uk/ fundraising There are many ways you can raise funds or give to Diabetes UK. Visit our website to find out how you can help us to improve the lives of people with diabetes. CALL OUR CARELINE 0845 123 2399 A free and confidential service offering information on living with diabetes and giving people the opportunity to talk things through. GET SUPPORT FROM PEERS 0843 353 8600 A helpline and email service delivered by specially trained volunteers who have first-hand experience in living with diabetes. JOIN A Voluntary group voluntarygroups@diabetes. org.uk Our local support groups offer the chance to share experiences with others in your area and keep up to date with our work. GO online www.diabetes.org.uk Our website offers information on all aspects of diabetes and access to our activities and services. and twitter communities Our facebook provide support and a chance to talk to others. Get support 2013 Type 2 diabetes 49 FOOD ALCOHOL Party on down You can still enjoy an alcoholic drink with diabetes. Here’s how to keep safe W hen you’re having fun, it can be easy to get carried away and not notice how much alcohol you’re drinking. But, whether you have diabetes or not, government guidelines recommend a limit of 3–4 units a day for men, and 2–3 units per day for women. Hypos Drinking alcohol makes hypoglycaemia (low blood glucose – �hypos’) more likely for people who treat their diabetes with insulin or certain tablets such as 50 Type 2 diabetes 2013 sulphonylureas. It also slows down the release of glucose from the liver, and glucose is needed if you have a hypo. If you have too much alcohol, you might not be able to recognise a hypo or treat it properly. Other people can mistake a hypo for drunkenness, especially if you smell of alcohol. It’s important to tell the people you are out with that you have diabetes, and what help you might need if you have a hypo. Also, make sure you carry some ID to let others know that you have diabetes, such as an ID card, medical necklace or bracelet. If you drink more than a few units in an evening, you will have an increased risk of hypos all night and into the next day, too, as your liver continues to get rid of the alcohol. Always have a starchy snack, such as cereal or toast, before going to bed to help minimise this risk. The morning after If you end up having one too many, despite your best intentions, drinking a pint of water before you FOOD ALCOHOL How many units? Can (440ml) lager, beer or cider (5% ABV) 2 1 pint lowerstrength lager, beer or cider (3.6% ABV) 1 pint higherstrength lager, beer or cider (5.2% ABV) 3 2 Bottle (330ml) lager, beer or cider (5% ABV) 1.7 Small glass (125ml) white, rosé or red wine (12% ABV) 1.5 Large glass (250ml) white, rosé or red wine (12% ABV) Pub measure (25ml) spirit, eg vodka, gin, whisky (40% ABV approx) 1 3 Bottle (275ml) alcopop (5.5% ABV) go to bed will help to keep you hydrated and may help to prevent a hangover. If you do wake up with a hangover, you’ll need to drink plenty of water. And if you are suffering the typical hangover symptoms of headache, nausea, shaking and sweating, check your blood glucose level as you may actually be having a hypo. No matter how awful you feel, you need to treat a hypo straight away – don’t ignore it. Likewise, you must stick to your usual 1.5 Medium glass (175ml) white, rosé or red wine (12% ABV) 2.1 medication. Always have some breakfast to aid blood glucose control. If you can’t face food, or if you are being sick, take as much fluid as you can, including some sugary (non-diet) drinks. Painkillers may help with a hangover headache, but try to avoid them until your liver has had time to recover. Remember, the morning after doesn’t have to feel like this – try following our steps to safer drinking, above, right. i www.drinkaware.co.uk top Safer tips drinking • Eat something carbohydrate-based before you drink, and snack on starchy food during the evening to keep your blood glucose levels up. • Tell the people you are with you have diabetes and carry medical ID. • Alternate alcoholic drinks with loweralcohol or alcohol-free alternatives. • Pace yourself – enjoy your drink slowly and keep track of how much you are drinking. • Don’t forget to take your hypo treatment with you. Carry some form of medical ID so that other people know that you have diabetes ” 2013 Type 2 diabetes 51 FOOD Religious fasting RELIGIOUS FASTING Fasting forms a significant part of many religious faiths varying in timings, durations and restrictions. Here’s how you can fast with diabetes F asting is an important spiritual aspect of many religions, such as Christianity, Islam, Hinduism and Judaism. As well as the abstinence from food (and sometimes drink), fasting is also usually a time of prayer, reflection and purification. It is an opportunity for people to adapt to a healthier lifestyle by learning self-control and making changes to their diet. People with diabetes are usually exempt from fasting, although many may still choose to fast. Speak to your religious leader if you want information about whether you are exempt from fasting. Planning ahead and speaking to your healthcare team is the key to ensure that diabetes control is not affected. What happens to your body during fasting? Changes to the body during fasting depend on the length of the continuous fast. Usually your body enters into a fasting state eight or so hours after the last meal. Your body will initially use stored sources of glucose and then later in the fast it will break down body fat to 52 Type 2 diabetes 2013 use as the next source of energy. Using your body’s fat stores as an energy source can, in the long run, help to reduce your cholesterol levels and blood pressure, as well as your weight. Losing weight, particularly if you are overweight can also lead to better control of you gain weight. Try using some of the tips to adapt your recipes on page 44. Additionally, drink plenty of water or sugar-free and decaffeinated drinks to avoid dehydration. If you like sweet drinks, use a sweetener instead of sugar. ahead “Planning is key to ensuring your diabetes isn’t affected during fasting ” diabetes. However, fasting should not be used as a way of losing weight in the long term. Changes to your diet When you do eat during the fasting period, your eating pattern and the types of food and drink you have may be very different compared to normal. However, it is important to keep to a balanced way of eating, including food from all of the food groups and to not eat excessively. When you break the fast, only have small quantities of sugary and fatty foods, such as sweets, cakes, and fried snacks – too many can make ACTION POINTS • • • • peak to your diabetes S healthcare team, if you are planning to fast, for advice on adjusting your medication and/or insulin, testing and how to avoid highs and lows. Continue a varied and balanced diet. Try not to have too many sugary and fatty foods when you break the fast. When you break the fast, ensure you drink plenty of water, sugar-free and decaffeinated drinks to avoid dehydration. Questions & ANswers Food queries solved FOOD Is it true that I shouldn’t eat bananas or grapes? No. All fruit is good for you. Eating more fruit can reduce the risk of heart disease, some cancers and some gut problems. Eat a variety of different fruit and vegetables for maximum benefit. Can I still have some sugar in my diet? Yes. Eating sugar doesn’t cause diabetes and people with diabetes don’t need to have a sugar-free diet. It’s ok to have foods like chocolate and cakes occasionally alongside a healthy diet. But remember, sugary foods provide empty calories. Is it ok for me to take a vitamin supplement now that I have diabetes? Diabetes UK doesn’t recommend that people with diabetes take a supplement. If your diet is deficient in some nutrients, then you may benefit from taking one, but this should be decided in conjunction with your doctor and/or dietitian. (Women with diabetes should take a supplement of 5mg of folic acid when planning pregnancy and continue to take it until the end of the 12th week of pregnancy. This dose of folic acid is only available on prescription.) I’d like to use a sweetener instead of sugar in my tea, but I’ve heard that they aren’t safe. Is this true? All sweeteners have to undergo rigorous safety tests before they can be sold in the UK. The government sets safe limits and surveys groups of individuals to see whether they are exceeding these limits. At the moment, there is no evidence to suggest that the general public is exceeding these safe limits, but if you are at all concerned you can minimise this risk by using a variety of sweeteners. Can people with diabetes follow a vegetarian diet? Yes, although following a vegetarian diet does not necessarily mean a healthier diet. You still need to have a good balance of different foods. To make sure you’re following a healthy, balanced vegetarian diet, visit The Vegetarian Society’s website: www.vegsoc.org. 2013 Type 2 diabetes 53 HERE’S A WINNING WAY TO SUPPORT THE WORK OF DIABETES UK! WIN WEEKLY CASH PRIZES £12,500 £1,000 POT JACK YEAR 2 PER RIZE TOP P EEK ERY W EV PLUS CA W INNER YO SE E S Y WE AS ER SH T O SPEND K U P LEA 100 E V ER K P R £1 E V F LAY O 99 CASH PRIZES EVERY WEEK! Y WE E ENTER ONLINE NOW: www.diabetes.org.uk/weeklylottery CALL NOW TO ENTER: You’ll find our full lottery rules on the website. 01628 822 271 and quote �Jackpot’ Thank you so much for joining in. A charity registered in England and Wales (215199) and in Scotland (SC039136). weight management Living with diabetes WATCHING YOUR WEIGHT Achieving your ideal weight is often easier said than done. But being overweight makes diabetes control difficult Here we look at the positive steps you can take to lose any extra pounds T here’s a lot of evidence to show that managing weight (if you are overweight) is the most important element of controlling Type 2 diabetes. Losing some of the weight has also been shown to improve blood pressure and blood fats (cholesterol). These benefits will help reduce the risk of developing any long-term health problems. There are three key essentials to getting motivated and staying on track. They are known as �WHY’, �WHAT’ and �HOW’ • Know WHY you are doing something, as it will help you to stay motivated and keep you on track. • Decide WHAT you are going to do. • Work out HOW you are going to do it – do your homework, speak to your dietitian (or ask your GP to make a referral). How do you know if you need to lose weight? There are several ways you can measure yourself to find out if you are overweight: • Calculate your BMI (Body Mass Index). BMI looks at a person’s weight in relation to their height. This will give you an idea of what range your weight is in. Find out your BMI using the BMI chart (see p57). Find the point where your height and weight meet on the chart to see what range your weight is in. (Weight classification is slightly different for people of South Asian origin and these 2013 Type 2 diabetes 55 Living with diabetes Weight management your weight is the most important “ Managing element of controlling Type 2 diabetes ” ranges are outlined on the table.) • Measure your waist: You can measure your waist circumference, which shows the amount of weight you carry around your waist. If you need to lose weight, reducing your waist size will help to improve blood glucose control and reduce Staying on track top tips Feeling like you’ve hit a brick wall? Here’s how you can stay motivated and committed to your weightloss plan: •See it through. • Know your goals. •Be prepared – think ahead. •Overcome obstacles. Think about what might stop you and devise a game plan. See how far you have come – take time to assess your progress. Visualise your success – see it, feel it and remember it. • • 56 Type 2 diabetes 2013 your risk of developing long-term health problems. To measure your waist, find the bottom of your ribs and the top of your hips. Measure around your middle at a point midway between these (for many people this will be the tummy button). Guideline measurements are: • White and Black men: below 94cm (37in). • South Asian men: below 90cm (35in). • White, Black and South Asian women: below 80cm (31.5in). How much weight should I lose? Ideally, you should aim for a target weight that gives you a BMI in the normal weight category (see chart, above right), but if you have a considerable amount of weight to lose, this may seem extremely daunting and impossible to achieve. Instead, you may prefer to set an initial weight loss that moves you down a couple of BMI notches, or perhaps shifts you from one category to another. Research shows that losing just 10 per cent of excess weight will improve your health – and you can always set new goals along the way. On the other hand, you may already be in the normal range category. But if your weight is gradually increasing, now’s the time to act and shift those kilos before you end up becoming medically overweight. While many of us might like to slim down to a weight we were when we were 18, it’s important to be realistic about whether you can really achieve this. For most of us, this may not be practical. It’s better to focus on reaching a target weight that leaves you looking and feeling slim, fit and healthy. Once you’ve decided on a realistic weight goal, you’ll be able to work out how long it will take to reach this. If you are aiming to shed some weight, you will need to be aware of your daily calorie intake – and reduce it (a calorie – Kcal – is a unit of energy). What’s this about calories? The body uses energy not only for exercise, but also for everything we do (even breathing and sleeping). The Guideline Daily Amount (GDA) of calories needed per day is 2,000 for women and 2,500 for men (to replace the energy used and to maintain a healthy weight). However, these recommendations are for the average adults of normal Living with diabetes Weight management How long should it take? A safe and achievable target is to lose 1–2lb (0.5–1kg) a week. To lose around 1lb a week, you will need to consume 600 less calories per day than your body needs to maintain weight. This is because there are around 3,500 calories in 1lb of body fat, so it will take around six days to lose it. Increasing your physical activity will help you to burn off more calories and lose weight more quickly. Beware of cutting calories too low, as this can put your health at risk. You may lose more weight in the beginning as your body gets rid of water, as well as fat. In the long-term, though, weight loss of more than 2lb a week means that you have seriously ese Mo rbi dly ob es e Ob Height in metres 1.91 1.88 1.85 1.83 1.80 1.78 1.75 1.73 1.70 1.68 1.65 1.63 1.60 1.57 1.55 1.52 1.50 1.47 ight Ove rwe ight Hea lthy we und erwe 6’3 6’2 6’1 6’0 5’11 5’10 5’9 5’8 5’7 5’6 5’5 5’4 5’3 5’2 5’1 5’0 4’11 4’10 ight 38 44.5 51 57 63.5 70 76.5 82.5 89 95.5 102 108 115 121 127 134 140 146 153 159 Weight in kilograms 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 healthy weight. How many calories you need per day can vary greatly depending on your lifestyle, age, height, weight and level of physical activity. If you consume more calories than you need, the excess will eventually turn to fat, causing weight gain. But if you consume fewer calories than you need, you will lose weight. So, in a nutshell, you need to consume fewer calories than you are burning off if you want to lose weight. Height in feet and inches 1ft=0.3m (approx) 1lb=0.45kg (approx) Weight in stones Underweight Healthy weight Overweight Obese Morbidly obese BMI up to 18.4 18.5–24.9 25–29.9 30–39.9 40 or more South Asian adult less than 18.5 18.5–22.9 23–24.9 25–34.9 35 or more To calculate your BMI: weight (kg) height (m) x height (m) So, if you’re 1.80m tall and 95kg, your BMI would be 29 slashed the calories – and ultimately this makes it harder for your body to lose weight. Very low calorie intakes push your body into starvation mode and it preserves the fat stores for when it really needs them – and uses muscle tissue instead. The loss of muscle, results in the body slowing down the metabolism so that it needs less 95 (1.8 x 1.8) = 29 (BMI) food and drink to keep it going – not ideal if you are wanting to shift unwanted weight. What works? There are many approaches to losing weight – there’s no quick fix or one-size-fits-all approach. Evidence shows that for successful long-term weight loss, small and 2013 Type 2 diabetes 57 Living with diabetes Weight management ACTION POINTS realistic changes are crucial, as well as sticking to a slimming plan that you enjoy and fits in with your life. It’s important the eating plan is balanced – low in saturated fat, salt and sugar, and contains fibre. And regular exercise is good for both your waistline and health – especially your heart. See p32 for more information on a balanced diet, including portion sizes. Eating more healthily and leading a more active lifestyle isn’t easy for everyone. You may need more support and choose to join a weight-loss programme Commercial weight-loss programmes are likely to involve one or a combination of: • calorie controlled weight-loss eating plan • individual, group or online support • meal replacements, such as milkshakes, ready meals or bars • psychological support. Q& A It is important that the programme provides support and education to ensure that the weight loss you are promised is realistic and sustainable. You need to make sure it follows healthy weight-loss guidelines. What should I look for in a weight-loss programme? Ask yourself the following: • Is the weight loss offered realistic? • Does the programme provide complete nutrition (or nutritionally adequate)? • Does the programme give support and education? • Has a healthcare professional been involved? • Does the programme offer advice on your diabetes (especially if you are at risk of hypoglycaemia)? Remember to let your diabetes team know if you are starting Can I exercise more, instead of watching what I eat? Physical activity on its own will only lead to weight loss if you do at least 60 minutes a day, and evidence shows that combining physical activity and diet will lead to the biggest weight loss. Physical activity, regardless of weight loss, leads to improvements in blood pressure, blood fats and glucose levels and has positive effects on heart health. I am extremely overweight and feel like I need to do more than eat healthily. What can I do? For some people with diabetes, weight loss medication and surgery may be a good option. To find out more about whether these are right for you, talk to your GP or diabetes healthcare team. 58 Type 2 diabetes 2013 • Calculate your BMI. • Set a realistic target weight. • Work out how long it will take. • Decide on a slimming plan. Once you’ve set a realistic target weight and know roughly how long it should take, you can devise a slimming plan that will work for you. a programme, as it may affect your blood glucose levels and medication. How will losing weight affect my diabetes? If you manage your diabetes with insulin and/or tablets you may need your doses to be adjusted as you lose weight and become more active. Your diabetes healthcare team can advise you about any changes to your medication, and your dietitian can help you to design a weight-loss programme that works for you. If you haven’t seen a dietitian, ask your GP to make a referral. Weight management Living with diabetes How to set your weight-loss goals First, make sure your goals are realistic. Write them down. Assess and review them regularly – and make sure that you celebrate your successes. Here is an example of a long-term goal: What’s my motivation for losing weight? I want to be healthy and be able to play with my children. How much weight should I aim to lose? I’d like to lose 1 stone in the next year – 10 per cent of my body weight. Instead of crisps every day, I’ll have a piece of fruit on at least five days a What action week. will I take? How will I achieve this? I will take a piece of fruit to work each day. I’ll start on Monday, once I’ve done my weekly shop What do I need to do to make this happen? I’ll buy fruit and veg that are in season and on special offer each week. When will I start? How will I monitor my success? I will start a diary with my three goals and tick each day that I achieve them. 2013 Type 2 diabetes 59 Living with diabetes Calorie swaps Swap ’n’ save If you want to cut back on calories, here are some suggestions and savings you can make to your daily routine Breakfast Tall (12 fl oz) semi-skimmed latte 150Kcal 2 medium slices of toast, 70% fat margarine (20g) and jam (30g) 345Kcal Save 60 calories Save 175 calories Tall (12 fl oz) cappuccino with semiskimmed milk 90Kcal 2 wheat biscuits and 85ml semi-skimmed milk 170Kcal Lunch Prawn mayo sandwich 350Kcal 60 Save 50 calories Save Low-fat prawn mayo sandwich 300Kcal Packet of crisps (30g) 160Kcal 100 1 medium pear 60Kcal Standard size chocolate bar (55g) 280Kcal Save 2-finger chocolate wafer biscuit 105Kcal Type 2 diabetes 2013 calories 175 calories Calorie swaps LivingTESTIN with diabetes Dinner 2 grilled pork sausages (110g) 324Kcal Bakewell tart 140Kcal Snacks High-street coffee shop skinny blueberry muffin 370Kcal Medium slice of flapjack (60g) 300Kcal Save 183 calories Save 85 calories Save 275 calories Save 200 calories Save 2 chocolate digestive biscuits 170Kcal 70 calories Small roasted chicken breast (95g) 141Kcal 100g pot of low-fat yogurt 55Kcal High-street coffee shop portion of fruit salad 95Kcal Medium slice of malt loaf (35g) 100Kcal Medium banana 100Kcal Alcohol Glass of medium dry white wine 175ml 130Kcal Save 75 calories 1 single (25ml) measure of vodka and slim-line tonic water 55Kcal 2013 Type 2 diabetes 61 Living with diabetes PHYSICAL ACTIVITy Moving on up Being active is not only great for your health, it can also make you feel more positive and give you more energy 62 Type 2 diabetes 2013 Living with diabetes PHYSICAL ACTIVITy P hysical activity is an important part of your diabetes management. It can help to improve blood glucose, as well as improve fitness, prevent excess weight gain, keep the heart healthy and lower blood pressure. It also improves self-esteem and reduces the symptoms of depression and anxiety. The Department of Health recommends: • Adults should aim to be active on a daily basis. • Working towards a target of at least 150 minutes (2½ hours) over the course of a week. Moderate intensity activity can be done in bouts of 10 minutes or more, so you could aim for 30 minutes a day on at least five days a week. • If you choose to do vigorous intensity activity, then 75 minutes can be spread across the week. • Include activities that increase your muscle strength at least twice a week. What is moderate intensity? This causes you to feel warmer, breathe harder and your heart to beat faster, but you should still be able to hold a conversation. Examples are brisk walking and cycling. What is vigorous intensity? This causes you to feel warmer, breathe harder and your heart to beat faster but it would be difficult to hold a conversation. Examples include running, swimming or playing sports, such as football. What is musclestrengthening activity? This involves using body weight or working against resistance. Examples are: dancing (stepping or jumping), exercising with weights or carrying or moving a heavy load, such as food shopping. If possible, get into good habits, such as cutting down the time you spend in sedentary (sitting) activities, such as watching TV, playing electronic games or using the computer. The time spent in these activities could be interspersed with action, even just doing some stretching exercises or running up or down the stairs. As time goes by As you grow older it may not be as easy to be physically active, but even if you can’t reach the government targets, remember that some activity is better than none as it helps your �feel good’ hormones. To improve your balance and co-ordination try Yoga or Tai Chi. If you are unable to stand, then try to do some exercises while sitting in your chair, eg gentle stretches, leg and arm raises, and neck exercises. These can also be done from your bed or a wheelchair. Movement can help keep the mobility you have and even increase it. Your GP may be able to refer you to a physiotherapist who can help you or a local exercise programme. top tips Increasing activity 1 2 Use stairs instead of a lift or escalator. 3 4 Cycle or walk short journeys, rather than using the car. Get off the bus or tube a stop earlier. Use your lunch break to go for a brisk walk. 5 If you’re in a sedentary job, try to get up and walk about regularly. 6 7 Walk a dog regularly. T ake up swimming or playing golf. Remember, all activity counts, but try to vary the type of activity you do so that you don’t get bored. 2013 Type 2 diabetes 63 Living with diabetes PHYSICAL ACTIVITy Keep it safe Staying motivated Many people start out with great determination but soon find they lose interest or the determination to continue. So it’s important to: • Find an activity you enjoy and you will be more likely to keep it up. Better still, try taking up an activity the whole family or your friends can enjoy. • Set yourself daily, weekly and monthly targets. • Keep a physical activity diary to track your progress and celebrate your successes. • Keep it exciting by trying new activities. 64 Type 2 diabetes 2013 taking up an “Try activity the whole family or your friends can enjoy ” Before you start any new activity check with your diabetes healthcare team if you: • are taking diabetes or heart disease medication • have any complications of diabetes like foot or eye problems • are not sure which activities suit you • have any conditions that may restrict your mobility or ability to be active, eg high blood pressure, angina, osteoporosis, asthma or have had a heart attack. This is general information, talk to your diabetes healthcare team for individual advice. PHYSICAL ACTIVITy Living with diabetes top tips Physical activity 1 2 3 4 5 Warm up before exercise and have a period to cool down afterwards. Wear the right footwear during activity. Speak to your podiatrist if you are not sure. Keep your feet dry and inspect them before and after the activity. W ear diabetes ID such as an identity card, bracelet or necklace. Drink fluids regularly to avoid dehydration. Increasing your activity levels can be combined with a social event Photo: James Clarke Q& A I want to keep fit but the gym and even going for a swim is very expensive. What can I do? Many GP surgeries offer �exercise on prescription’. You’ll be referred to a local active health team for a fixed number of sessions under the supervision of a qualified trainer. You decide with your GP and the active health team what type of activity will suit you. Depending on your circumstances and what’s available, the exercise programme may be offered free or at a reduced cost. Will I have a hypo if I do lots of exercise? If your diabetes is treated with certain diabetes medication or insulin, then you may be at risk of a hypo if you do intense exercise for a period of over an hour. Discuss this with your diabetes healthcare team. You may need to check your glucose levels before and during the exercise and to keep some fast-acting glucose, such as a non-diet drink, close by. ACTION POINTS • Take advice from your diabetes healthcare team on the types of activity most suitable for you. • Try to increase your activity levels by introducing some simple activities at first and increasing duration and intensity. • If you belong to a gym, the fitness instructors need to know about your diabetes so they can carry out a health review. 2013 Type 2 diabetes 65 Living with diabetes Accepting diagnosis Take time to adjust Being diagnosed with diabetes isn’t the best news you have ever received or the easiest to fully understand initially. As Jane Matera from Diabetes UK Careline explains, you, and those close to you, will need some time to absorb the news Talk about your feelings with friends and family O n the face of it, the diagnosis of Type 2 diabetes seems straightforward. A doctor looks over pages of test results, and says, almost by the way, “Oh. Did you know you had diabetes?” Or maybe you’d been to the surgery with what seem innocently-other symptoms: a recurring infection; extreme tiredness, and now the results have shown this. Your busy doctor is probably already clicking into routine: book appointment for nurse/dietitian/eye scan. HbA1c in three months. 66 Type 2 diabetes 2013 You may accept this and it might not have come as a surprise, but on the other hand, it may be a shock and you may feel as if you’ve seemingly walked into the surgery as a person you know, and walked out as someone else altogether. Out of the blue Being diagnosed with any long-term condition can come much like a bereavement. As with bereavement, whether it comes as a bolt out of the blue or whether it’s half-expected, it still comes as a shock. There may be fear. There may be a sense of anxiety, �What does this mean for me?’ And meanwhile, your diagnosis is possibly being treated in a very matter-of-fact way that, if anything, confuses you even more. Nobody is really acknowledging the emotional shock, they’re too busy with the practical. Friends may minimise it. “What are you so fussed about? It’s only Type 2,” they may say. “You don’t have to inject, do you? Well then.” This is the point at which many people call the Diabetes UK Careline. They want to know what to do. Two things help enormously: Accepting diagnosis diagnosis may not have come “Your as a surprise, but on the other hand, it may be a shock ” • Get the right information First of all, it’s important to have the right information to understand your diabetes better, so that you feel reassured. This can be anything from knowing what to eat to how to take your medication. • Talk to someone who’ll listen Talking about what may have led up to the diagnosis, how you were diagnosed and how you are now feeling is likely to give you immeasurable relief. The more you talk it through, the more release you will experience. The shock will slowly evaporate. You’ll begin to gather up your own strengths. The realisation that others have gone through this self-same experience may well also be of benefit. Patterns of coping Be aware, if you’re not already, that we all have learnt patterns around how to deal with the great difficulties of life; how to cope. Yours may be one you’ve learnt, through hard experience, to get you through. Now might be a good time to look at your pattern. Denying a difficult reality, ignoring it, or putting it to one side is tempting, and it’s a totally understandable reaction. You might be thinking like this for days, weeks, even longer after diagnosis. But, where diabetes is concerned, this can only really be a short-term solution. Or maybe your pattern is to head straight to the positive, whatever the situation. Can-do, will-do. There is courage in this. But it may mean that you’re skipping the necessary grieving process which will help you slowly integrate this new reality, so that you can move on with your life. Nobody says it is easy. But if the process is difficult, be assured that you don’t need to go through it alone. Living with diabetes Diabetes UK Careline Diabetes UK’s Careline provides confidential support and information to all people affected by diabetes. Call 0845 123 2399, and ask to speak to Careline. Open Monday to Friday, 9am–5pm. Careline accepts TypeTalk calls and has an interpreting service. Please check the cost of calls to 0845 numbers with your phone provider. Write to: Diabetes UK Careline, 10 Parkway, London NW1 7AA for a response within 21 days. Email [email protected] for a response within 10 working days. Careline cannot provide individual medical advice. 2013 Type 2 diabetes 67 Living with diabetes Telling people A new beginning Telling those close to you about your diabetes will mean you get more support After being diagnosed, some people may feel like hiding it from the world. But telling certain people can really help you and is also a good way of getting extra understanding and support I t’s perfectly understandable that you may not be looking forward to telling people about a newly diagnosed condition like diabetes – initially, they will probably know very little about it and how it may affect your daily life. However, don’t let this put you off, most people find their employers, friends and family are very understanding once the news has been shared. Also, they 68 Type 2 diabetes 2013 often find that they get more support and are better able to cope with their newly altered circumstances. Friends and family Friends and family can give you valuable support, especially when you are newly diagnosed or when you’re struggling to manage your diabetes. Telling them can also help them understand the part they can play to help diabetes fit into your life. For example, you may find sharing aspects such as eating healthily and keeping physically active, helpful. They may be able to help you stick to the correct diet, especially if you have been advised to lose weight. Physical activity is also a very important part of managing your diabetes (see p62) and friends and telling people family can play a key role by participating in any sports or exercise that you take up, and of course it will be beneficial to all those who take part. It is also important that your friends and family realise that they do not need to treat you any differently, and they can’t �catch’ diabetes from you. Finally, some medicines could cause your blood glucose level to drop too low for you to be able to function normally. If your friends and family are aware of what the symptoms of this are, they can help you to get the correct treatment and prevent any misunderstandings. Healthcare team and hospital staff If you have to go to hospital, tell the staff you have diabetes, don’t assume they already know. Although your diabetes won’t necessarily be affected, it is sensible to make sure anyone who is looking after your health knows about it. This includes dentists, opticians and podiatrists. �Alternative’ practitioners such as osteopaths, chiropractors, aromatherapists, and anyone giving massage or reflexology treatment will also need to know. Telling your employer and colleagues There’s no legal requirement to tell your employer that you have diabetes. But they will probably want to know what has been happening to you, especially if you had time off work. Accentuate the positive – stress that diabetes means you must be aware of time, have a regular routine and try to follow a healthy lifestyle, as well as having a thorough medical each year. It may not be something employers openly admit to, but people with diabetes may occasionally face discrimination because of the misconceptions that some people have about the condition. The more you know about diabetes, the more you can explain it, and why it won’t interfere with your ability to do your job. i For more on diabetes and work see p80. Telling insurance companies You must declare that you have diabetes to any insurance companies that you hold a policy with. Car: You probably won’t be asked any further questions, but your insurance could be invalid if you had an accident and hadn’t told your insurance company. Also, if you are treated with insulin, you will have to tell the Driver and Vehicle Licensing Agency (DVLA), or in the case of Northern Ireland the Driver and Vehicle Agency (DVA) because of the increased risk of hypos. Your driving licence will be reissued for a Living with diabetes one, two or three yearly term and you will have to reapply each time (this is free of charge). i F or more on driving and diabetes see p86. Travel: Most travel insurance policies exclude pre-existing medical conditions (medical conditions you had before the policy was taken out) such as diabetes. You should always declare it for your travel insurance to make sure that you are covered. Some insurers will not give cover to people with diabetes or charge a much higher premium. i F or more about travelling see p82. Home, mortgage or life insurance: Once you have been diagnosed with diabetes getting this type of insurance can sometimes be difficult, so Diabetes UK has produced a factsheet to help. i A free download is available at: www.diabetes.org.uk/How_we_ help/Financial_services more you know “The about diabetes, the more you can explain it properly ” 2013 Type 2 diabetes 69 Living with diabetes LOVE LIFE Staying close Having diabetes should not affect your desire for or ability to have sex. However, diabetes can cause problems which you need to be aware of Safe sex It’s important to practise �safe’ sex and this includes not only protecting yourself against sexually transmitted diseases (STDs) by using a condom, but also to prevent an unplanned pregnancy. All forms of contraception are suitable for people with diabetes. See p72 for the different types available. 70 Type 2 diabetes 2013 LOVE LIFE S ex is an important part of relationships for adults of all ages. An unfulfilling sex life can lead to feelings of guilt and rejection, causing problems within a relationship. Some people who have diabetes may encounter sexual problems. But by talking about the issues with your partner and consulting a doctor, you’ll be taking the important steps to resolving things. Here are some things to be aware of: Thrush This is a common condition that is made worse by high blood glucose levels. The best way to limit your chances of developing it is to control your diabetes well. If you do develop it, even though there are creams that you can buy without a prescription for treating it, it is better to consult your diabetes healthcare team about it, as they will help you to sort out both problems. Hypos Insulin and some other diabetes treatments can increase the risk of a hypo if you are very active during sexual intercourse. Therefore, it is important that you have some form of hypo treatment to hand that’s easy to take if needed. You might want to tell your partner what to expect if you have a hypo, especially if they’re a new partner. Problems Around 50 per cent of men with diabetes and 25 per cent of women with diabetes will experience some kind of sexual problems or loss of sexual desire as a result of their diabetes. The most common sexual problems experienced are erectile dysfunction and female sexual dysfunction. Not everyone experiences these problems. Other possible causes are smoking, drinking excess alcohol and the use of some recreational drugs. Tiredness, stress and poor selfimage can all contribute. Erectile dysfunction (ED) or impotence is the medical term for being unable to get and/or keep an erection for intercourse. Not only is it important to talk to your doctor about this because of your relationship, but it can indicate other health problems, such as heart disease. There are various treatments available for men with erectile dysfunction which include tablets, injection, vacuum therapy and implants. Men often feel embarrassment and this leads them to buy these products via the internet. Do avoid this, as these products may be expensive and they may not contain the correct amount of medication for you. Treatment for ED is free on prescription to men with diabetes, so talk to your doctor as he/she can discuss your choices and prescribe the appropriate treatment for you. Female sexual dysfunction can cause dyspareunia (pain with intercourse), and a loss of desire, arousal and orgasm. Very little research has been done into this and there is very little treatment, although a vacuum device is available, which fixes onto the clitoris to encourage blood flow and lubrication to the genitalia and vagina. Living with diabetes Q& A What are the physical causes of sexual dysfunction? There are many possible reasons: • a hardening of the arteries (a complication of diabetes) causes problems with the blood flow needed for arousal • diabetic neuropathy can damage the nerves involved with sex • surgery on the bladder, bowel, or prostate, can cause damage to nerves • some medicines for high blood pressure and heart disease, and some sedatives, tranquillisers and antidepressants can affect your desire and arousal, and possibly lead to orgasmic dysfunction. I find it hard to talk to my partner, what should I do? Many couples are reluctant to talk about their problems for fear of causing each other more stress. They often feel embarrassed, frustrated and guilty and their partners often feel rejected and angry, especially if they don’t know or understand the cause of the problem. Counselling or sex therapy may be enough to resolve any issues. 2013 Type 2 diabetes 71 Living with diabetes ContracEption Contraception options H aving diabetes should not affect your desire for or ability to have sex, but it is really important to avoid an unplanned pregnancy. This is because high blood glucose levels at the time of conception can affect the foetus, causing damage to the developing heart and blood vessels, and a lack of folic acid could lead to neural tube defects, such as spina bifida. Concerns Some women are concerned that having diabetes means they are unable to take the oral contraceptive pill. Any form of contraception that releases either of the hormones oestrogen or progesterone carry the risk of raising blood pressure or causing a blood clot (thrombosis). Women with diabetes are susceptible to the same – but no higher – risks as any other woman who uses these forms of contraception, but if they have any diabetes complications they should be advised to avoid hormonereleasing contraceptives. Another concern is that contraception will affect diabetes control. Some women do experience a slight deterioration in control when they first start using a form of contraception that contains hormones. But this can be easily monitored and controlled by a slight change in diabetes medication. 72 Type 2 diabetes 2013 There are lots of contraception options available. We take a look at the pros and cons of each and their impact on diabetes Used correctly, most contraception has more than 90 per cent effectiveness, but some forms need more care than others, eg remembering to take a pill at the same time every day. Your GP or a family planning clinic will help to ensure that the best choice of contraception is prescribed for you. Metformin can sometimes make women more fertile so even if you think you are too old to have children or are nearing menopause you may need to consider contraception. THE COMBINED PILL How it works There are several types, but they all prevent the ovaries from releasing eggs and thicken the mucus at the neck of the womb, which makes it harder for sperm to enter. Advantages Can make periods lighter and less painful. Disadvantages May cause weight changes, breast tenderness and headaches. Women who have had diabetes for more than 20 years should avoid the combined pill, as well as those who smoke or are aged over 35. Diabetes effects? The hormones may affect blood glucose levels. PROGESTOGEN ONLY PILL (POP) How it works Thickens the mucus in the neck of the womb, making it harder for sperm to enter the womb. It also thins the lining of the womb so that there is less chance of a fertilised egg implanting. Advantages Providing there are no medical problems, such as heart disease or stroke, it can be taken until menopause or the age of 55. Disadvantages Periods may be irregular. Side effects at first can include spotty skin, breast tenderness, weight change and headaches. It has to be taken at the same time every day or it will not protect against pregnancy. Diabetes effects? The hormone may affect blood glucose levels. VASECTOMY/TUBAL LIGATION How it works A vasectomy (for men) cuts the tubes that deliver sperm, and a tubal ligation (for women) blocks the fallopian tubes, so a fertilised egg can’t reach the womb. Advantages Very reliable. Disadvantages Involves surgical procedure. Diabetes effects? No. ContracEption CONDOM How it works Covers the penis, preventing sperm from entering the womb. Advantages Protects from sexually transmitted infections. Only used when you have sex. Disadvantages Can interrupt sex. May break. Some people are sensitive to the chemicals in latex or spermicide. Diabetes effects? No. CAP/DIAPHRAGM How it works Fits inside the vagina and covers the cervix, which prevents sperm from entering the womb. A spermicide (a chemical that kills sperm) is also used. Advantages Only has to be used when you have sex. Disadvantages Can interrupt sex. Spermicide can be messy. Can take time to learn how to use it. Cystitis can be a problem for some women. Some people are sensitive to the chemicals in latex or spermicide. All types of diaphragm and cap need to be kept in place for at least six hours after intercourse and no longer than 30 hours (latex) or 48 hours (silicone). High failure rate if used incorrectly or they burst. Diabetes effects? No. IMPLANTS How it works A small flexible rod is placed just under the skin in the upper arm, which releases a progestogen hormone that acts in the same way as the combined pill. Advantages Lasts for three years, so you don’t have to think about it very often and may reduce painful, heavy periods. Disadvantages Requires a small procedure to have it fitted and removed. Side effects may include headaches, breast tenderness and mood changes. May also cause weight gain and increase blood pressure. Diabetes effects? The hormone may affect blood glucose levels. INJECTIONS How it works The hormone progestogen is injected into a muscle, and acts on the womb lining in the same way as the combined pill. Advantages Depending on which type you are given, it lasts for eight or 12 weeks. Disadvantages Fertility may take a long time to return. If you have any side effects you have to put up with them for a long time. May cause thinning of your bones and should only be given to those over the age of 18 after careful evaluation by a doctor, as it can affect bone development. Can cause weight gain. Diabetes effects? The hormone may affect blood glucose levels. Living with diabetes INTRAUTERINE DEVICE (IUD) How it works A small plastic and copper device that does not contain any hormone, but works by stopping sperm reaching an egg due to the release of copper. May also work by stopping a fertilised egg from implanting in the uterus. Advantages It’s effective as soon as it is inserted and lasts for five years, although it can be removed sooner. Disadvantages Can be painful to insert. Diabetes effects? No. INTRAUTERINE SYSTEM (IUS) How it works A hormonereleasing version of the IUD (above), which acts on the womb lining in the same way as the combined pill. Advantages It’s effective as soon as it is inserted and lasts for five years, although it can be removed sooner. Disadvantages Can be painful to insert. Diabetes effects? The hormone may affect blood glucose levels. 2013 Type 2 diabetes 73 Living with diabetes pregnancy & labour Great expectations Having children is a big decision for anyone. If you are a woman who has diabetes, however, it is a decision that requires much more thought and careful planning M ost women who have Type 2 diabetes have healthy pregnancies and healthy babies. But this isn’t to say that it’s an easy experience – it requires a lot of work, planning and dedication on your part. This is because diabetes can increase risks to both you and your baby of serious problems. The information here is intended to inform, not alarm. It’s important that you are aware of the difficulties so that you and your doctors can discuss them together and work to prevent them. You may be diagnosed with Type 2 diabetes at an age when you are not thinking about pregnancy or perhaps your family has grown up. Being prescribed metformin may increase your fertility, so if you 74 Type 2 diabetes 2013 haven’t completed your menopause, remember that contraception is the key to avoiding an unplanned pregnancy (see p72). Risks to you • P re-existing retinopathy may get worse, so it is really important that you have your retinal screening done if it has not been done in the last 12 months. • Pre-existing nephropathy may get worse, so your kidney function should be checked as early as possible so that you can be referred for treatment if required. • Hypoglycaemia: as you try to manage your blood glucose and get tight blood glucose control, you may find that you have more hypo episodes if you are on meds Inform your diabetes healthcare team if you are planning to become pregnant that cause them. It is important to be aware of your warning signs and always have your treatment to hand. •P re-eclampsia: although all pregnant women are at risk, diabetes increases the risk of this happening. If your blood pressure is high, you have fluid retention and protein in your urine, you will be closely monitored until it is possible to deliver your baby safely. • Pre-term labour: although this may not be as you planned, you may need to deliver your baby earlier than expected, either for your safety or your baby’s. Some of the reasons may be if you have pre-eclampsia, your baby having grown too large or deterioration in your kidney function. pregnancy & labour women with diabetes have healthy “Most pregnancies and healthy babies ” Risks to your baby • Not developing normally and having congenital abnormalities, particularly heart abnormalities. • Having a neural tube defect, such as spina bifida. • Being large for gestational dates, known as macrosomia. This can cause difficulties with a vaginal birth and lead to birth injuries. • Being stillborn or dying soon after birth. How to reduce these risks Before pregnancy: • Tell your diabetes team that you are planning to become pregnant. • If you are overweight with a body mass index (BMI) over 27 kg/m2 you may want to try to lose some weight (see p55). • Work on getting good blood glucose control. This reduces the risk of your baby having congenital abnormalities. If your HbA1c is more than 86mmol/mol you should delay becoming pregnant, ideally it should be below 43mmol/mol. Your diabetes healthcare team can help you with this. • Start taking 5mg folic acid each day until the end of the 12th week of your pregnancy, to help prevent neural tube defects. This dose can’t be bought over the counter, but is prescribed by your doctor. • Check the tablets you are on. Metformin may be used before and during pregnancy, so your diabetes treatment may need to be changed or you may be put on to insulin for the duration of your pregnancy. If you are prescribed statins or certain blood pressure tablets, such as ACE inhibitors, you must stop taking them as they could damage your developing baby. Your doctor will change you to a type that is safe for your baby. • Ask to be referred to a pre-conception clinic which is usually run by the diabetes midwife and the diabetes specialist nurse. • Avoid alcohol while trying to conceive. Don’t panic if you find you are pregnant before you have had a chance to do all this preparation, make an appointment to see your doctor as soon as possible. Living with diabetes top tips During pregnancy Just like all pregnant women, with or without diabetes, it is important to follow these tips: 1 Alcohol. Alcohol should be avoided by all women during pregnancy because of the health risks to the baby. 2 Stop smoking. The chemicals in cigarettes are taken in your bloodstream to your unborn baby. This reduces the essential nutrients such as oxygen reaching your baby, causing your baby’s heart to beat faster and so work harder. It can also affect your baby’s growth rate and the development of your baby’s brain. 3 Eat a healthy, balanced diet. Discuss your recommended weight gain with your diabetes team. �Eating for two’ is not necessary and can cause more harm than good. 4 Stay active. If you were inactive before you became pregnant, don’t suddenly take up strenuous exercise. Choose an activity you like and feel comfortable doing. Remember that you may need to slow down as your pregnancy progresses. Physical activity can also help you to maintain good blood glucose control. 2013 Type 2 diabetes 75 Living with diabetes pregnancy & labour Once you are pregnant �Morning sickness’ can cause problems with your blood glucose control. • Try to eat small, regular starchy snacks, such as soup and crackers or plain biscuits. • Try sipping a drink before getting out of bed in the morning. • If you don’t feel like eating and you are treated with insulin, drink a sugary drink to avoid going hypo, but always remember not to stop taking your insulin. If this doesn’t help, your doctor may be able to prescribe a safe medicine to control the vomiting. If you have repeated vomiting and/or a large level of ketones on testing, you should seek medical advice as soon as possible to prevent the ketones from harming your baby. You should be offered joint antenatal and diabetes clinics where your diabetes and pregnancy teams can plan and discuss your pregnancy with you. You should also be offered an appointment with a dietitian. Because good blood glucose control is so important to your baby’s good health, if you don’t already self-monitor, you should be given a blood glucose meter for testing and shown how to use it and what to look out for. You may need to test up to eight times a day and so you will need plenty of test strips. Your diabetes healthcare 76 Type 2 diabetes 2013 team will advise you about when to test and why, but as a minimum you should be testing before breakfast, one hour after each meal and before you go to bed. Your personal target should be agreed between you and your team, but in general the rule is to aim for a fasting blood glucose of between 3.5 and 5.9mmol/l and less than 7.8mmol/l one hour after eating. If your diabetes is being treated with insulin you should be told about hypoglycaemia and given concentrated oral glucose solution to use if it occurs. As well as your routine antenatal appointments, you should have contact with your diabetes healthcare team every one to two weeks during your pregnancy to discuss your blood glucose levels. This may be by phone or in person. During labour If your labour starts before 37 weeks you may be given steroids to help your baby’s lungs to mature. Steroids can raise your blood glucose level so you may have to take extra insulin and monitor your blood glucose closely. Throughout your labour and the birth you should try to monitor your blood glucose hourly, aiming to keep it between 4–7mmol/l. You may be offered an intravenous infusion (drip) of dextrose and insulin if you are unable to keep your levels within your target range. i You can find more information in the NICE guidance for Diabetes in pregnancy at www.nice.org.uk/CG063 Q& A Will my baby be affected by my diabetes after birth? Your baby should stay with you unless there is a medical reason why he or she needs extra care. All babies’ blood glucose levels drop after they are born, so it is important that you should start to feed your baby as soon as possible – certainly within 30 minutes of birth, and then every two to three hours. Your baby’s blood glucose will be tested two to four hours after birth, (unless there are signs of hypoglycaemia) the target being to keep it above 2mmol/l. Once I’ve given birth, will my diabetes treatment go back to how it was? Unless you are breastfeeding (which provides the best nutrition for your baby, gives protection against infections and helps you to bond), after you’ve delivered your baby you will be able to resume your pre-pregnancy medications. pregnancy & labour Living with diabetes Specific antenatal care for women with diabetes Appointment Your heathcare professional should: First appointment (joint diabetes and antenatal clinic) Give you information, advice and support about your blood glucose levels. Ask you questions about your health and diabetes. Discuss your current medications. Offer an eye examination (retinal screening) and a kidney test if these have not been done in the last 12 months. 7–9 weeks Check that you are pregnant and confirm the gestational age of your baby. Booking appointment (ideally by 10 weeks) Offer information, education and advice about how diabetes will affect your pregnancy, birth and early parenting (such as breastfeeding). 16 weeks Offer you a repeat eye examination if you were found to have retinopathy at your first antenatal appointment. 20 weeks Offer you a test to check the development of your baby’s heart. 28 weeks Offer you an ultrasound scan to check your baby’s growth. Offer you a repeat eye examination if you did not have retinopathy at your first antenatal appointment. 32 weeks Offer you an ultrasound scan to check your baby’s growth. 36 weeks Offer you an ultrasound scan to check your baby’s growth. Give you information about: • planning the birth, including timing and types of birth, pain relief and anaesthesia and changes to your insulin during and after birth • looking after your baby following the birth, including starting breastfeeding and the effects of breastfeeding on your blood glucose levels • contraception and your care after the birth. Arrange for you to see an anaesthetist to prepare for the safe administration, should it be necessary, during the birth. 38 weeks Offer to induce your labour or offer a caesarian section if it is the best option for you. Offer to start regular tests to check your baby’s health if you are waiting for your labour to start. Every week from 39 weeks to birth Offer tests to check your baby’s wellbeing. 2013 Type 2 diabetes 77 Living with diabetes Illness & Infections Feeling off colour? Falling ill is never fun, and having diabetes means that you may need to consider a few more things. So here are a few tips to help you on your way to a speedy recovery Y our diabetes means that you have to pay close attention to any illness or infections you pick up from time to time. Like other forms of stress on the body, illness can raise your blood glucose levels. Some examples that will upset your diabetes control include: • colds, bronchitis and flu • vomiting and diarrhoea • urinary infections (eg cystitis) • skin infections (eg boils, inflamed cuts and skin ulcers). Milky drinks and soup are a good way of taking on carbohydrate 78 Type 2 diabetes 2013 Managing at home However you manage your diabetes it’s important not to stop taking your medication. When you’re ill or have an infection your blood glucose levels will rise even if you’re not eating as much as usual or are being sick. Try to drink plenty of unsweetened fluids and to rest, as exercise will make things worse. Your carbohydrate intake may need to be taken in an easily digested form. The following carbohydrate-containing foods may be useful alternatives to solid food when you are feeling unwell: • milky drinks • soup • ice-cream • Complan/Build-Up • drinking chocolate • ordinary squash or fizzy drinks. If you test your blood glucose levels then you may need to do this more regularly while you’re unwell. When to get medical help • you are unable to eat or drink • you have persistent vomiting or diarrhoea • you become drowsy or confused. You must also seek medical advice if you are treated with insulin and: • you have a blood glucose higher than 25mmol/l despite increasing your insulin. • you have low glucose levels. • you are taking metformin and you are too ill to drink good amounts of fluid, your medication may need to be stopped to reduce the risk of lactic acidosis. Hyperosmolar Hyperglycaemic State Hyperosmolar Hyperglycaemic State (HHS) occurs in people with Type 2 diabetes, who may be experiencing very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness, dehydration and an inability to take normal diabetes medication due to the effect of illness. Symptoms can include frequent urination and great thirst, nausea, dry skin, disorientation and, in later stages, drowsiness and a gradual loss of consciousness. Illness & Infections Living with diabetes top tips For diabetes when you’re ill If you’re unable to drink you may be at risk of HHS and you may need to be admitted to hospital for insulin and intravenous fluids. You may also be admitted to hospital if: • a heart attack or intestinal obstruction is suspected • you are unable to swallow or keep down fluids • you have persistent diarrhoea • your blood glucose level remains above 20mmol/l despite attempts to get it lower • there are any clinical signs of your condition worsening, eg Kussmaul’s respiration (deep, gasping breaths), severe dehydration, abdominal pain • you live alone, have no support and may be at risk of slipping into unconsciousness. Managing your diabetes in hospital The responsibility for managing your diabetes should be shared between you and the hospital staff. Although they should be able to provide you with diabetes medication and insulin, if possible take some with you to avoid delays and take your own diabetes equipment (pens, meters etc) because they won’t be able to supply this. Once your condition has stabilised don’t assume everyone treating you will know you have diabetes – it’s better to be over-cautious and keep mentioning it. Good diabetes control is important to speed your recovery. Stress and periods of inactivity might affect your blood glucose levels, so if you test it is important to test more often. Even if you go to A&E as an emergency, you may have to wait to receive treatment. In this case, don’t eat or drink anything should you need surgery. If your diabetes treatment means you are at risk of hypos (see p18), as soon as you arrive, tell a staff member that you have diabetes and may need to eat or drink to avoid going hypo. i See �Your care explained’, from p24. 1 2 3 Continue to take your medication even if you don’t feel like eating. If you test your blood glucose levels do so more frequently. If your blood glucose levels are consistently over 15mmol/l, contact your diabetes healthcare team. 4 If you don’t feel like eating, or you are feeling sick or can’t keep anything down, replace meals with snacks and drinks containing carbohydrate, which will provide energy. Sip sugary drinks or suck on glucose tablets. 5 D rink plenty of unsweetened fluids. ACTION POINTS • If you are admitted to hospital make sure that everyone treating you knows you have diabetes. • Become familiar with the signs that indicate you should seek medical advice, and make sure that a close friend, family member, or your carer are also aware of these points. 2013 Type 2 diabetes 79 Living with diabetes Work & Discrimination An even playing field being honest “By and showing how you cope with your diabetes, your employer is fully in the picture ” Unfortunately you may come across some discrimination at work. Here is some advice that should help you deal with the situation, should it arise Your employer should work with you and make adjustments to your role if required T hankfully, blanket bans on the recruitment of people with diabetes are almost a thing of the past. The UK armed forces are one of the very few employers who list people with diabetes as being ineligible to apply. Some jobs, however, especially those involving safety-critical work, will have legitimate health requirements that may exclude people with particular medical conditions and on certain medication, including diabetes. Disability discrimination is a vast area, but the Equality Act 2010 makes it unlawful for an employer to discriminate against people because of their disability. Many people with diabetes would not class themselves as 80 Type 2 diabetes 2013 disabled. Nevertheless, they can fall within the scope of the Equality Act 2010 and therefore benefit from the Act’s protection. The Equality Act applies to England, Wales and Scotland and the Disability Discrimination Act applies in Northern Ireland. The Act defines �disability’ as a physical or mental impairment that has a substantial and longterm adverse effect on a person’s ability to carry out normal dayto-day activities. It is important to remember that medical or other treatment and aids, which relieve or remove the effect of the impairment, are ignored when assessing whether the effect is substantial and long-term. The Act offers protection in a number of different areas, of which employment is one. Unfortunately, people with diabetes do sometimes face discrimination in the workplace, so the definition is there to protect their rights. The Act states that an employer must not treat a disabled person unfavourably and put them at a disadvantage because of their disability. This protection applies to every stage of the employment process; recruitment, terms and conditions of employment, opportunities for promotion, training or any other benefit and selection for redundancy or dismissal. Work & Discrimination Reasonable adjustments The Equality Act states that employers have to make reasonable adjustments (changes to the way they would normally do things) to prevent someone being placed at a disadvantage. Reasonable adjustments can take many different forms and for many people, a few minor adjustments may be all that is required. Depending on the circumstances, examples of reasonable adjustments might be, altering duties or working hours. Although there is no legal requirement to tell your employer that you have diabetes, if there is a health section on an application form you should state that you have diabetes. If you are asked how diabetes might affect your work, be honest. You may need to ask for time off for a clinic appointment or, depending on your treatment, you may need to take time out to do a blood test. Keep positive By being positive, honest and showing how you cope with your diabetes, your employer is fully in the picture. If you then have problems in managing your diabetes, your employer should be more aware and understanding about the condition. If you develop diabetes while in employment, your employer may offer to change aspects of your job, for instance by altering your shift patterns. If you’re no longer able to Living with diabetes meet the health requirements of your job, your employer may offer you a different job. If you have any problems with your employer’s response to your diagnosis, you can contact the Diabetes UK Advocacy Service (see details in Further information or visit www.diabetes.org.uk/ advocacy). You can also discuss the matter with your union, the Equality and Human Rights Commission (EHRC), or your local Citizens Advice Bureau (CAB), see below. i Equality and Human Rights Commission (EHRC): www.equalityhumanrights.com Citizens Advice Bureau (CAB): www.citizensadvice.org.uk Q& A ACTION POINTS • Be honest with your employer if they don’t know you have diabetes. • If you feel you can’t cope with your job in its present format, ask your employer to make some reasonable adjustments to your role. Can I appeal if my current job changes or my employment is terminated due to my diabetes? If you find that you’re being moved to another job or being discharged on medical grounds, you may wish to appeal against the decision. Check your position with a union rep, the local Citizens Advice Bureau (CAB), or the Equality and Human Rights Commission (EHRC). Can I appeal if I am turned down for a job after an interview? If you’ve been refused a job and you think it’s solely because of your diabetes, it may be worth appealing the decision. Again, get advice from your local CAB, or EHRC. Your diabetes healthcare team should be able to provide you with a supporting letter and the Diabetes UK Advocacy Service can give you more general information and refer you on to other possible sources of support if the CAB or EHRC can’t help. 2013 Type 2 diabetes 81 Living with diabetes TRAVEL Broad horizons The world is your oyster and diabetes shouldn’t get in your way. Here are some general points and tips to help you have the trip of a lifetime “Planning your trip well in advance will give you plenty of time to get organised ” H aving diabetes doesn’t mean your globe trotting days are behind you. Whether you’re planning to take a chance with the weather and holiday close to home in the UK, or you’re heading for more exotic climates, there’s no reason to shelve your travel plans. You will find that you have to plan your trip carefully and add a few extra items to your checklist. Before you go Planning your trip well in advance will give you plenty of time to get organised: • Order plenty of supplies (see essentials to pack, right) from your GP. It’s a good idea to take twice the quantity of medical supplies you would normally use for your diabetes. Most pharmacies want at least 82 Type 2 diabetes 2013 48 hours’ notice to prepare your prescriptions. If you would like to take extra supplies, you may need to allow longer time to arrange this. • Shop around for travel insurance (see top tips for insurance, right). • Apply for a European Health Insurance Card (EHIC). If you are travelling to a European Union member country – it will ensure that you have easy access to healthcare in that country. Visit www.ehic.org.uk, call 0845 605 0707 or fill in a form at the Post Office. • Talk to your diabetes healthcare team about how to manage your diabetes while you’re away and while you’re travelling, especially if you’re crossing time zones. • If you’re treated with insulin or a GLP-1 analogue (exenatide or liraglutide), then you should carry diabetes ID and ask your diabetes healthcare team for a letter explaining you have diabetes and your treatment. • Arrange to have any vaccinations or malaria tablets you may need. A safe getaway If you’re flying, here are a few things to consider: • Don’t feel like you have to order the diabetic meal rather than the standard one, ask for whatever you prefer. • Don’t expect to have perfect control while travelling. Interruptions to your routine, sitting for long periods and unexpected delays can cause blood glucose levels to be higher or lower than usual. • On long-haul flights take some healthy snacks with you. Living with diabetes TRAVEL • Don’t store your diabetes supplies in baggage that is going to be checked-in at the airport unless you absolutely have to. If you are taking insulin, the low temperate in the hold can damage it and the blood testing strips. Instead, keep insulin and equipment in your hand luggage, and keep the insulin cool by using an insulated bag (eg Frio) or Thermos flask. • If you take insulin, pack it in a flask or bubble wrap and place it in the centre of a suitcase. • If you take medication that could cause hypos, keep your hypo treatment close to hand, as well as your blood testing meter if you test your blood glucose levels. While you’re away It’s tempting on holiday to forget all about healthy eating, especially if you are on a cruise or an allinclusive holiday where the food supply is constant. • Balance an over-indulgent meal with some healthy eating to try to avoid straying too far from good diabetes management. You should be able to choose foods from local menus and still eat a balanced diet. • Overseas travel is also an ideal time to try different foods. • Try to be as active as possible. If the weather is good, go for evening walks or try some beach sports or activities. • Don’t forget to take your medication. Travelling across different time zones may mean that you have to adjust the timing of your medication, do talk to your diabetes healthcare team about how to do this whether you are treated with tablets or injections. • It is a good idea to take the right side of your prescription with you in case you are ill when away from home. This means that any doctor treating you knows exactly what medications you are currently prescribed and saves you struggling to remember. • If you take insulin, keep it cool either in a fridge, insulated bag or Thermos Flask. Insulin that is in a device can be kept at room temperature (under 25°C) for no longer than 28 days. i Diabetes UK Insurance Services provides travel insurance. Call 0800 731 7431 or visit www.diabetes.org.uk/travel for details. 3 Essentials to pack • Your medication. If you take injections, take your injecting device. •If you test your blood glucose: a finger pricking device, blood glucose meter and glucose testing strips. •if you take medication that could cause hypos, take a hypo treatment. •Travel insurance emergency contact number. •European Health Insurance Card (EHIC), if appropriate. top tips Insurance 1 Buy your insurance at least two weeks before your holiday. 2 D on’t just buy on price and check the cover is what you need (read the small print). 3 C hoose an insurance policy that covers illness (including a stay in hospital), emergency travel home and any expenses caused by an extended stay. 4 Be honest and declare all pre-existing medical conditions, such as your diabetes. If you don’t, it could lead to difficulty if you need to claim. Many insurers exclude pre-existing medical conditions, including diabetes, or raise the price when they hear you have diabetes. You can get a quote from Diabetes UK Insurance Services and use it as a comparison. By following these tips and preparing carefully well in advance there’s no reason why you won’t have a fantastic trip! 2013 Type 2 diabetes 83 Living with diabetes Festivals Mud, rain and  rock ’n’ roll Camping in a field and listening to loud live music shows no sign of going out of fashion. So, if you’re going to brave the elements, here are our tips for staying safe S leep deprivation, dodgy food and, of course, mud and rain – but don’t let that put you off! The plus points of a weekend away in the fresh air with friends and great music will always outweigh a few negatives. But make sure you have these points covered so you can fully enjoy yourself. Be prepared • Visit the festival’s website and download a map. Work out where the first aid tent is so you can get help if you feel unwell. • If you’re treated with insulin, or non-insulin injections, get a letter from your doctor to say you have diabetes and need to carry needles and syringes as some venues will need this. The letter could also say that you need to take food into the festival as you have diabetes; some festivals don’t let you take in food, and it 84 Type 2 diabetes 2013 Get a map of the site and familiarise yourself with the location of the main facilities can be very expensive to buy on site. • Check you’ve got all your diabetes supplies and equipment: – medication and your injection pen/syringe – if you test, your blood glucose monitoring kit – If you are at risk of hypos, your hypo treatment – snacks. What to take • Make sure you have ICE (In Case of Emergency) on your phone contacts list – put a number of someone at the festival and someone at home – paramedics will look for this if you’re too ill to tell them who to contact. • If you are treated with insulin keep it cool using Frio packs. They work by being held under running water so they’re very useful: www.friouk.com. General points • Carry your diabetes medication, equipment and hypo treatment if you need it, with you when you move around the festival. You may be a long walk from your tent. • Consider telling your friends about your diabetes and how you act when you are hypo so they can help you if you need it. • Charge your phone. Think about solar power via a backpack or a charger which uses standard batteries for your phone. Ask your local phone store, they’ll be able to help. • Remember to take your medication on time. You may want to put a reminder on your phone or ask your friends to remind you. • Body art is best avoided, especially if your diabetes is not well controlled, as you’re at more risk of skin infections. Festivals Living with diabetes top tips Staying safe 1 2 Carry some kind of diabetes ID. Drink plenty of sugar-free fluids to keep you well hydrated, and check your blood glucose regularly. 3 Consider reducing your insulin dose if you’re doing a lot of activity or if it’s very hot. 4 Keep plenty of carbohydrate-based snacks to hand. 5 6 7 M ake sure you always have something to treat a hypo with you. Make sure your phone is charged. K eep to the recommended limits for alcohol, that is two to three units per day for women, and three to four units for men. See p50. 8 Keep away from drugs. See p88. WALKING RUNNING CYCLING SWIMMING Challenges to suit all ages and abilities – there really is something for everyone. Find out more: CLICK www.diabetes.org.uk/events CALL 0845 123 2399 EMAIL [email protected] A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2013 0071A 2013 Type 2 diabetes 85 Living with diabetes DRIVING The road ahead Diabetes doesn’t stop you from driving. However extra care has to be taken 86 Type 2 diabetes 2013 DRIVING D iabetes won’t stop you from driving, however extra care has to be taken and certain authorities need to be informed. Firstly, tell your insurance company about your condition – you don’t want to find any unknown small print if you come to make a claim. If you treat your diabetes with insulin, you must also tell the Driver and Vehicle Licensing Agency (DVLA) or Driver and Vehicle Agency (DVA) if in Northern Ireland about your diabetes. You’ll be asked to fill in a medical questionnaire. If your diabetes is well controlled, with no complications and you have a good awareness of hypos, you’ll normally be issued with a new licence within eight weeks. The licence will be valid for one, two or three years and will need to be renewed. This is so your fitness to drive is assessed on a regular basis – but you won’t be charged anything for the renewal. Group 2 licences Since November 2011 you can hold a licence to drive a �Group 2’ vehicle (HGV and PCV) if your diabetes is treated with insulin or medications that could cause hypoglycaemia. But you have to undergo an independent medical assessment every year to assess your fitness to drive and your diabetes control. You should monitor your blood glucose regularly and store results on a memory meter. Hypos and driving People who treat their diabetes with certain tablets or insulin injections are at risk of hypos (see p18). A hypo while driving can be fatal, not only for the driver, but for others as well. Always have some form of snack and hypo treatment in the car. Even a mild hypo, because of its effects on the brain, can seriously impair your driving ability. It’s an offence to drive while hypo. Living with diabetes So always check your blood glucose levels before and during a journey. If you feel like you are going hypo, stop driving, remove the keys from the ignition and leave the driver’s seat before testing yourself. Either move to the passenger seat or step out of your vehicle, if it is safe to do so. If you are on a motorbike or moped, you must remove the keys from the ignition and dismount. If the test shows you are hypo, treat it in the usual way and wait for your blood glucose levels to rise before continuing. The DVLA recommends that you wait 45 minutes after the blood glucose levels have risen to above 4mmol/l. You shouldn’t test blood glucose levels or treat a hypo while in or on the driver’s seat – and you mustn’t start driving again until you have dealt with the hypo. i Visit www.diabetes.org.uk/driving for more information. ACTION POINTS • Check blood glucose levels before driving. If below 5mmol/l have something to eat. • Don’t delay or miss a meal or snack. Try not to drive for more than two hours without stopping to test your blood glucose and having a snack, if necessary. • If you feel like you are going hypo, stop driving as soon as possible, remove keys from the ignition, leave the driving seat and test yourself. You must not drive until 45 minutes after your blood glucose levels have risen to above 4mmol/l. • Have hypo treatments to hand. 2013 Type 2 diabetes 87 Living with diabetes smoking & Drugs positive changes Smoking Nearly one-sixth of people in the UK smoke, and people with diabetes are no exception – the proportion of smokers is exactly the same. Having diabetes means that you have a higher risk of damaged blood vessels, which can lead to certain conditions including heart disease, stroke, problems with the blood supply to your legs, and kidney damage. And smoking greatly increases these risks. Studies also show that smoking increases the risk of people with diabetes developing nephropathy (kidney disease) and 88 Type 2 diabetes 2013 retinopathy (eye disease). We all know that smoking is very bad for us but that doesn’t make it any easier to give up and if you’ve already made lots of lifestyle changes because of your diabetes, smoking may be the one �pleasure’ you are determined to hold on to. But quitting smoking is the single most positive thing you can do to improve your health and reduce the risk of major complications later in life. For prolonged good health stopping smoking is as important as good blood glucose control, healthy eating and being active. Feel the benefit after quitting smoking 20 minutes: your blood pressure and pulse rate return to normal. 8 hours: Nicotine and carbon monoxide levels in blood reduce by half, oxygen levels return to normal. 24 hours: Carbon monoxide has left your body and the lungs start to clear themselves of mucous. 48 hours: There is no nicotine in your body. Your ability to taste and smell is greatly improved. 72 hours: Your breathing will become easier as your bronchial tubes begin to relax and energy levels increase. 2–12 weeks: Your circulation will have improved. 3–9 months: Any coughs, wheezing and breathing problems will improve as your lung function increases by up to 10 per cent. 5 years: Your risk of heart attack falls to about half compared to a person who is still smoking. 10 years: Your risk of lung cancer falls to half that of a smoker and your risk of heart attack falls to the same as someone who has never smoked. You can only give up if you want to. It’s no good other people nagging a smoker to stop. Different people have different needs and you may prefer to have an individual session each week with your practice nurse or you may like to join a support group. There are a variety of nicotine replacement treatments available, and these are all free on the NHS. Call Quit on 0800 002 200 or visit their website at www.quit.org.uk for support and practical advice. smoking & Drugs Recreational drugs Diabetes UK doesn’t advocate the use of recreational drugs but if you’re using drugs of any kind, even on a one-off basis, you need to know about the effect they can have. Even if you take drugs in small doses, they’ll reduce the control you have over your muscles, lessen your reaction time and affect your concentration, so you might forget to eat or take your diabetes medication. There are many different drugs around, some legal, some illegal. Remember – no drug is a safe drug. There are risks associated with any drug you take, not just affecting your diabetes. Some drugs are illegal and there are heavy penalties for possessing and supplying them. Drugs fall mainly into the following categories: • downers (or depressants) • uppers (or stimulants) • hallucinogenic. Watch out for people offering you �legal highs’. These are substances used to replicate the effects of illegal drugs such as cocaine, ecstasy or amphetamines. Their chemical structure is slightly different, meaning they avoid being classified as illegal under the Misuse of Drugs Act 1971, but this doesn’t mean that they are safe or approved for people to use. It just means that they’ve not been declared illegal to use or possess. Living with diabetes Some drugs marketed as legal highs actually contain some ingredients that are illegal to possess. There are many more drugs around in many forms, so if you have any questions about drugs and you don’t want to talk to your diabetes healthcare team, contact �Talk to Frank’ on 0800 776 600 (24 hours a day, 365 days a year). This is a free, confidential information service or you can visit the website at www.talktofrank.com. Although they don’t talk about diabetes specifically, they give full descriptions of the effects of each drug, so you can see the knock-on effect on your condition. ACTION POINTS • If you can, quit smoking. The benefits of quitting are immense while the costs of smoking are numerous. 2013 Type 2 diabetes 89 Complications Cardiovascular Disease Looking after your Heart People with diabetes have a higher risk of cardiovascular disease, so it’s important to look after yourself to reduce this risk Y our heart is an organ that pumps oxygen and many other substances via your blood around your body. Blood vessels carry blood to and from your heart as well as to all parts of your body. Damage to the heart and blood vessels is collectively known as cardiovasular disease and people with diabetes have a higher chance of developing it. Cardiovascular problems Your major blood vessels consist of arteries which carry blood away from your heart, and veins which return it. Damage to these vessels is referred to as macrovascular disease. Capillaries are the tiny vessels where the exchange of oxygen and carbon dioxide takes place and when damage occurs to these vessels it’s referred to as microvascular disease. When fatty materials, such as cholesterol, form deposits on the walls of the vessels (known 90 Type 2 diabetes 2013 as plaque), furring up the artery and reducing the space for blood to flow, this is described as arteriosclerosis or atherosclerosis. If the plaque ruptures the artery walls, blood cells (called platelets) try to repair the damage, but this will cause a clot to form. Over time, the walls of blood vessels lose their elasticity. This can contribute to the development of high blood pressure, or hypertension, which will cause more damage to the blood vessels. The force of the blood being pumped from the heart can make the clot break away from the artery wall and travel through the system until it reaches a section too narrow to pass through. If this happens the narrow section will become partially or completely blocked. Blockage of an artery leads to the part of the body it supplies being starved of the oxygen and nutrients it needs. This is the cause of heart attack or strokes (affecting the brain). Narrowing of the blood vessels can affect other parts of the body, such as the arms or legs. This is called peripheral vascular disease (PVD). PVD may produce an intermittent pain known as intermittent claudication (pain in the calf muscle). If left untreated, amputation of the limb may eventually be necessary. Blood vessels are damaged by high blood glucose, high blood pressure, smoking or high levels of cholesterol. So, it is important for people with diabetes to manage these levels by making lifestyle changes, such as eating a healthy diet, taking part in regular activity, reducing weight if you are overweight and stopping smoking. See �Action points’ for all the steps you can take to stay healthy. i For more on CVD, visit www.diabetes.org.uk/cvd Cardiovascular Disease Complications ACTION POINTS Steps you can take to help prevent CVD • If you smoke, ask for help to stop. • Eat a healthy, balanced diet (see p32). • Be more physically active. Choose something you enjoy. • If you’re overweight, try to get down to a healthy weight. Any weight loss will be of benefit (see p55). • Take your medication as prescribed. • Get your blood glucose levels, blood pressure and blood cholesterol checked at least once a year and aim to keep to the target agreed with your healthcare team (see p22). • If you have any chest Keeping active is an excellent way to look after your heart pain, intermittent pain when walking, impotence or signs of a stroke, such as facial or arm weakness or slurred speech, you should contact a doctor as soon as possible. 2013 Type 2 diabetes 91 Complications Complications retinopathy looking after your eyeS Keeping a close check on your eyes and getting them examined every year are some of the best ways of reducing the damage that retinopathy can cause T o see, light must be able to pass from the front of the eye through to the retina, being focused by the lens. The retina is the light-sensitive layer of cells at the back of your eye – the �seeing’ part of the eye. It converts light into electrical signals. These signals are sent to your brain through the optic nerve and your brain interprets them to produce the images that you see. A delicate network of blood vessels supplies the retina with blood. When those blood vessels become blocked, leaky or grow haphazardly, the retina becomes damaged and is unable to work properly. Damage to the retina is called retinopathy. There are different types of retinopathy: background retinopathy, maculopathy and proliferative retinopathy. Background retinopathy This will not affect your eyesight, but it needs to be carefully monitored. The capillaries (small blood vessels) in the retina become blocked, they may bulge slightly (microaneurysm) 92 Type 2 diabetes 2013 and may leak blood (haemorrhages) or fluid (exudates). Maculopathy describes when the background retinopathy is at or around the macula. The macula is the most used area of the retina. It provides our central vision and is essential for clear, detailed vision. If fluid leaks from the enlarged blood vessels it can build up and causes swelling (oedema). This can lead to some loss of vision, particularly for reading and seeing fine details, and everything may appear blurred, as if you are looking through a layer of fluid not quite as clear as water. Proliferative retinopathy occurs as background retinopathy develops and large areas of the retina are deprived of a proper blood supply. This stimulates the growth of new blood vessels to replace the blocked ones. These growing blood vessels are very delicate and bleed easily. The bleeding causes scar tissue, that starts to shrink and pull on the retina – leading it to become detached and possibly causing vision loss or blindness. Once the retinopathy has reached this stage it will be treated with laser therapy. Beams of bright laser light make tiny burns to stop the leakage and to stop the growth of new blood vessels. Q& A My vision hasn’t changed, but my eye specialist has told me I need laser treatment. Is this correct? Retinopathy frequently has no symptoms until it is well advanced. Your eye specialist has probably caught your retinopathy at an early stage before you notice any visual changes. Will I be able to drive if I have retinopathy? You must tell the DVLA (DVA in Northern Ireland) if you develop retinopathy. For more on driving, see p86. retinopathy Complications macula sclera cornea pupil iris vitreous/ humour aqueous humour retina optic nerve lens ACTION POINTS Steps you can take to avoid retinopathy Everyone over the age of 12 with diabetes should have the retina of their eyes photographed each year to check for retinopathy, so that treatment can be given at the right time. This forms part of the annual review. High blood glucose levels are the main cause of retinopathy, but high blood fats and high blood pressure also play a part. So, to help prevent any eye problems developing: • Try to keep your blood glucose, blood fats and blood pressure at your agreed target (see p22 regarding target ranges). This is agreed between you and your healthcare team. • Tell your doctor if you notice any changes to your vision (don’t wait until your next screening appointment). • Take your medication as prescribed. • If you’re overweight, try to lose excess weight. • Eat a healthy, balanced diet. • If you smoke, ask for help to stop. • Attend your annual eye screening appointment. 2013 Type 2 diabetes 93 Complications neuropathy looking after your nerves Keeping a close eye on your blood glucose levels and having your feet checked every year are steps you can take to avoid neuropathy N erves carry messages between the brain and every part of our bodies, making it possible to see, hear, feel and move. Nerves also carry signals that we’re not aware of to parts of the body such as the heart, causing it to beat, and the lungs, so we can breathe. Damage to the nerves is called neuropathy. Diabetes can cause neuropathy as a result of high blood glucose levels damaging the small blood vessels which supply the nerves. This prevents essential nutrients reaching the nerves. The nerve fibres are then damaged or disappear. There are three different types of nerves: sensory, autonomic and motor. 94 Type 2 diabetes 2013 Sensory neuropathy affects the nerves that carry messages of touch, temperature, pain and other sensations from the skin, bones and muscles to the brain. It mainly affects the nerves in the feet and the legs, but people can also develop this type of neuropathy in their arms and hands. Symptoms can include: • tingling and numbness • loss of ability to feel pain • loss of ability to detect changes in temperature • loss of coordination – when you lose your joint position sense • burning or shooting pains – these may be worse at night time. The main danger of sensory neuropathy for someone with diabetes is loss of feeling in the feet, especially if you don’t realise that this has happened. This is dangerous because you may not notice minor injuries caused by: • walking around barefoot • sharp objects in shoes • friction from badly fitting shoes •b urns from radiators or hot water bottles. If ignored, minor injuries may develop into infections or ulcers. People with diabetes are more likely to be admitted to hospital with a foot ulcer than with any other diabetes complication. Autonomic neuropathy affects nerves that carry information to your organs and glands. They help neuropathy Complications important to have “It’s your feet checked at least once a year ” Q& A Can neuropathy be treated? The symptoms caused by neuropathy can be treated, such as medication for nausea and vomiting, or painkillers for sensory neuropathy, but these symptoms will be helped more by getting your blood glucose levels on target. What do I do if I become impotent? If you have neuropathy you may pick up minor injuries by walking around barefoot to control some functions without you consciously directing them, such as stomach emptying, bowel control, heart beating, and sexual organs working. Damage to these nerves can result in: • Gastroparesis – when food can’t move through the digestive system efficiently. Symptoms of this can include vomiting, bloating, constipation or diarrhoea. • Loss of bladder control, leading to incontinence. • Irregular heart beats. • Problems with sweating, either a reduced ability to sweat and intolerance to heat or sweating related Talk to your doctor. There are a number of treatments available and if you also get your blood glucose well controlled your problem may be resolved quite quickly. to eating food (gustatory). • Impotence (inability to get or keep an erection). Motor neuropathy affects the nerves which control movement. Damage to these nerves leads to weakness and wasting of the muscles that receive messages from the affected nerves. This can lead to problems such as • muscle weakness which could cause falls or problems with tasks, such as fastening buttons • muscle wasting, where muscle tissue is lost due to lack of activity • muscle twitching and cramps. ACTION POINTS Steps you can take to avoid neuropathy • Keep your blood glucose within your target range (see p22). • Have your feet checked at least once a year. • Tell your diabetes healthcare team if you think you’re developing any signs of neuropathy. • If you think you’ve lost sensation in your feet, protect them from injury and check them every day. And talk to your diabetes healthcare team. 2013 Type 2 diabetes 95 Complications Nephropathy looking after your kidneys Keeping your blood glucose and blood pressure levels on target will help to keep your kidneys in good working order T he kidneys are bean-shaped organs about the size of a fist, which sit at the back of your body at the bottom of your ribcage. Most people have two kidneys but some people are born with only one or have one removed for a variety of reasons and live perfectly healthy lives, as long as the remaining kidney is functioning well. What the kidneys do Kidneys are very important as they perform a number of vital functions. After the body uses food for energy and self-repair, the waste is sent to the blood. The most common waste products are urea and creatinine, but there are many other substances that need to be eliminated. Using a system of tiny blood vessels, the kidneys act as very efficient filters for getting rid of waste and toxic substances, and returning vitamins, amino acids, glucose, hormones and other vital 96 Type 2 diabetes 2013 substances into the bloodstream. The waste products, along with extra fluid that the body does not need, are then converted into urine and passed out of the body. In 24 hours, your kidneys filter around 150 litres of blood and produce roughly 1.5 litres of urine. The kidneys secrete a number of hormones, which are important for normal functioning of the body. One hormone is rennin, which keeps blood pressure normal. If your blood pressure falls, rennin is secreted by the kidneys to make the small blood vessels narrower, and so increase your blood pressure. If your kidneys aren’t functioning correctly, too much rennin can be produced, which leads to high blood pressure. Blood pressure Kidney failure causes high blood pressure but also, high blood pressure can cause kidney failure. High blood pressure can damage the blood vessels and if the blood vessels in the kidneys are damaged they are unable to remove the waste and extra fluid from the body. The extra fluid left in the blood vessels may then raise the blood pressure even more, so it is a dangerous cycle. Another hormone is called erythropoietin. This acts on the bone marrow to increase the production of red blood cells. If your kidney function is reduced, not enough hormone is produced and the number of red blood cells being produced will fall, resulting in anaemia. kidneys “The perform a number of vital functions ” Nephropathy Complications Q& A How will I know if I have a problem? There are usually no symptoms at first, but if you notice your ankles or fingers swelling you should see your doctor urgently. Your blood pressure may rise and a kidney function blood test would be done to measure urea, creatinine, estimated glomerular filtration rate (eGFR) and electrolytes (blood salts) . Any abnormal or high levels of these would indicate that your kidneys are not working correctly. There will be protein present on urine testing. Keeping active can help control your blood pressure which in turn can prevent nephropathy Calcium Vitamin D is essential for a number of bodily functions including the absorption of calcium by the intestine, the normal structure of bones and effective muscle function. Vitamin D from your diet needs to be slightly altered by the kidney before it can act within the body. If your kidneys are not working properly you may have low levels of blood calcium resulting in muscle weakness and a softening of the bones. Nephropathy means damage to or disease of a kidney. Diabetes can cause damage to the tiny blood vessels which supply the kidneys if blood glucose levels stay too high. The walls of these blood vessels in the kidneys become thickened or irregular, which prevents them from filtering waste products out of the blood into the urine properly. ACTION POINTS Steps you can take to avoid nephropathy The best ways to prevent nephropathy developing are: • Keep your blood glucose and blood pressure levels within your target range (see p22). •Have your urine tested for protein and a blood test to measure kidney function at least once a year. •Take your medication as required. Is nephropathy treatable? Prevention is the best way to avoid kidney damage. Early treatment includes keeping your blood glucose and blood pressure within your target range, eating a healthy diet, not smoking, and being physically active. You may also be prescribed medications called ACE inhibitors. If the kidney damage progresses dialysis and transplantation may be options. In some cases of kidney transplant, it is done alongside a pancreas transplant. Because the new organ or cells are �foreign’ to the body, drugs must be taken for life to stop the body rejecting them. 2013 Type 2 diabetes 97 Further information about Diabetes UK ABOUT Diabetes UK Diabetes UK is the leading UK charity that cares for, connects with and campaigns on behalf of all people affected by and at risk of diabetes. GET in touch Call us: 0845 123 2399 Email us: [email protected] Website: www.diabetes.org.uk need to talk? Careline: 0 845 123 2399 Monday–Friday, 9am–5pm ADDRESS:Macleod House, 10 Parkway, london NW1 7AA Join us Become a member, or, if you’re a healthcare practitioner, a professional member of Diabetes UK. You’ll receive many benefits, including our magazines and updates on the latest developments in diabetes treatment, care and research. Visit www.diabetes.org.uk/join. 98 Type 2 diabetes 2013 Campaign with us We work hard to make sure every person with diabetes, whether Type 1 or Type 2, wherever they live in the UK, gets the best treatment and services. Our Diabetes Voices help us make a difference by working alongside us to campaign and influence for change. Sign up at www.diabetes.org.uk/DiabetesVoices. CARE Connect Campaign NATIONAL OFFICES CONTACT DETAILS Scotland The Venlaw, 349 Bath Street, Glasgow G2 4AA Tel 0141 245 6380 Email [email protected] Northern Ireland Bridgewood House, Newforge Business Park, Newforge Lane, Belfast BT9 5NW Tel 028 9066 6646 Email [email protected] Cymru Argyle House, Castlebridge, Cowbridge Road East, Cardiff CF11 9AB Tel 029 2066 8276 Email [email protected] HOW DIABETES UK HELPED ME They put me in touch with local support groups and gave me lots of practical information. Ronnie Auguste Type 2 diabetes creating healthier communities together Working in partnership with Diabetes UK and Tesco are working together to create healthier communities, and to help support those affected by and at risk of diabetes. Our partnership will change lives – it aims to raise £10million to: • help support the 3 million people who have to live with diabetes and its effects every day • help hundreds of thousands of people to take action to reduce their risk of Type 2 diabetes • invest in ground-breaking research to find a vaccine for Type 1 diabetes. For more information and support: • Talk to your Tesco Pharmacy. Find your nearest Tesco Pharmacy at Tesco.com/storelocator or call 0800 505 555* • Visit www.diabetes.org.uk *calls are free from a BT landline.
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