TYPE 1 DIABETES treatment food Lifestyle WHAT YOU NEED TO KNOW Newly diagnosed with type 1 diabetes? There’s a revolutionary new way to help keep you safe at night. Introducing for accurate, non-invasive detection of sleep-time hypos As someone newly diagnosed with type 1 diabetes, the number one concern you will face in the years ahead is the prospect of night-time hypoglycaemic events and their potentially serious consequences. Indeed research has shown that it is impossible to identify a pre-sleep glucose level that minimises risk of hypo1 and that over half of severe hypos (BGL<2.8mmol/L) occur during sleep.2 This has led to use of various monitors associated with invasive procedures – as that is all that has been available… UNTIL NOW Over 10 years of extensive research and development has resulted in HypoMon – a sophisticated monitoring device that sets new standards of performance and comfort. What HypoMon users say: “I’m delighted with HypoMon. Not only is it simple to put on, it’s comfortable to wear around the chest and, most importantly, sleep with.” Young Adult – Female “Having had diabetes for 20 years I’m naturally sceptical of so called non-invasive alternatives. But HypoMon is not only easy to use, it truly works. It detected and alerted me of a hypo within the first few nights of use.” Young Adult – Male A safer night’s sleep. ● Outstanding accuracy – detects and alerts users to >80% of night-time hypos. ● Non-invasive and comfortable – no implanting or inserting required; sensors, comfortably belted to the body, monitor and transmit the body’s physiological markers of hypoglycaemia. ● Simple and easy to use – the HypoMon belt is easy to fit and wear. Once set up it logs the physiological changes and a hypo will trigger the alarm with a sequence of flashing light and sound alarm of up to 85 decibels. ● Enhancing diabetes management – the HypoMon supplements other diabetes management practices to identify additional nocturnal hypoglycaemia events which would typically be missed. MKT17 If you are aged 10–25 with type 1 diabetes, HypoMon could be for you. For more information please visit www.hypomon.com or talk to your diabetes advisor. © 2010 AIMEDICS PTY LTD All rights reserved. AIMEDICS and HypoMon are registered trademarks of AIMEDICS PTY LTD This information is for people with diabetes. Use only as directed and see your healthcare professional for medical advice. 1. American Journal of Medicine, 1991; 90(4): 450-9 2. Matyka KA Pediatric Diabetes 2002; 3:74-81 Testing Pumps 16 Education Healthy eating 30 13 Welcome Welcome to What You Need to Know – Type 1 Diabetes. This is an introductory guide for adults who’ve recently been diagnosed with the condition, but it’s also a handy refresher for those who’ve had Type 1 diabetes 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’ll cope. This guide will answer a lot of your questions and address your doubts and concerns by giving you the facts. It will also tell where you need to go for further information. This guide will take you through diabetes care and living your day-to-day life – from work and illness, to socialising and travel. We’ll also shed light on the complications that you need to be aware of and the steps you can take to prevent them. Plus, there’s lots of information about how Diabetes UK can support you as you continue to live your life to the full. Eating out 52 36 what’s inside... INTRODUCTION 5 Debunking the myths 6 What is diabetes? DIABETES CARE 8Insulin 10Injections 13Pumps 16Testing 18 Hypos & hypers 23 Long-term testing 24 The care to expect 30 Education 31 Health information online 32 Associated conditions 34 Eating disorder FOOD 36 Healthy eating 41 Balanced diet 42 Carbohydrate counting 44 Food GI 45 Food labelling 48 Healthy cooking 52 Eating out 54 Questions & answers 2013 Type 1 diabetes 3 Physical activity Pregnancy 62 Work Travel 92 80 74 LIVING WITH DIABETES 56 Weight management 62 Physical activity 66 Accepting diagnosis 68 Telling people 70 Love life 72Contraception 74 Pregnancy & labour 78 Illness & infections 80 Work & discrimination 82 Driving 84Travel 86 Religious festivities 88 Alcohol, smoking & drugs 92Festivals Editor: Angela Coffey Sub Editor: Nick Myall Designers: Clara Medves, Wendy Riley Photography: Phil Starling Printer: Newnorth Print Ltd Advertising Manager: Claire Barber, Ten Alps Media Published in April 2013 by Diabetes UK, 10 Parkway, London NW1 7AA Tel: 020 7424 1000 Website: www.diabetes.org.uk Email: [email protected] © Diabetes UK 2013 Product code: 6954 Festivals 84 complications 94 Cardiovascular disease 96Retinopathy 98Neuropathy 100Nephropathy FURTHER INFORMATION 102About Diabetes UK With thanks to all the contributors and advisors, and the volunteers who participated in photoshoots. 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. Paid adverts do not necessarily represent the views of Diabetes UK. Complaints regarding advertised services or products should be addressed to: Claire Barber, Advertisements Manager, Ten Alps Publishing, One New Oxford Street, London WC1A 1NU. 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). debunking theTESTIN myths diabetes myths INTRODUCTION There are many myths surrounding diabetes – here are some of the main ones Myth: People with diabetes can’t play sport Myth: It’s not safe to drive if you have diabetes If you are responsible and have good control of your blood glucose levels, you’re just the same as everyone else on the roads. Nevertheless, the myth persists that people with diabetes are unsafe to drive. 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 you should still be able to enjoy a wide variety of foods, including some with sugar. 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. • For more on exercise, see p62. • For more on driving, see p82. Myth: People with diabetes should eat �diabetic’ foods �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 you want to treat yourself occasionally, then you should go for the real thing. • For more on food, see p36. • For more on food and healthy eating, see p36. 2013 Type 1 diabetes 5 Introduction TESTINis diabetes? what Type 1 diabetes Explained You’ll hear a lot of differing opinions and rumours surrounding diabetes and how it affects people, so it’s important to have all the facts from the outset It�s important to keep physically active D iabetes is a condition where your body can’t produce the hormone insulin, or doesn’t produce enough, or where your insulin doesn’t work properly. Insulin is a chemical messenger that helps your body use the glucose in your blood to give gullet liver stomach pancreas 6 Type 1 diabetes 2013 you energy. And if you don’t have the right amount of insulin, or if your insulin isn’t doing its job properly, you can get very ill. So what should happen? Our bodies need glucose for energy. Glucose enters the bloodstream when you 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. Glucose is also produced by the liver. In people without diabetes, insulin carefully controls the amount of glucose in the blood. Insulin is made by an organ called the pancreas, which lies just behind the stomach. Insulin acts as the �key’ that �unlocks’ the body’s cells to let the glucose in. The body’s cells then convert the glucose into energy. What happens in someone with Type 1 diabetes? Because Type 1 diabetes develops when the pancreas doesn’t produce any – or very little – insulin, glucose is unable to enter their cells to be converted into energy and this is why people with untreated diabetes often feel tired. As glucose can’t provide energy, the body tries to get it from elsewhere and starts to break down stores of fat and protein instead, which can cause weight loss. Because the body doesn’t use the glucose it ends up passing into the urine. This can mean lots of trips to the loo and dehydration, which then causes extreme thirst. what is diabetes? TESTIN INTRODUCTION no “There’s reason for diabetes to stop you living a healthy, happy and successful life ” Q& A Symptoms The main signs of untreated diabetes are: • frequent urination • increased thirst • extreme tiredness • weight loss. If diabetes is not well managed, these symptoms can return. How is diabetes treated? Type 1 diabetes can be successfully treated with insulin, either by injections or via a pump, and by following a healthy, balanced diet and regular physical activity. Looking after diabetes needs planning and attention, which may feel overwhelming, but there’s no reason for it to stop you living a healthy, happy and successful life. How does Type 1 differ from Type 2 diabetes? There are two main types of diabetes – Type 1 and Type 2. Unlike people with Type 1, those with Type 2 still have some insulin-producing cells, but either not enough insulin is produced or it doesn’t work properly. In most cases, Type 2 is linked with being overweight and usually appears in people over the age of 40 or over 25 in South Asian people. Recently, however, more children are being diagnosed with Type 2. Type 2 diabetes is treated with lifestyle changes, such as a healthy diet, weight loss and increased physical activity. Medication, including insulin, may also be needed. There are also other, quite rare, forms of diabetes, such as Maturity Onset Diabetes of the Young (MODY) and neonatal diabetes. Information about these conditions can be found at www.diabetes.org.uk/What_is_diabetes 2013 Type 1 diabetes 7 Diabetes care Insulin ins and outs of insulin Insulin is a necessary treatment for people with Type 1 diabetes. Let’s find out more about it... I nsulin is a type of hormone (a chemical messenger) that is produced by the pancreas. Your insulin will come from one of two sources – animal or human insulin. Human insulin isn’t made from humans, but is genetically engineered so it’s identical to human insulin. Some people use animal insulin, which is made from the pancreas of cows or pigs, but it’s unlikely that you will be started on animal insulin. Before human insulin was developed, these were the only types of insulin available. There are also analogue insulins, where the chemical structure has been changed to make them act 8 Type 1 diabetes 2013 more quickly or more slowly than regular human insulin. insulin types There are different insulins to choose from: Rapid-acting analogues • injected immediately before a meal • peak action is at around two hours after injecting • lasts for around four hours. Short-acting insulins • injected approximately 15–45 minutes before a meal • peak action is at around 2–4 hours after injecting • lasts for around 6–8 hours. Medium/long-acting insulins • injected once or twice a day • peak action up to 12 hours after injecting • lasts around 20–24 hours. Long-acting analogues • injected once or twice a day (at the same time each day) • lasts around 24 hours (there’s no peak, they stay at the same concentration). Mixed insulins • a mixture of rapid-acting analogue or short-acting insulin and medium/long-acting insulin • usually injected before breakfast and dinner • peak action 2–8 hours. Insulin diabetes care top how often should insulin be taken? Four times a day (or basal bolus): most people who are newly diagnosed with Type 1 diabetes are likely to be on this regime, which mimics the action of a healthy pancreas more closely and there’s less chance of a hypo. Basal bolus also allows more flexibility with meal times and the amount you can eat, but for best results you’ll need to learn to carbohydrate count (see p42). Twice a day: this is less common but involves needing to eat at similar times each day and take in similar amounts of carbohydrate at each meal. Q& A Does insulin go off? Yes. Clear insulin will go cloudy when it’s off. It will also go a bit lumpy and stick to the side of the container. If you’re not sure, don’t use it and check the expiry date. How do I know what the best regimen is for me? You and your diabetes healthcare team will decide which is the best insulin or combination of insulin for you. This will depend on your diabetes control and your lifestyle. The most common combination is basal bolus. You will know when you are on the right regimen as your blood glucose levels will be managed well and it will fit into your lifestyle. tips Storing insulin 1 2 Keep any insulin that you’re not using in the fridge, between 2–8oC. With the insulin that you are using, keep it at room temperature (under 25oC) as this will make it more comfortable to inject. 3 Don’t let insulin get too hot – never place it near a radiator, in direct sunlight or on top of electricals, like a TV or computer. 4 5 6 Don’t let insulin freeze – this will stop it from working properly. Check the expiry date and don’t use if it has passed this date. Keep spare vials or cartridges of insulin in their boxes in the fridge so you always have expiry date details. 7 If you need to transport insulin (eg when travelling) keep it cool in a Frio bag or flask (see p84). insulin will come from “Your one of two sources – animal or human ” 2013 Type 1 diabetes 9 Diabetes care Injections Injecting insulin By following some simple guidelines, injections can become just another part of daily life Your stomach is one of the main places you can inject insulin I nsulin needs to be taken via a pen injector or small syringe, or via a pump (see p13). That’s because insulin is a protein, so it can’t be given as a tablet – otherwise the stomach would digest it in the same way as other types of protein, such as meat and fish. The needles used are very small because insulin only needs to be injected under the skin – not into a muscle or vein. Once it’s been injected, insulin soaks into small blood vessels and is absorbed into the bloodstream where it gets to work. Injections can be a little painful, especially the first few, because you may be 10 Type 1 diabetes 2013 tense. But as your confidence grows and you become more relaxed, they’ll get easier and will soon become second nature. Keep on moving It’s really important that you rotate or change the area where you inject. If you keep injecting into the same site, small lumps can build up under the skin. These won’t look or feel very nice, and can also mean that the insulin doesn’t work properly because it’s harder to absorb through the lumps. Also, be careful not to inject in the same spot within each site – change it each time. By rotating injection sites and spots you can help avoid getting lumps (any that may have formed will slowly disappear). Different insulins are absorbed at different rates from different injection sites. Several things can speed up the action of insulin after it’s been injected: • heat – sunbathing or a hot bath • exercise – using a limb you’ve just injected, eg injecting into your leg and then going running • massage. All these things can make a hypo more likely, so, if you’re doing any of these activities, you’ll need to test your blood glucose levels more often. Injections Where to inject How to inject There are four main places: 1 2 diabetes care Make sure your hands and the area you’re 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. Arms* Stomach Bottom Thighs * check with your diabetes healthcare team as arms aren’t suitable for everyone. 5 6 ACTION POINTS • If you don’t feel confident with your injection technique ask your diabetes healthcare team to review it. • Are you rotating and changing injection sites regularly? Keep a log of the places you use each week to make sure. 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. Put the needle in quickly. If you continue to find injections painful, try numbing an area of skin by rubbing a piece of ice on the site for 15–20 seconds before injecting. 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 Release the skin fold and dispose of the used needle safely. Remember to use a new needle every time. Reusing a needle will make it blunt and can make injecting painful. o avoid lumps, change the spot “ Twhere you inject each time ” 2013 Type 1 diabetes 11 ACCU-CHEK and ACCU-CHEK MOBILE are trademarks of Roche. © 2012 Roche Diagnostics Limited. Accu-Chek® Mobile Strip Free, Simple, Smart. NEW for INSULIN USERS All-in-one system: test whenever, wherever. Visit www.accu-chek.co.uk/DUKmobile or ask your healthcare professional Experience what’s possible. Roche Diagnostics Limited, Charles Avenue, Burgess Hill, RH15 9RY. Company registration number: 571546 PUMPS diabetes care pump it up As an alternative to pens, insulin pumps can help to improve overall diabetes control and allows more freedom Using a pump means you can have a more flexible lifestyle O ver recent years, insulin pump therapy (also known as continuous subcutaneous insulin infusion or CSII) has risen in popularity. A pump – about the size of a small mobile phone – delivers a steady flow of rapidacting insulin round the clock from a reservoir, which usually holds about two to three days’ supply of insulin. This insulin is delivered through an infusion set – a very fine tube that runs from the pump to a cannula (a very thin and flexible plastic tube), which is inserted under the skin. The cannula can be left in for two to three days before needing to be replaced and moved somewhere else on the body. The pump is battery operated and delivers a varied dose of rapid-acting insulin continually during the day and night, at a rate that is pre-set according to your needs (known as a basal rate). Then, when you have something to eat, you can give extra insulin (known as a bolus dose) by pressing a combination of buttons. Your nurse or dietitian will teach you how to work out the carbohydrate content in your food, so that you’re able to give the right bolus dose. A bolus can also be given if blood glucose levels have risen too high. While pumps are popular, bear in mind that they aren’t suitable for everyone. If you’re considering it, talk to your diabetes healthcare team to find out whether or not it’s right for you. pros & cons Advantages • fewer injections – the cannula is only replaced two to three times a week • your lifestyle can be more flexible – you don’t have to plan so carefully or eat at set times • you may be able to reduce the total dose of insulin as your diabetes control improves • as you can give a bolus dose whenever you need to, a pump gives you better control of your diabetes. Disadvantages • you need to test your blood glucose levels more frequently – the insulin is short-acting so it’s important you are always aware of your insulin needs • you may forget your bolus doses – this is usually while you get used to using a pump • infection may develop at the insertion site • you may get scarring at the insertion site, which means changing the infusion set more often. 2013 Type 1 diabetes 13 Diabetes care Pumps Q& A Can I use a pump? The National Institute for Health and Clinical Excellence (NICE) has published certain criteria that people should meet in order to use a pump (you can access this criteria by visiting the NICE website at www.nice.org.uk). Talk to your healthcare team about this criteria and whether or not pump treatment is suitable for you. What types of pumps are available? There are a number to choose from. Your healthcare team will help you with your choice. While basic features are largely the same, there are differences in colours, battery life, screen size and extra features. Some pumps come with a remote control and one is even disposable. How will I know how to use it? You should receive training from your healthcare team when starting to use a pump and you should receive ongoing support. Many healthcare teams have experience in using them but in some cases you might need to see another team for your pump care. You can also get a lot of support from the company that makes your pump – most have helplines and a representative may even be there when you start using a pump. There are also support groups for pump users and those wanting to use a pump: INPUT (www.input.me.uk) and Insulin Pumpers (www.insulin-pumpers.org.uk). Who pays for the pump? If you and your healthcare team decide pump therapy is right for you – and you meet the criteria set by NICE – funding for the pump, tubing and needles should come from the NHS. If you don’t meet the criteria, you will have to pay for everything – except the insulin – yourself. Pumps cost between £2,000 and £2,500, and should last between four to eight years. The disposables cost about £1,500 per year. If you use a pump you need to test your blood glucose levels more frequently A pump delivers a steady “flow of rapid-acting insulin round the clock ” ACTION POINTS • If you’re considering a pump speak to your diabetes healthcare team first to discuss whether it’s suitable for you. • If you are using a pump, join a support group for pump users (see left). This will increase your confidence when using it. 14 Type 1 diabetes 2013 WHAT DID YOUR METER TELL YOU TODAY? Meet OneTouch® Verio®IQ. The meter with Verio® PatternAlert™ Technology. NEW Every time you test, it looks for hidden patterns of high and low blood sugar and alerts you when it finds one — right on screen. On insulin treatment? OneTouch® Verio®IQ may be suitable for your needs. Put it to the test. Call OneTouch® Customer Care to order your FREE* trial: 0800 279 4142 (UK) quoting code AE243 Or visit www.LifeScan.co.uk/Bal Receive personalised meter training and on-going support from OneTouch® Customer Care: 0800 279 4142 Lines open 8.30am-6pm Mon-Fri, 9am-1pm Sat *TERMS AND CONDITIONS Offer open to those who are on insulin and making their own insulin dosing decisions (e.g. Multiple Daily Injections of insulin), aged 16 or over and resident in the UK and Republic of Ireland, including users of meters other than OneTouch® meters. Applicants who currently use a OneTouch® meter must have had their meter for 12 months or more and not received a free OneTouch® upgrade during this period. Offer closing date 31st Dec 2012. Those eligible to participate in the free meter trial will be offered a OneTouch® Verio®IQ Blood Glucose Monitoring System, 25 test strips and a questionnaire about their experience of using the OneTouch® Verio®IQ to complete and return in the reply paid envelope provided. Only one free OneTouch® Verio®IQ trial per person. Meters are subject to availability. This offer is limited to a maximum of 4,000 free OneTouch® Verio®IQ meters. Allow 28 days for delivery. LifeScan, LifeScan Logo, OneTouch® and OneTouch® Verio®IQ are trademarks of LifeScan Inc. © 2012 LifeScan, Ortho-Clinical Diagnostics. AW 099-111A. 12-144 Diabetes care TESTING time to tesT It’s recommended to prick the side, rather than the middle, of your finger B lood testing is an integral form of treatment for people with Type 1 diabetes, as it gives you an accurate �real time’ picture of your blood glucose levels. It can help you to maintain day-today control, find out if you are hypo (hypoglycaemia – low blood glucose levels), and also help to provide information that can be used to prevent long-term complications. Simply relying on how you feel isn’t recommended, as you might not always notice when your blood glucose levels are too high or too low. What testing involves 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 16 Type 1 diabetes 2013 blood glucose meter. Your diabetes healthcare team should provide education that teaches you self-monitoring skills so that you’re confident in knowing how to act on your results, which may include adjusting your treatment or activities accordingly. Good control of blood glucose levels (and blood pressure) greatly reduces the chance of developing the long-term complications of diabetes. Regularly testing and responding to the results appropriately helps you to keep good control and protect against these complications. Your healthcare team should assess how you monitor your blood glucose levels every year (or more often if it’s needed), as well as check that you know what to do with your results. Regular testing can put you in control of your diabetes. Let’s find out more How to test 1 Wash your hands rather than using wet wipes (these contain glycerine that could alter the result). 2 Make sure your hands are warm – if they are really cold it’s hard to draw blood, and finger-pricking will hurt more. 3 Prick the side of a finger (not the index finger or thumb) – don’t prick the middle, or too close to a nail, because this can really hurt. 4 5 Use a different finger each time and a different part – this will hurt less. Keep a diary of your test results, this will help your diabetes healthcare team suggest adjustments to your treatment, if needed. Try the Diabetes UK Tracker Smartphone app. www.diabetes.org.uk/tracker-app TESTINg When to test It’s often recommended to test at the following times: • before a main meal • before bed • if you feel unwell • before and after physical activity • if you feel hypo • before driving. Your diabetes healthcare team may also ask you to test at other times, too (eg during the night), in order to get an overall view of your diabetes control. There are also other circumstances when you’ll need to test more often, such as if you’re planning to conceive and during pregnancy. If you have recently been diagnosed it’s even more important to test regularly so that you get a good idea of what’s happening with your blood glucose levels. What is �good diabetes control’? It means keeping your blood glucose levels as near normal as possible (see �Your target range’, right). But don’t panic if you have an occasional high or low test – this happens to everyone. Good control also means understanding how your medication, food and activity affect your blood glucose. This will give you the confidence to adjust your treatment, activity, and what and when you eat, in order to avoid high or low blood glucose levels. Then you can fit diabetes into your life, rather than planning your life around it. Good control also means taking the complications of diabetes seriously and minimising your risks – you need to make sure you are receiving all the essential checks and 15 healthcare essentials – see 29. It also means keeping your blood pressure under 130/80mm Hg, as this can also greatly reduce the risk of complications later in life. As with all targets, everyone is different so discuss with your healthcare team what your ranges should be. Choosing a meter Most people are given a meter by their healthcare team, but if you need to choose a blood glucose meter, it can be complex. 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). diabetes care 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 which 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. HbA1c 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, helps your doctor to see how well your treatment is working and to make any changes necessary. See p23 for more on the HbA1c test. 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 1 diabetes are: – 4–7mmol/l before meals – less than 9mmol/l two hours after meals. ACTION POINTS • Ask your diabetes healthcare team what blood glucose 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. 2013 Type 1 diabetes 17 Diabetes care hypos & hYpers managing highs & lows People with Type 1 diabetes may be at risk of hypos and hypers. Understanding these will help you to manage them T he key to controlling diabetes is to balance your food, activity and insulin. 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 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 Type 1 diabetes, while this mechanism still works, it’s not so effective because the insulin they have injected can’t be �switched off’. So it will continue to work, even though blood glucose is too low. Explaining what hypos are all about to your friends is a good idea 18 Type 1 diabetes 2013 Spotting the symptoms Hypos can come on quickly and you’ll 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 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 there are some things that can mean it’s more likely: • too much insulin • a delayed or missed meal or snack • not enough carbohydrate • unplanned physical activity (see p62). • drinking large quantities of alcohol or drinking alcohol without food (see p88). 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 hypos & hYpers diabetes care tend to develop symptoms that “You’ll will signal you are having a hypo ” 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. treating a hypo There are a series of steps to take when treating a hypo: Immediate treatment If you have tested your blood glucose levels and they are 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 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. carbohydrate, such as: • half a sandwich • fruit • a small bowl of cereal • biscuits and milk • the next meal, if due. Retest Check your blood glucose after 15–20 minutes and, if it’s still low, repeat with the same treatment. severe hypos Follow-on treatment To prevent your blood glucose levels dropping again, you may need to follow with 15–20g of a longer-acting 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: • If possible, you should be placed Hypos & everyday life There are a few things that you need to be aware of when it comes to day-to-day activities and hypos: 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 p82 for details. Exercise Exercise will generally lower blood glucose levels, so you might need to eat some carbohydrate or reduce your insulin beforehand. The effect of strenuous or long periods of exercise can last for several hours, so you may have to alter your insulin doses and carbohydrate intake accordingly and keep some fast-acting glucose, such as a non-diet drink close by. See p62 for details. 2013 Type 1 diabetes 19 Diabetes care hypos & hYpers 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 at night Many people worry about having a hypo at night and that they may not be woken by mild symptoms. This means that the blood glucose levels may drop further and the hypo may become more severe. Keep hypo treatments by your bed just in case. If you’ve had a night-time hypo and haven’t been aware of it, you may wake up in the morning feeling very tired, perhaps with a headache or a hangover feeling, and find it difficult to concentrate. When you test your blood glucose it may be higher than expected. The best way of telling that you’re having hypos at night is testing during the night. Ask your healthcare team about the best time to do this as it can depend on your insulin regimen. To help prevent a night-time hypo, have a longeracting carb snack, eg milk, half a sandwich, fruit or yogurt before bed. But if you do find that you keep having hypos at night, talk to your team – you might need to adjust your insulin dosage. Don’t forget that having sex can be strenuous exercise and may cause a delayed hypo. top tips 1 heck your blood C glucose at times when your hypos are most likely to happen. 2 3 eep hypo treatments K with you at all times. If you have had a hypo during the night, you may wake up in the morning feeling very tired 20 Type 1 diabetes 2013 Hypos Make sure you carry some form of ID, an identity card, bracelet or necklace. This will help if you become unwell or if you’re unable to communicate in an emergency because people will be aware that you have diabetes. Visit https:// shop.diabetes.org.uk hypos & hYpers diabetes care Q& A Should I keep my blood glucose levels high to avoid hypos? No. It can be harmful for you if you try to keep 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 may start to feel like you did before you were diagnosed. You may also develop ketones (see p22) and long-term high blood glucose levels can lead to complications (see from p94). 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 insulin dose or due to unplanned exercise. Stress, or very hot or cold weather, also cause 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 insulin 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 a hypo, your blood glucose level may actually rise. Don’t be tempted to increase your insulin dose. This rise may have occurred 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. 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’re at risk of more, so you should take particular care. There’s also some evidence that people who’ve had diabetes for a long time 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 tailored advice. I’ve heard about someone having an islet cell transplant – what is this? For some people with severe problems with hypoglycaemia, islet cell transplants are available. This is where insulin-producing cells (called islet cells) are taken from donated pancreases and injected into the liver, where they start to produce insulin. It takes three to four pancreases to give one person a sufficient amount of islet cells. Can I die from a hypo? In most cases, even if you become unconscious and don’t treat the hypo, your body will slowly respond by naturally increasing blood glucose levels and you’ll eventually become conscious again. Despite this, it’s important to treat a hypo. On very rare occasions, excessive alcohol or the administration of huge insulin doses may cause a hypo that results in death. 2013 Type 1 diabetes 21 Diabetes care hypos & hYpers 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: • missing an insulin dose • injecting too little insulin • eating too much carbohydrate • 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 to prevent yourself from developing diabetic ketoacidosis: • Check your blood or urine for ketones if your blood glucose level is 15mmol/l or more (see p78 on how to do this) • If ketones are present it’s likely sure you drink “Make plenty of sugar-free fluids ” that you don’t have enough insulin in your body, so you may need to increase the dose or give an extra dose. Talk to your diabetes healthcare team about how to do this. • Make sure you drink plenty of sugar-free fluids • If you have ketones and feel unwell, especially if you are vomiting, you must contact your healthcare team as soon as possible for advice. Diabetic Ketoacidosis (DKA) DKA is when a severe lack of insulin upsets the body’s normal chemical balance and causes ketones to be produced. Ketones are poisonous chemicals, which if left unchecked, will cause the body to become acidic, hence the name �acidosis’. DKA can develop: • When you are first diagnosed with Type 1 diabetes • When you are ill • If you have not taken your insulin dose(s). DKA generally develops over a long period of time, possibly over 24 hours or more. It has to be treated in hospital, as you will need a drip and an insulin infusion. Signs of DKA • ketones in the blood/urine • abdominal pain • nausea/vomiting • rapid breathing. If you have high blood glucose levels and any signs of DKA, contact your diabetes healthcare team immediately. If DKA is left untreated it could cause you to become unconscious. But if picked up early it can easily be treated with extra insulin and fluid. ACTION POINTS • Try to understand the main causes of hypos and hypers and take steps to keep yourself safe. • Familiarise yourself with If you have any signs of DKA “you must contact your diabetes healthcare team immediately ” 22 Type 1 diabetes 2013 your warning signs and symptoms for hypos and hypers, and try to have the right treatment available at all times. long-term testing diabetes care long-term control You’ll be invited for various tests to check on your overall health now that you have diabetes, and there are particular targets to be aiming 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: • HbA1c: 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 p94. Q& A I have sickle cell anaemia and my doctor says 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. 2013 Type 1 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 what care and services to expect and who will be looking after you 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 local hospital. It is best to discuss with your nurse or consultant the roles and responsibilities of those providing your diabetes care. It’s important to identify the key members of your 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. The goals you agree during your discussions 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. Type 1 diabetes 2013 The care to expect diabetes care top tips What to expect Appointments 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. 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. 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) • 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. ccess to a member of your healthcare team for • A specific support and advice when you need it. This could be in person, by phone, email or text. 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. As part of your ongoing care your healthcare team is there to support you to manage your diabetes. They will: • Provide 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. 2013 Type 1 diabetes 25 Diabetes care The care to expect • Make 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. • Ask 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. • Encourage you to gain support from your friends, partner and/or relatives and from other people with diabetes. • P rovide you with ongoing education sessions, appointments and information on different ways you can learn about diabetes. • Offer you a medication review, which may be via your pharmacist. • Give you information on the effects of diabetes and treatments when you are ill or taking other medication. • Help you access specialist services when you need them, for example specialist foot services. 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, syringes, insulin pen, or insulin pump and how to dispose of needles and lancets (sharps). • Being shown how to test your blood glucose and test for ketones 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 hypos and hypers, 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 diabetes during these times. Prescriptions Your GP will be responsible for the care you receive at your local surgery 26 Type 1 diabetes 2013 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 finger-pricking 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 have a planned operation, 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 and snacks, you could ask a friend, carer or relative to bring them 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. The most important “person in your diabetes team is you ” 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 copy of your care plan should be “Agiven to you by a member of your diabetes healthcare team ” 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 1 diabetes 27 Diabetes care The care to expect Meet your team Your GP provides you with your prescriptions and will deal with any other medical issues or problems. They might also be involved in your diabetes care. Practice nurses are based at your surgery. Some may 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 28 Type 1 diabetes 2013 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 your 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 5 13 6 14 7 8 15 et your blood glucose levels measured at least G 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. 9 ttend an education course to help you A 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, 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. Checks and services for children. Children should receive more frequent HbA1c measurements and regular weight, height and general health checks from their healthcare team. Formal screening for complications generally begin at age 12. 2013 Type 1 diabetes 29 Diabetes care Education Following the right course Courses can either be taught in group form, one to one 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, 30 Type 1 diabetes 2013 With a broad range of educational courses available for people with diabetes, to help you learn about and manage your condition, it is important to pick one that is right for you one-to-one sessions or even online. When choosing an education course, 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, so talk to your nurse and/or dietitian about what is available. i For examples of the types of courses available, visit www.diabetes.org.uk/ structured-education Q& A 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 • Speak with your diabetes healthcare team about what local courses are available. health informationTESTIN 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 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. heck that links on the site • C are still �live’. �Dead’ links tend to indicate that other information on the site will also be out of date. • Be critical. Remember that if it sounds unbelievable, it probably is. • Don’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 120 2960 or email [email protected] • Don’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 Online forums are a good place to share your experience of diabetes 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 1 diabetes 31 Diabetes care Associated conditions On guard Coeliac Disease M Thyroid problems can be treated with tablets Having Type 1 diabetes can raise the risk of developing other autoimmune conditions ThYroid problems T he thyroid is a gland in the neck, situated just below the Adam’s apple, and it produces hormones to regulate the body’s metabolism (the chemical reaction that occurs in the body’s cells to convert food to energy). There are two types of thyroid disorder: hypothyroidism (when the body doesn’t produce enough thyroid hormones) and hyperthyroidism (when it produces too much). Symptoms include the following: Hypothyroidism • tiredness • feeling cold all the time • constipation • more frequent hypos. 32 Type 1 diabetes 2013 Hyperthyroidism • weight loss • feeling warm all the time • diarrhoea. What can cause thyroid problems? Type 1 diabetes is where the body’s cells attack the pancreas and destroy the insulin producing cells. In a similar way, thyroid conditions can occur if the body’s cells attack the thyroid. For this reason, thyroid problems are more common in people who have Type 1 diabetes, particularly hypothyroidism. Neither hypo- nor hyperthyroidism can be cured, but both can be treated successfully with tablets. ore common in people with Type 1 diabetes, coeliac disease is where the body reacts to gluten (a protein found in wheat, barley and rye), which damages the gut lining and affects absorption of food. Symptoms can include stomach ache, diarrhoea, constipation, anaemia, poor growth and unexplained hypos. But sometimes there are no symptoms. You should be assessed for coeliac disease if you are displaying symptoms. This is done by a blood test. If the blood test is positive, the diagnosis will be confirmed by a gut biopsy under general anaesthetic. The only treatment is a permanent change in diet to avoid gluten, and it is essential that you see a dietitian who can advise on both diabetes and coeliac disease. If you think you might have coeliac disease, discuss your symptoms with your GP. You shouldn’t start a gluten-free diet until you have a definite diagnosis. Following a gluten-free diet before a test for coeliac disease may give an inaccurate result. i www.coeliac.org.uk The MiniMed Paradigm® Veo™ System The freedom you and your child deserve UC200904670 EN Round-the-clock support for the very first time The Paradigm Veo is the only insulin pump that can actively protect against severe hypoglycaemia – even at night when your child is fast asleep. Unlike any other pump, the Paradigm Veo uses sensor data to recognise when your child’s glucose levels are dangerously low. It then responds by suspending insulin delivery for two hours, giving you both the peace of mind you need to live life to the full. The MiniMed Paradigm® Veo™ System Live More, Worry Less www.medtronic-diabetes.co.uk ARE YOU AN ADRENALIN JUNKIE? For the challenge of a lifetime, and to raise vital funds for Diabetes UK, look no further Not for the faint hearted jump out of a plane zip slide from iconic buildings abseil from a great height For an unforgettable experience contact [email protected] or call 020 7424 1000 www.diabetes.org.uk/events 2013 Type 1 diabetes 33 Diabetes care eating disorder sharing a secret People with diabetes who cut back on the amount of insulin they take, in order to shed the pounds, are putting themselves at risk of developing long-term complications S ometimes people with Type 1 diabetes deliberately skip insulin injections in an attempt to lose weight. This pattern of behaviour is referred to as �diabulimia’ (initially coined by the media to describe the phenomenon). However, diabulimia is not currently recognised as a formal diagnosis by the medical or psychiatric communities, but that doesn’t mean that it shouldn’t get some serious attention. It’s estimated that about one in three women with Type 1 diabetes under the age of 30 may be abusing insulin because of a fear of weight gain (or have done in the past). But diabulimia is often a hidden condition, so these numbers may be higher. And, of course, it can also affect men. About one in three women with Type 1 diabetes under the age of 30 may be abusing insulin 34 Type 1 diabetes 2013 eating disorder diabetes care Diabulimia is often a “hidden condition but it’s really important to get some help ” Skipping insulin If your body doesn’t have enough insulin, it can’t move the glucose from your blood into your body cells, which need it for energy. When this happens, it tries to get the energy it needs elsewhere by breaking down your fat stores instead – this makes you lose weight. Health effects When you haven’t got enough insulin in your body your blood glucose rises. This can seriously affect your health both in the short and long term. In the short term, it can cause diabetic ketoacidosis (DKA, see p22). If you’ve been missing your insulin doses you’ll have a lot of glucose in your blood that can’t get into your body cells to give you energy. But your body still needs energy to work properly, so it starts to break down fat as this is another source of energy. As fat breaks down, acidic chemicals called ketones are released into your blood stream. This leads to breathlessness and vomiting and eventually the high level of acidic ketones can lead to unconsciousness and, if untreated, death. In the long term, continuous high blood glucose can damage your small and large blood vessels, which can increase your chances of developing the serious complications of diabetes, such as stroke, blindness, heart attack, kidney disease and amputation. warning signs • weight loss • fear of gaining weight • distorted perception of body shape or weight • denying there’s a problem • changes in personality and mood swings • symptoms of high blood glucose levels – thirst, passing urine frequently (especially at night), and extreme tiredness. Getting help If you’re stuck in a cycle of skipping insulin and can’t seem to break out of it, it’s really important you get some help. You’re risking your health and, potentially, even your life. But it can be difficult to do it alone, so try to open up to somebody: • your family and friends can be a great source of support in helping you to break the cycle • your healthcare team will have come across this before and can refer you on to a psychologist if necessary • call Diabetes UK Careline on 0845 120 2960 or email [email protected] • seek help from Diabetics with Eating Disorders – a registered charity which provides support and advocacy for people with both diabetes and an eating disorder, www.dwed.org.uk 2013 Type 1 diabetes 35 FOOD HEALTHY EATING Food matters No food is out of bounds, but food choices are an important part of your diabetes management Bread, rice, potatoes, pasta and other starchy foods Fruit & vegetables can Foods can ““Foods bebe divided divided into fivefive main into main food groups food groups ”” Meat, fish, eggs, beans and other non-dairy sources of protein E ating the right foods should be seen as part of your diabetes treatment, like taking your medication, testing blood glucose and being active. A healthy, balanced diet is recommended – but what is that? Foods can be divided into five main food groups. The �Eatwell plate’ (above) represents the proportions of the food groups in a balanced diet. Foods from each of these should be eaten to provide 36 Type 1 diabetes 2013 Milk & dairy foods Foods & drinks high in fat and/or sugar all the nutrients needed for good health – no single food group can provide everything we need to stay healthy. See p41 for a portion size guide. Fruit & vegetables They contain essential vitamins and minerals that are important for good health. Fruit and veg can help to protect against strokes, heart disease, high blood pressure and some cancers. They also contain fibre to maintain a healthy gut and prevent constipation. At least five portions a day is recommended – this can be hard to manage but HEALTHY EATING fresh, dried, frozen or tinned fruit and veg all count towards your �five a day’. Variety is best, so try eating as many different colours as possible. Bread, rice, potatoes, pasta & other starchy foods Carbohydrate is a nutrient that is an important source of energy in the diet. All carbohydrates are broken down into glucose, which is used by the body’s cells as fuel. Glucose from carbohydrate is essential fuel for the body, especially the brain, and high fibre carbohydrates play an important role in the health of the gut. Carbohydrates increase blood glucose, so it’s important to be aware of how much you eat and include them in your sums if you are carbohydrate counting (see p42). FOOD Milk & dairy foods These foods contain calcium, which helps to keep your bones and teeth strong. But some are high in fat so try to choose lower fat options – this will reduce your intake of saturated fat – the type linked to heart disease. Most dairy products contain lactose (a natural milk sugar), which will have an effect on blood glucose. Cheese is an exception and doesn’t contain carbohydrate – the process that turns milk into cheese uses up the lactose. meat, fish, eggs, beans & other non-dairy sources of protein These foods are high in protein, which is important for growth and repair. Some are high in iron, which is needed for producing red blood cells. Omega 3 fats, which are found in oily fish such as mackerel, salmon and sardines can help protect the heart. Good sources of protein for vegetarians are beans, pulses, lentils, soya, tofu and Quorn. Protein doesn’t have a direct effect on blood glucose, but can affect the digestion and absorption of carbohydrate foods. 2013 Type 1 diabetes 37 FOOD HEALTHY EATING Foods & drinks high in fat and/ or sugar These foods should make up the smallest part of your diet. It is important to be aware of the amount and type of fat you eat. There are two main types of fat: saturated and unsaturated (monounsaturated and polyunsaturated). Eating too much saturated fat can increase your risk of heart disease. The type of fat found in oily fish is protective against heart disease. All fats (eg, butter, cream, oil, margarine) don’t have a direct effect on blood glucose levels, but will delay the digestion and absorption of glucose from carbohydrate-containing foods. Too many foods from this group can lead to weight gain. Watch the salt Too much salt can lead to high blood pressure, which can damage the kidneys. Beware of hidden salt in processed foods, such as: • bacon, ham, cheese, sausages, meats • breakfast cereals, bread, cakes • crisps, nuts, savoury snacks • ready-made soups, sauces, tinned vegetables, ready meals. Balancing act Try to have a balanced main meal every day. Using your plate as a rough guide will help you to eat foods in the recommended proportions, as shown in this example. This will help if you are aiming to maintain your weight, but if you’re trying to lose weight see p56. 38 Type 1 diabetes 2013 HEALTHY EATING 10 steps Eating well 1   Eat regular meals Avoid skipping meals and space out your breakfast, lunch and evening meals over the day. This will help control your appetite and your blood glucose levels, especially if you are on twice-daily insulin. 2  Eat starchy carbohydrates Carbohydrates will have an effect on your blood glucose levels, so it’s important to be aware of the amount you eat. The actual amount needed varies from person to person. Examples of starchy carbohydrates include bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. Try to include those that are more slowly absorbed (have a lower glycaemic index) as these won’t affect your blood glucose levels as much. Better choices of starchy carbs include: pasta, basmati or easy-cook rice, grainy breads such as granary, pumpernickel and rye, new potatoes, sweet potato and yam, porridge oats and natural muesli. FOOD 3  Cut down on the amount of fat you eat, particularly saturated fats A low-fat diet will benefit your health. Choose unsaturated fats or oils, such as monounsaturated or polyunsaturated fats (eg olive, rapeseed and sunflower oil), as these types can help maintain healthy cholesterol levels. Eating less fat will help you to lose weight if you need to. Here are some tips to help you cut down: •use less saturated fat by having less butter, margarine and cheese •choose chicken, turkey, lean meat and fish as low-fat alternatives to fatty meats • remove the skin from poultry • choose lower fat dairy foods such as skimmed or semi-skimmed milk, low-fat or diet yogurts, reduced-fat cheese and lower-fat spreads • grill, steam or oven bake instead of frying or cooking with oil or other fats • watch out for creamy sauces and dressings and swap for tomato-based sauces or low-fat dressings instead. 4   Eat more fruit & veg Aim for at least five portions a day to provide you with vitamins, minerals and fibre to help you balance your diet. For example, one portion is: a banana or apple, a handful of grapes, one tablespoon of dried fruit, a 150ml glass of fruit juice or fruit smoothie, three heaped tablespoons of veg or a cereal bowl of salad. 5   Include more beans & lentils Examples include kidney beans, butter beans, chickpeas or red and green lentils. These have less of an effect on your blood glucose levels and may help to control your blood fats. Try adding them to stews, casseroles and soups, or to a salad. 2013 Type 1 diabetes 39 FOOD HEALTHY EATING 6  Try to eat at least two portions of oily fish a week Examples include mackerel, sardines, salmon and pilchards. Oily fish contains a type of polyunsaturated fat called omega 3 which helps protect against heart disease. 7  Limit sugar & sugary foods This doesn’t mean you need to eat a sugar-free diet. Sugar can be used in foods and in baking as part of a healthy diet. Using sugar-free, no-addedsugar or diet fizzy drinks and squashes instead of sugary versions can be an easy way to reduce the sugar in your diet. Sugary drinks are best used as a treatment for hypos. Sweeteners can also be used as an alternative to sugar. 8 Reduce your daily salt intake to 6g or less a day More than this can raise your blood pressure, which can lead to stroke and heart disease. Limit the amount of processed foods you eat, as these are usually high in salt, and try flavouring foods with herbs and spices instead of salt. 40 Type 1 diabetes 2013 9  Drink alcohol in moderation That’s a maximum of 2–3 units of alcohol per day for a woman, and 3–4 units per day for a man. For example, a single pub measure (25ml) of spirit is about 1 unit, or half a pint of lager, ale, bitter or cider has 1–1½ units. Over the years the alcohol content of most drinks has gone up. A drink can now contain more units than you think – a small glass of wine (175ml) could contain as much as 2 units. Never drink on an empty stomach, as alcohol can make hypoglycaemia (low blood glucose levels) more likely to occur. Remember, alcohol contains empty calories so think about cutting back further if you are trying to lose weight. 10 tay away from S diabetic foods They offer no benefit to people with diabetes. They will still affect your blood glucose levels, contain just as much fat and calories as the ordinary versions, can have a laxative effect and are expensive. for at least “Aim five portions of fruit and veg a day ” balanced diet FOOD what’s in a portion? People have different ideas about what a portion of food is – let’s find out more T he number of food portions you require from each food group will depend on your needs. The portion ranges below are only a guide and you should speak to your dietitian for specific advice about how many portions of each food group you should eat every day. Bread, cereals, rice, pasta & potatoes One portion is equal to: • 2–4 tbsp of cereal • 2–3 tbsp of rice, pasta, couscous, noodles or mashed potato • 1 slice of bread • half a small chapatti • 2 new potatoes or half a baked potato • 2–3 crispbreads or crackers Daily portion range: 5–14. Meat, fish & alternatives One portion is equal to: • 2–3oz (60 – 85g) of meat, poultry or a vegetarian alternative like soya or Quorn • 2 eggs • 2 tbsp of nuts • 4–5 oz (120 –140g) of fish • 3 tbsp of beans, lentils or dahl, chick peas, mung beans, pulses Daily portion range: 2–3. Choose the lower-fat types whenever possible and eat more beans and pulses. Fruit & vegetables One portion is equal to: • a banana or apple • a handful of grapes • a slice of melon • a cereal bowl of salad • 2 plums • 3 heaped tbsp of vegetables • 1 medium glass of fruit juice or smoothie • 3 dates Daily portion range: 5 or more. Choose a wide variety of foods from this group, including fresh, frozen, dried and tinned. Milk & dairy One portion is equal to: • ¹∕ 3 of a pint milk • 2 tbsp of cottage cheese • a small pot of yogurt • 1½oz of cheese (40–45g, matchbox size) Daily portion range: 3. Choose lower-fat versions of milk and dairy foods. Fatty & sugary foods One portion is equal to: • 2 tsp of spread, butter, oil, or salad dressing • 1 mini chocolate bar • 2 tsp of sugar, jam or honey • half a sausage • 1 scoop of ice cream or 1 tbsp cream • a rasher of bacon • half a pack of crisps • ¹∕ 3 of a vegetable samosa • 1 tbsp of Bombay mix Daily portion range: 0–4. Cut down on sugary and fatty foods. 2013 Type 1 diabetes 41 FOOD CARB COUNTING The carb connection Carbohydrate is an essential form of energy, but what exactly is it, and how can the amount you eat affect your glucose levels? T here are two main types of carbohydrate: Starchy These include bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. Sugars These can be broken down as: • natural sugar, eg fruit sugar (known as fructose) and milk sugar (known as lactose) • added sugar, which includes table sugar (eg caster, granulated), glucose, glucose syrup, invert syrup and honey. ugars can often be identified on S food labels as those ingredients ending in –�ose’. Both the amount and type of carbohydrate you eat and drink will have an effect on your glucose levels. Another type of food that can affect blood glucose levels are nutritive sweeteners, including 42 Type 1 diabetes 2013 polyols. If you’re not sure what these are, they tend to end in -ol, eg sorbitol, maltitol, xylitol and mannitol. Why you need carbohydrate carbohydrate on a day-to-day basis. Work with your dietitian or diabetes healthcare team to find the right balance for you. Carbohydrate Carbohydrate is the body’s preferred counting source of energy in the diet. All carbohydrates are broken down into glucose, which is essential fuel for the body – especially the brain. High-fibre carbohydrates, such as wholegrains and fruit, play an important role in the health of your digestive system. how much you need The amount of carbohydrate that the body needs varies depending on your age, weight and activity levels. For good health, most of the carbohydrate you eat should be from starchy carbohydrate, fruits and some dairy foods. Carbohydrate from added sugar or table sugar should be limited. If you are on a fixed insulin regimen, you may find it beneficial to have consistent amounts of Carb counting means that insulin can be individually matched to your food choice at the time of eating. It’s a vital part of making the most of intensive diabetes management, whether you use injections or a pump (it’s less likely to be used on mixed insulin regimens). It means portion sizes can reflect your appetite rather than a fixed amount of carbohydrate to match a fixed amount of insulin. It doesn’t mean total food freedom as this would be unhealthy for anyone, although special occasions and treats can be more easily incorporated and insulin adjusted to match. Carb counting can mean more work at first – working out or weighing foods to calculate the carbohydrate, but it does get easier. Once you’re confident you should be able to: FOOD CARB COUNTING • vary the times you eat and the amount of carbohydrate you eat • predict blood glucose responses to different foods • enjoy a wider variety of foods. Working it out Carbohydrate can be counted in grams or, carbohydrate portions (CPs). Your diabetes healthcare team will help you determine your insulin to carbohydrate ratio; for example 1 unit of insulin for 10g of carbohydrate. This will depend on your age, weight, activity levels and how long you have had diabetes. If you know how many grams (or portions) of carbohydrate are in a meal and your carbohydrate-to-insulin ratio, then you can work out the number of units for the meal. Nutrition information labels on packaged foods can tell you how much carbohydrate (in grams) is in 100g or in a portion of that food. Use the �total carbohydrate’ figure, not the �of which sugars’ value when matching insulin. (See p45 for information on food labelling.) Your diabetes healthcare team may provide you with a list of foods and the amount of carbohydrate they contain. Diabetes UK provides a downloadable carbohydrate reference list. (See the end info, below). There are also books often aimed at people trying to lose weight (called calorie counters), they list the grams of carbohydrate, either per 100g or per portion. And books and apps are available, which include photos of food portions and their carbohydrate values. i Download a free copy of Carbs count, as well as the carbohydrate reference list, at www.diabetes.org.uk/carbcount See overleaf for information on the Glycaemic Index. amount of “The carbohydrate you need depends on your age, weight and activity levels ” Carbohydrate & your insulin In Type 1 diabetes the pancreas doesn’t release any insulin, so the aim of insulin treatment is to mimic normal insulin production in someone without diabetes. This is done using: Basal insulin This deals with the glucose produced by your liver. If you skip a meal, your basal insulin alone should be able to keep your blood glucose levels stable. Bolus insulin While basal insulin influences your blood glucose levels in between meals, it’s the bolus (fast-acting) insulin that deals with the carbohydrate contained in any food and drink you have. 2013 Type 1 diabetes 43 FOOD Glycaemic index the gi concept What is the Glycaemic Index, and how can it help you with your blood glucose control? T he Glycaemic Index (GI) is a ranking of carbohydratecontaining foods based on their overall effect on blood glucose levels. Slowly absorbed foods have a low GI rating, while foods that are more quickly absorbed will have a higher rating. Foods are given a GI number according to their effect on blood glucose levels. Some research has shown low GI diets have benefited blood glucose control, though the majority of this research was in people with Type 2 diabetes. If you want to choose lower GI carbohydrate-containing foods: • Instead of instant cooked rice or long grain rice choose basmati or easy cook. You could also try pasta or noodles instead. • Switch white baked or mashed potato for sweet potato or boiled new potatoes. • Choose granary, pumpernickel or rye bread instead of white and wholemeal bread. • Swap rice snap breakfast cereal or cornflakes for porridge, natural muesli or wholegrain breakfast cereals. 44 Type 1 diabetes 2013 A variety of foods contribute to a healthy balanced diet Eating to control your diabetes isn’t just about GI ratings and shouldn’t be used in isolation. It’s important to stress it’s the total amount of carbohydrate you eat which will have the greatest effect on your blood glucose levels after meals. The overall balance of your diet is also important and it should be low in fat, salt and sugar with plenty of fruit and vegetables. i www.diabetes.org.uk/gi the total amount “It’s of carbohydrate you eat which will have the greatest effect on your blood glucose levels ” FOOD LABELLING FOOD Making healthier choices Making sense of food labelling isn’t always easy. Here’s how you can pick the options that are right for you T here’s a huge variety of food on the shelves. So what to choose? Both Traffic light labelling and Guideline Daily Amounts (GDAs) on food and drink labels can be a starting point to help you to see how healthy or unhealthy something is. They also help you to compare brands. Traffic light labelling The traffic light colours on some packaging tell you whether the product has low, medium or high amounts of fat, saturated fat, sugars and salt: Red means high – keep an eye on how often you are choosing these foods. Choose them less often or eat them in smaller quantities. All measures per 100g Low – healthier choice OK choice High – LEss healthy choice Sugars 5g or less 5.1g–15g More than 15g Fat 3g or less 1.6g–20g More than 5g Saturates 1.5g or less 1.6g–5g More than 5g Salt 0.30g or less 0.31g–1.5g More than 1.5g Amber means medium – it’s ok to have these foods some of the time but when you have a choice, try to go for green. Green means low – a healthier choice. Most foods will have a mix of coloured lights so try to choose more products with green and amber and less with red. You don’t need to avoid all foods high in fat, sugar or salt – it’s the overall balance of your diet that counts. Eaten occasionally, or in small amounts, red foods won’t significantly affect your overall diet. If the traffic light label doesn’t tell you enough, check the back of packs for detailed information. The government has announced that in 2013 all major manufacturers will be using a consistent system of food labelling: including the traffic light colours, text and percentage Guideline Daily Amounts. 2013 Type 1 diabetes 45 FOOD FOOD LABELLING Guideline Daily Amounts Not all manufacturers use the traffic light system so you may see a Guideline Daily Amount (GDA) label on some of the foods you buy. This gives information on the amount of sugar, fat, saturated fat and salt as well as the number of calories in each portion of the product. The percentages refer to the proportion of the total amount of the nutrient that is recommended for an average adult per day. These figures are based on GDAs for women, to encourage people who need less energy to eat or drink fewer calories. This system needs a greater level of interpretation than the traffic light system. Calories Sugars Fat Saturates Salt 116 11g 0.9g 0.5g 0.3g 6% 12% 1% Amount in product Calories Fat (of which saturates) Guideline daily amounts are what an average adult of normal healthy weight should Carbohydrate (of which total sugars) eat per day. Needs vary depending on age, weight Salt and activity levels, but here is the average guide. SODIUM FIBRe 2% 6% % of adult guideline daily amount 2,000 kcals 2,500 kcals 70g 20g 95g 30g 230g 90g 300g 120g less than 6g less than 6g less than 2.4g less than 2.4g 24g 24g magazines for you A quarterly magazine packed with games and cartoons, helping your child learn about diabetes in a fun way. Packed with news, features, research, healthcare information, celebrity interviews, columns and prize giveaways, balance is a lively, entertaining bi-monthly magazine for anyone connected to diabetes. These are free to Diabetes UK members. Find out more by calling 0845 123 2399 or visiting www.diabetes.org.uk/join. Type 1 diabetes 2013 46 FOOD LABELLING is it really healthy? Most supermarkets now offer their own �healthy eating’ ranges. Although they can help you find healthier options, you still have to think about how that food fits into your diet. It’s important not to rely on foods marked as healthy options as a healthy diet is made up of a variety of foods and some products may be labelled as low fat but still be high in sugar, and vice versa. Products labelled �low’ contain less of that nutrient (ie fat, salt, sugar, etc) than those labelled �reduced’ – but whether a food is labelled �diet’, �light’, �low’ or �reduced’, all of them are a healthier choice than standard versions of the same food. But beware, the calorie, fat or sugar savings made by choosing these versions may not be as great as you think – especially foods which are high in fat and/or sugar anyway, eg cakes, biscuits and crisps. Also, bear in mind that some foods are naturally low in fat, sugar or salt, or high in fibre. Starchy foods like cereals and pasta are always low in fat, yet some brands are sold with the claim �low-fat food’. By checking the ingredients list, you can really get to grips with the food’s nutritional value. Remember, the proportion of ingredients in a product are listed from the highest first. food labels will list “Some Guideline Daily amounts instead of using the traffic light system ” FOOD Carb counting Food labels can be a useful and convenient way of finding out the carbohydrate content of foods and drink. Here are some tips to help you use the food label to count carbohydrate: • Double check whether the value you are using is per 100g. • If it’s per portion or serving, check portion or serving size? • The amount of carbohydrate you should count is the �Total carbohydrate’ rather than the �of which sugars’. • Check whether the amount of carbohydrate is for the raw or cooked product, especially with foods containing pasta or rice. • Consider what ingredients make up the product you’re looking at. If it’s a food that contains a lot of very slowly digested carbohydrates, such as beans or tomatoes you wouldn’t count this carbohydrate. But the carbohydrate value will include them. Check the ingredients list to get a sense of how much of these foods are in the product. 2013 Type 1 diabetes 47 FOOD HEALTHY COOKING Healthy food for healthy appetites Adapting recipes to be lower in fat, sugar and salt involves some trial and error. But these tips will have you cooking up a delicious meal in no time E ating healthily will benefit you in a number of ways, and it doesn’t mean you have to miss out on your favourite meals. Depending on the type of food you are preparing these following tips will be useful: South Asian foods • Add millet or chickpea flour to chapatti flour to make it lower in GI (glycaemic index) and more filling. • 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. • Make low-fat paneer using skimmed/semi-skimmed milk. • Grill, bake, poach, steam, or boil foods rather than cooking them with added fat. • Reduce any amount of coconut cream or milk and try a reducedfat version instead. • Measure the amount of oil you use, don’t just pour. A good guide is 1 teaspoon of oil per person. • Reduce the amount of salt used and go for spices and herbs to add flavour. • Limit foods such as pickles, which are very high in fat and salt. 48 Type 1 diabetes 2013 HEALTHY COOKING FOOD • Cut back on snacks such as chevda. Instead, try plain popcorn or roasted corn and keep an eye on your portion sizes. • Roast your poppadoms instead of frying them. African & Caribbean foods • Use less saturated fat such as palm oil, coconut oil and butter. • Choose chicken, turkey, lean meat and fish as low-fat alternatives to fatty meats and remove the skin from chicken. • Choose lower fat dairy foods, such as skimmed milk, low-fat yogurts, and reduced-fat cheese. • Grill, steam or oven bake foods such as jerk chicken, jerk beef, corn and pineapple fritters instead of frying or cooking with oil or other fats. • Watch out for creamy sauces and dressings and swap for tomato-based sauces instead. • Skim the fat from the top of stews and one-pot meals tops tip • 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. • If you choose to have more traditional foods such as plantains, fish, breadfruit, yams or dumplings try to choose healthier ways to cook them, such as baking, grilling, boiling or poaching and avoid re-frying leftovers. for “Go spices and herbs to add flavour ” Cutting calories By following some common sense advice you can cut down on the calories and still keep the flavour: • Use low-fat dairy products 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 for flavour. Grated cheese tends to go further, too. You can also try reduced-fat varieties. • Use pulses such as peas, beans or lentils to replace some of the meat in shepherd’s pie, casseroles and lasagne. They’re low in fat and high in fibre, and can also be used in soups and salads. • Use lean cuts of meat, remove visible fat and remove the skin from poultry. Dry fry and drain off any excess fat before adding the remaining ingredients (eg for casseroles or stir-fries). • Use low-fat cooking methods where possible, such as grilling or baking, instead of frying. • Reduce the amount of oil you use and still avoid foods sticking to the pan by cooking on a low heat and stirring often, using a non-stick pan and a low-fat spray, or using a splash of water. 2013 Type 1 diabetes 49 FOOD HEALTHY COOKING Desserts Puddings can still be enjoyed – and by making some small changes or �swaps’ you can keep the flavours and save even more on the calories: • Experiment by using less added sugar in your baking recipes. Most 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 – but check that the recipe is suitable for freezing. • When making jams and marmalades, ordinary sugar will do but try to reduce the traditional ratio of 1lb fruit to 1lb sugar to 1lb fruit to ¾lb sugar. • Use sweeteners to add extra sweetness instead of sugar, eg cold desserts and hot puddings. • Light crème frâiche is heat stable and ideal for use in savoury sauces. It’s also delicious served on hot or cold puddings instead of double cream. • Fromage frais is fresh skimmedmilk cheese, but is more like a natural yogurt. It’s not heat stable so is best used in desserts and dips in place of cream or Greek yogurt. • When you feel nothing but cream will do, spoon extra thick single cream onto fruit or puddings instead of double cream. Whip up whipping cream rather than double cream for filling cream buns or cakes, or make a butter cream using a low-fat spread. • You don’t need to adapt your recipes when baking if you only eat cakes at special occasions such as birthdays. • Try using filo pastry instead of normal pastry and spread with beaten egg in between the sheets instead of butter. can “You reduce the ratio of sugar when making jams ” 50 Type 1 diabetes 2013 30 lk Gyym wa urdaClass eve 18.30 Sat Thurs 8.1 mmo l/L 2.30 pm und ay ast Need help organising your diabetes information? Bayer’s CONTOUR® NexT USB meter can help you organise your information to see the complete picture. • Easy-to-use,straightoutofthebox • Testyourbloodglucoseandmark yourresultsoraddanote,ifrequired • Reviewyourlogbookandtrendson small yourmeter,ordownloadandshare withyourhealthcareprofessional banana - 4 pm 5 4 10. 14 /L ol 11 am m m Coffee crum pet and cake and j am Ask y nurs our dia bet ea new bout Ba es yer ’s Con t nex our t ® u toda SB y, or mete www r v i sit .bay erc onto uru Blood Glucose Monitoring System Bayer®, the Bayer Cross®, CONTOUR, No Coding, and the simplewins logo are trademarks of Bayer. © 2012 Bayer plc. All rights reserved. sb.c o.uk /ad USB T1DC 10/12 ken dwich • Optiontoaddyourcarbohydrateand insulinunits FOOD EATING OUT What’s on the menu? Eating out is something most of us like to do, whether it’s a late-night biryani or a lunchtime Italian. But there are healthy choices you can make without spoiling your fun T hese days we tend to have more meals away from home, whether it’s a meal in a restaurant or grabbing a sandwich on the run. But, away from home, we tend to eat different portion sizes, and the foods we choose tend to be higher in fat than their homemade versions. A change in your usual routine and diet when eating out can have an affect on your diabetes control. This can be balanced out by adjusting the timing, the amount and how you take your insulin. Timing Changes in meal times can have a big impact on your timing of insulin injections. If you’re going to eat a meal later than usual, you may be able to delay your insulin until you are about to eat. If you are on twice-daily insulin injections and eating lunch later than usual, you may need to have a snack before you go out or to make sure you have bread on the table when you arrive. Doing this will help to prevent a hypo. 52 Type 1 diabetes 2013 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. Being on a flexible insulin regime can make it easier to vary the timing of all meals. Adjusting your insulin If you count carbs and are confident with adjusting your insulin you may be able to change the amount you inject to fit in with the food you eat. It may be difficult to estimate the amount of carbohydrate in your meal though many large chains and takeaway restaurants have websites that list the amount of carbohydrate in popular dishes. In some restaurants, the main course may not automatically come with starchy carbohydrates, such as rice, pasta, potato or chips. So make sure you check this when you order, and ask for extra side dishes if needed. How you take your insulin You may be choosing foods higher in fats than usual. Fat slows down the absorption of carbohydrate into the bloodstream. So eating something like a pizza, fish and chips, or a curry can take hours to affect your blood glucose levels. This can mean when you give your bolus insulin, it might have finished working before all your carbohydrate has been absorbed, so you may need to alter how you give your insulin maybe splitting your dose. If you’re on a multiple daily injection regime, consider dividing your insulin into more than one injection. Eating out is often a leisurely event that can run over a few hours. And although you may not intend to have pudding, sometimes they just look too good to refuse. This means you’ll need to think about when to have your insulin: at the start of the meal, in the middle, or at the end. Alternatively – if you are on a flexible insulin regimen – you could divide your insulin into more than one injection. EATING OUT FOOD Q& A One of my favourite places for a drink before I was diagnosed has hardly any diet drinks and mixers. What can I do? If you eat and drink somewhere on a regular basis and they don’t serve what you want – like diet drinks or low-calorie mixers – speak to the manager. If they understand why people with diabetes need diet drinks and if they value your custom, then hopefully the restaurant or bar will start to serve them. How can I avoid any problems when eating at a friend’s place? Other people can panic about what they can and can’t serve you. Tell them not to go to any trouble and reassure them that you’re no different from anyone else. There are a few things to bear in mind though. If it’s a party rather than a meal, don’t assume that food will be provided. Check beforehand or eat before you go. Also, some barbecues and buffets may not have enough starchy food, in which case make a beeline for the bread and don’t be afraid to ask for something extra. I regularly go abroad – do I need to consider anything in particular about food? The same eating advice applies abroad – but obviously you may have to be extra careful if you don’t understand the menu or are unfamiliar with some dishes. If you’re travelling by plane be aware that some airlines offer special �diabetic’ meals. It is actually better to avoid them because they can be low in carbohydrate – caterers often don’t realise that balance is the main thing, not cutting down on carbohydrate. Also, it’s a good idea to take extra carbohydrate snacks in your hand luggage. See p84 for more on travel. Eating out is not all about food. It is often accompanied by a few glasses of wine or a beer. You may even be going out clubbing afterwards. Alcohol and activity can affect your blood glucose levels and this will also need to be taken into account when deciding what to do with your insulin. • See p88 for more on alcohol. change in your “Ausual diet can be balanced out by adjusting the timing and the amount of insulin you take ” ACTION POINTS • Check the websites of your favourite restaurants so you can see what sort of ingredients they serve. They may even list carbohydrate counts. • Remember to always carry hypo treatments with you, such as glucose tablets. 2013 Type 1 diabetes 53 FOOD Questions & Answers Q& A 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.) More information is available at www.diabetes. org.uk/mineral_supplements 54 Type 1 diabetes 2013 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. 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 then 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. The ONLY meter you’ll ever need... To receive a meter quote AD4 at www.glucomen.co.uk Or call 0800 243667 www.glucomen.co.uk People with Diabetes trust Living with diabetes WEIGHT MANAGEMENT Weighty issues If you’re carrying some excess pounds getting your weight down is a wise move. Not only will you feel fitter, it will help you manage your diabetes better I f you need to lose weight it will always be beneficial to your health. Studies show that losing just 10 per cent of your body weight will bring about huge health benefits, including helping you to manage your, blood pressure and cholesterol levels. How to measure your waist Find the bottom of your ribs and the top of your hips. Measure around your middle at a point mid-way 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). 56 Type 1 diabetes 2013 How do I know if I need to lose weight? There are several ways you can find out if you’re overweight: Measure your waist If you need to lose weight, reducing your waist measurement will help to improve blood glucose control and reduce your risk of developing some diabetes complications. See box, left, on how to measure properly. 1 2 Compare weight and height Body Mass Index (BMI) is a measure of your weight in relation to your height. It’s a good indicator of what weight range you are in. The chart to the right will help you to determine your BMI. WEIGHT MANAGEMENT Living with diabetes Key Underweight: a BMI of up to 18.4, South Asian adult less than 18.5 Healthy weight: a BMI of 18.5–24.9, South Asian adult 18.5–22.9 Overweight: a BMI of 25–29.9, South Asian adult 23–24.9 Obese: a BMI of 30–39.9, South Asian adult 25–34.9 Morbidly obese: a BMI of 40 or more, South Asian adult 35 or more underweight Healthy weight Overweight Obese Morbidly obese 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 Your height in metres 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 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 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 as shown in the key. It is important to remember that the BMI measure can be inaccurate at times for people who have a lot of lean muscle such as rugby players or weight lifters. You can discuss your BMI with a member of your healthcare team if you think this might apply to you. Your height in feet and inches 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 Your weight in kilograms Your weight in stones To calculate your BMI: weight (kg) height (m) x height (m) For example, if you are 1.80m tall and 95kg, your BMI would be 95 (1.8 x 1.8) = 29 (BMI) 1ft = approx 0.3m 1lb = approx 0.45kg 2013 Type 1 diabetes 57 Living with diabetes WEIGHT MANAGEMENT Getting motivated If you do need to lose weight, beforehand you may find it helpful to prepare yourself mentally and motivate yourself by thinking about the benefits. Consider the possible challenges it will pose and the changes you will need to make to your current lifestyle. While there may be many things that can get in the way of losing weight, here are some ways to overcome some common barriers: Too busy? Try shopping in advance and pre-planning your week’s meals, That way you won’t have to think about what you’re going to cook and buy food every day – a real time saver. There are also healthy cookbooks for fast, fuss-free recipes. put the weight back on. There are many different approaches to losing weight, and no one way is better than another and it is important that you find a diet that you enjoy and fits into your lifestyle. It’s not the diet you follow that’s the most important factor but being able to choose a diet that you enjoy and can stick to. Following a combination of a healthy, balanced diet and physical activity together will result in more weight loss in the long term, than diet or activity alone. To start with, it’s important to understand the general principles of healthy eating, which are explained on p36. different ways to lose weight Controlling your portions This plate model offers a guide on what to eat on a daily basis: On a budget? Canned and frozen fruit and vegetables are just as good for you as fresh and they’re much cheaper. If you do want to buy fresh, chose fruit and veg that’s in season or on special offer – both good ways to save. Feel like diets don’t work? Try to understand what triggers you to eat and keep motivated by reminding yourself of the benefits of losing weight. If for instance you want to eat because your bored or stressed, perhaps go for a walk instead. Also, think about benefits losing weight could bring: • you might get back into some old clothes • enable you to play with the children without getting out of breath • improve your diabetes control and help prevent some complications. How to lose weight To lose weight the calories you take in from your food and drink must be less than the energy you burn off through daily living and physical activity. A calorie is a unit of energy. If you wish to lose weight aim for a realistic weight loss, losing weight slowly (0.5–1kg / 1–2lb a week). If you try to lose weight more quickly you may not be able to stick to it and are more likely to 58 Type 1 diabetes 2013 This gives you an idea of what the size of your portions should be for your main meal, whether it’s lunch or dinner. You can reduce the calorie content of your meal by filling up one half of your plate with vegetables or salad, one third with starchy foods such as bread, rice, potatoes, or pasta and the remainder with low-fat varieties of protein such as meat, fish, chicken, lentils, or beans. This might be more difficult to work out for meals where food groups are mixed, such as lasagne and stir-fry noodles. The following examples may help: Lasagne: The pasta sheets will count towards the starchy foods and the meat will contribute to the protein on your plate. Fill half the plate with lasagne and use salad or vegetables to fill up the rest of your plate. WEIGHT MANAGEMENT Beef noodles: The noodles and the beef will count towards the starchy foods and the protein. Add a large portion of vegetables to the stir-fry to make up the vegetables. Serve plenty of veg and salad with your meals. Calorie controlled plans Balanced, healthy eating plans that contain 600 calories a day less than a person needs will achieve sustainable weight loss. This can be through diet as well as increasing your activity levels which will burn up extra calories. Your activity levels, your weight, sex and Living with diabetes age will make a difference to how many you need. If you step up your activity levels for example this will help you burn more calories and help achieve long term weight loss success. In the table overleaf are some ideas to help you slash the calories without sacrificing taste. Low-fat diets Gram for gram, fat provides twice as many calories as carbohydrate or protein. Reducing how much fat you eat will help you to reduce your calories. A recent large study in the United States showed that changing your lifestyle, Swap and save... alories per 50 chalf pint Semi-skimmed milk, instead of full cream milk 40 calories per tbsp Half-fat fromage frais, instead of double cream 40 calories per biscuit Rich tea biscuit, instead of digestive biscuit 45 cperalories portion Chicken breast without skin, instead of chicken breast with skin 60 Reduced-fat cheddar cheese instead of full-fat cheddar cheese calories per 40g/1.5oz alories per 50 c10g/0.35oz Low-fat spread instead of Margarine/butter 2013 Type 1 diabetes 59 Living with diabetes WEIGHT MANAGEMENT Replace this….. Morning drink Tall (12 fl oz) semi-skimmed latte (150 calories) Breakfast 1 paratha 75g (243 calories) With this…. And save…. (calories) Tall (12 fl oz) cappuccino with semi-skimmed milk (90 calories) 60 2 wheat biscuits and 85ml (average serving for cereal) semi-skimmed milk (170 calories) 70 2 medium slices of toast, 20g 70% fat margarine and 30g jam (345 calories) 2 wheat biscuits and 85ml (average serving for cereal) semi skimmed milk (170 calories) 175 Morning snack Medium slice flapjack 60g (300 calories) Individual slice of malt loaf 35g (100 calories) 200 Lunch Prawn mayo sandwich (2 medium slices of bread) (350 calories) Low-fat prawn mayo sandwich (2 medium slices of bread) (300 calories) 50 2 chapatti 110g (222 calories) spread with 4 2 plain chapatti 110g (222 calories) and 220g teaspoons of ghee (180 calories) and lentil lentil and vegetable curry (333 calories) and vegetable curry 220g (333 calories) 30g packet of crisps (160) 1 medium pear (60 calories) Standard sized chocolate bar 55g (280 calories) Mid afternoon snack High street coffee bar skinny blueberry muffin (370 calories) 2 finger chocolate wafer biscuit (105 calories) High-street coffee bar portion of fruit salad (95 calories) Dinner Chicken curry 200g (411 calories), basmati Chicken curry 100g (274 calories), mung dahl rice 180g (248 calories) and 2 chapattis 100g (70 calories), bowl of salad (30 calories) 110g (222 calories) spread with and basmati rice 100g 4 teaspoons of ghee (180 calories) 2 grilled pork sausages (80g), medium jacket potato (160g) and 2 teaspoons of margarine, serving of peas (70g) and carrots (60g) (420 calories) Small roasted chicken breast (85g), medium jacket potato (160g) serving of peas (70 g) and carrots (60g) (315 calories) 150g pot of creamy yogurt (190 calories) 125g pot of low-fat yogurt (75 calories) 175ml glass of medium-dry white wine (130 calories) 1 single measure of vodka and slimline tonic water (55 calories) 180 100 175 275 549 105 115 70 Evening snack 2 chocolate digestive biscuits (170 calories) 60 Type 1 diabetes 2013 Medium banana (100 calories) 70 WEIGHT MANAGEMENT including following a low fat diet significantly reduced body weight, improved diabetes control and reduced cardiovascular disease risk factors. The table below can give you some ideas on how to slash the calories and fat by making simple, small changes. See p50 for practical ways you can cut down on calories and fat. Low-carb diets Carbohydrate is found in starchy foods such as bread, potatoes, pasta, rice, beans and pulses, as well as in fruit, most vegetables, some dairy foods and sugars. All carbohydrate affects blood glucose levels. There is evidence that shows low carbohydrate diets can help in the short term with achieving weight loss and improve diabetes control in people with Type 2 diabetes. But there is little evidence to support the use of low carbohydrate diets to support weight loss in people with Type 1 diabetes. Very low calorie diets These are specially formulated to provide nutritionally complete total diet replacements. There is evidence to show that this diet can help achieve weight loss. Meal replacement plans These consist of liquid shakes, soups or bars designed to be eaten in place of one or two meals daily, but make sure the meal replacements are nutritionally adequate. Evidence suggests they can help achieve weight loss over the short term (six months). Slimming clubs These use a variety of approaches, including group therapy, dietary advice and physical activity. There hasn’t been any published evidence regarding their effect on weight loss. If you’d like to meet other people who are also trying to lose weight, a slimming group or club could be useful. But these clubs may not run by registered dietitians, so bear the following tips in mind: • Ensure that the weight loss offered is realistic and that a healthcare professional has been involved in developing the programme. • Check with your healthcare team before joining and Living with diabetes show them a copy of the diet plan. Your insulin may need to be adjusted. • Monitor your diabetes control carefully while you’re slimming and consult your healthcare team if you have any concerns. • Always make sure that the meal plans include all of the food groups or are nutritionally adequate if they contain meal-replacement shakes. • Even if the club advises you not to snack between meals, do not cut out starchy snacks between meals if your diabetes healthcare team has advised you to continue them. For specific advice on your eating habits and to help you decide what diet is right for you it’s important you have the support of a registered dietitian, ask your GP to refer you. Q& A Can I get more active to lose weight? Having diabetes doesn’t mean you can’t become more active. The more activity you do the more calories you will burn. The Department of Health recommends at least one hour of exercise a day if you want to lose weight through physical activity alone. It’s also important before you start any new activity that you talk to your doctor. I need more support to help with losing weight and getting more active. It’s important you get the right support and advice when you’re trying to lose weight. Your GP, practice nurse or dietitian can help. As you eat less, become more active and lose weight, you may need your insulin to be reduced. Talk to your doctor or nurse if you need to know how to do this. Remember, you should also have support of a registered dietitian, see above. 2013 Type 1 diabetes 61 Living with diabetes TESTIN 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 At first, take some simple steps to increase your activity levels 62 Type 1 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 selfesteem 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. tops tip Increasing activity 1 2 Use stairs instead of a lift or escalator. 3 4 5 Physical activity & diabetes There are a few things to be aware of: • physical activity increases the amount of glucose used by the muscles for energy, so it may sometimes lower blood glucose levels • being active helps the body use insulin more efficiently, and regular activity can help reduce the amount of insulin you need to take • being active helps to maintain a healthy weight for your height, this in turn will help with your diabetes control. ycle or walk short C journeys, rather than using the car. et off the bus or tube G a stop earlier. Use your lunch break to go for a brisk walk. 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 1 diabetes 63 Living with diabetes PHYSICAL ACTIVITy Food & fluids • Eat or drink extra carbohydrate as needed to avoid hypos and to keep up your energy levels needed for exercise. • Keep carbohydrate-based foods to hand during and after exercise. i For more on physical activity, vigorous intensity activity If you’re doing strenuous sports there are some more specifics to think about when you test your blood glucose levels: • It’s generally safe to exercise if blood glucose levels are between 7–12mmol/l. • Avoid or delay your activity if pre-exercise levels are above 12mmol/l and you have ketones in your urine. • If your levels are above 12mmol/l but you don’t have ketones, don’t take extra carbohydrate until your levels come down. • Have some extra carbohydrate (about 30g) if your glucose levels are below 7mmol/l. • Check glucose levels before, every 30 minutes during, and after exercise. If exercise has been particularly vigorous, also check between 2–3am. This will help you to pinpoint if you need to change the amount of food or insulin you have and understand how different types of exercise affect you blood glucose. • Bear in mind that hypos can occur during or soon after physical activity or up to 24 hours afterwards. 64 Type 1 diabetes 2013 visit www.diabetes.org.uk/ Keeping-active For more detailed information on Type 1 diabetes and sport, visit www.runsweet.com 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/intensity as you improve. • If you belong to a gym, tell your fitness instructor that you have diabetes so that they can carry out a health review. Keep it safe • Make sure you warm up before you exercise, and cool down afterwards. Warm-ups should consist of 5–10 minutes of low intensity aerobic exercise, such as walking and 5–10 minutes of stretching. A cool down should last about 5–10 minutes, (include the same exercises as your warm-up, and slow your heart rate down to what it was before you started exercising). • Wear the right footwear for your activity and wear socks to prevent blisters. • Keep your feet dry and check your feet before and after activity. • Wear a diabetes medical ID bracelet. • Keep hydrated. • Carry a small bag containing all your necessary diabetes kit, blood glucose monitor, hypo treatments and a mobile phone. • Avoid going into remote areas when exercising. • Let others know that you are going out exercising and when you are expected back. General diet Berry tasty The same fast acting GlucoGel, now in a fruity flavour Now available in triple pack (3 x 25g tubes) Fast acting 40% glucose gel Easy to carry, easy to use, easy to swallow Raises sugar levels fast For people who require glucose, or are in need of an energy boost For more information visit www.glucogel.co.uk or call BBI Healthcare on 01656 868930 Living with diabetes Accepting diagnosis Take time to adjusT Being diagnosed with Type 1 diabetes often comes as a shock and the implications may not be easy to fully understand at first. As Jane Matera from Diabetes UK Careline explains, you, and those close to you, will need time to absorb the news and discuss how you feel Take some time out to discuss how you feel about your diagnosis D iagnosing Type 1 diabetes is often made after an episode of unexplained illness that may have resulted in a hospital admission. It can be a confusing time, but you’ll soon find that healthcare professionals will help you to get back on track. But you’ll need to be aware that this will involve you making some changes to your lifestyle and routine. Because Type 1 is generally diagnosed as an emergency, the main priority and focus in the first few hours, days, and weeks, is on 66 Type 1 diabetes 2013 the practical: learning how to inject; how much to inject, and when; balancing the insulin dose against food/exercise/stress; learning the hows and whens and whys of checking your blood glucose. But don’t worry, although this may initially seem daunting, with time and help you will become more relaxed and able to cope. It’s important while learning all these new things not to ignore the shock and emotions you may be feeling. The relief of explaining how you’re feeling can be immense, so it’s well worth taking some time out to discuss how you feel about your diagnosis with a nurse or doctor and the people close to you, as soon as you can. But what if no one asks? Or, if everyone, much too early, but possibly thinking it’s for your own good, urges you to adapt, accept, be positive, and move on? Or, if no one actually says anything much at all? This is the experience often described to the Diabetes UK Careline by newly diagnosed callers. What if you have Accepting diagnosis professionals will help “Healthcare you to get back on track ” the basics explained, and are then expected to return home, and carry on after so much change? Sometimes, the reaction of the person diagnosed can contribute to this situation. Often, because you’re in shock, you seem to accept the complicated instructions that you’re given. It may be all that you’re able to do. Your emotional reaction may be like this: �How are you?’ asks a kind nurse or doctor. �Fine,’ you say. �He/she seems ok with it all,’ reports back the nurse. �Coping well!’ End of story. Except that it might not be the case. Recognise your need for emotional expression and support It’s an extraordinary fact, but if you’d been diagnosed with cancer rather than diabetes, your need for emotional and psychological support would never be in question. But is Type 1 diabetes any different? Perhaps public ignorance of the nature of Type 1 and a lack of understanding may be to blame? Your shock can be helped along by the release of talking through what you have experienced, maybe over and over again, to someone who’ll listen. Talk about what your fears are. Are you angry? Do you feel it’s unfair? But there can sometimes be a huge obstacle in the way of this. It is fear of knowing what diagnosis means; fear and confusion as to what it might mean now and in the future. You may also be someone who doesn’t easily talk about what is important to you. But the right kind of help at the right time is what is most likely to help you now and in the long run. Don’t be afraid to be honest about what you feel, it will help you to gather up your strengths – and the needed resources to get on with your life. Living with diabetes Diabetes UK Careline Diabetes UK’s Careline provides confidential support and information to all people affected by diabetes. Call 0845 120 2960, 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 careline@diabetes. org.uk for a response within 10 working days. Careline cannot provide individual medical advice. 2013 Type 1 diabetes 67 Living with diabetes telling people A new beginning 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 Discussing your diabetes will help your friends understand how they can help you 68 Type 1 diabetes 2013 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 often find that they get more support and are better able to cope with their newly altered circumstances. Telling friends & family Friends and family can provide you with 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 that sharing aspects such as how you feel when you have a hypo helpful (see p18). If your friends are aware of what the symptoms are, then they can help you to get the right treatment and prevent misunderstandings. Also, when you are going out with friends it will give them a better understanding of why meal times or the type of food you eat might matter to you. Your partner, family or anyone who is involved in preparing the food at home will need to understand why carbohydrates matter to you. If they understand what carbohydrates are and how telling people much they put in your meal, this can help you calculate the correct amount of insulin. Telling 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 gym staff If you belong to a gym, the fitness instructors or personal trainers need to know about your diabetes so they can carry out a health review. The reason for this is that your diabetes may increase your risk of having high blood pressure or heart problems. Also, your blood glucose levels may be affected by the exercise you do. Telling your employer & colleagues There is 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 better informed you are about your diabetes, the better you will be able to explain why it won’t interfere with your ability to do your job. If you don’t tell your employer about your diabetes, it will be more difficult to pursue any issues with reasonable adjustments. 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: Your insurance could be invalid if you have an accident and you haven’t told your insurer that you have diabetes. Also, because of the increased risk of hypos, 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), that you are treated with insulin. Your driving licence will be reissued for a onetwo- or three-yearly term, and you’ll have to reapply each time (this is free of charge). i For more on driving and diabetes see p82. Living with diabetes 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 they will charge a much higher premium i For more about travelling see p84. 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 “The know about diabetes, the more you can explain it to others ” 2013 Type 1 diabetes 69 Living with diabetes Love life staying close Having diabetes shouldn’t 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 1 diabetes 2013 Consult your doctor at an early stage if you encounter sexual problems 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 will 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 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 woman 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 self-image 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), loss of desire, arousal and orgasm. Very little research has been done into this area 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: • 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 1 diabetes 71 Living with diabetes Contraception Contraception options There are lots of contraception options available. We take a look at the pros and cons of each and their impact on diabetes H aving diabetes shouldn’t 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 than any other woman who uses contraception, but if they have any diabetes complications they should be advised to avoid hormone-releasing 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 72 Type 1 diabetes 2013 form of contraception that contains hormones. But this can be easily monitored and controlled by a slight change in diabetes medication. 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. THE COMBINED PILL How it works There are several types, but they all prevent the ovaries from releasing eggs and thickens 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 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. IMPLANT 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 under 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 1 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 1 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 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. Contraception is the key to avoiding an unplanned pregnancy, (see p72) for the types available. 74 Type 1 diabetes 2013 Risks to you Having diabetes and becoming pregnant has a number of risks: • Pre-existing retinopathy This 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 This may get worse, so your kidney function should be checked as early as possible so that you can be referred for treatment as early as possible. • Hypoglycaemia As you try to manage your blood glucose and get tight blood glucose control, you may find that you have more hypo episodes. It is important to be aware of your warning signs and always have your treatment to hand. There are risks involved with pregnancy if you have diabetes which you need to be aware of • Hyperglycaemia Although DKA is not common, you would be admitted urgently as it can be dangerous to both you and your baby. • Pre-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 You may need to deliver your baby earlier than expected, either for your safety or your baby’s. Reasons include: pre-eclampsia, your baby having grown too large or deterioration in your kidney function. pregnancy & labour “ Most women with diabetes have healthy 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. • 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 avoid pregnancy, ideally it should be below 43mmol/mol. Your diabetes healthcare team can help you with this. ” • Start taking 5mgs 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. 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 which 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, bit do make an appointment to see your doctor as soon as possible. Living with diabetes tops tip 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 healthcare 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 1 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, 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. You will already have a blood glucose meter for testing, but you may need to increase the number of times you test each day and so will need more test strips. Your diabetes healthcare 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 76 Type 1 diabetes 2013 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. You should be given ketone test strips either for urine or blood, and you should be given a glucagon kit and shown how to use it. Make sure some members of your family are familiar with it, in case you should experience a hypo which you can’t treat yourself. 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 my be offered an intravenous infusion (drip) of dextrose and insulin to help to keep your levels within your target range. i You can find more information in the NICE guidance for diabetes in pregnancy at http://guidance.nice.org.uk/ CG63/PublicInfo/pdf/English Q& A Will my baby be affected by my diabetes once its born? 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 prepregnancy 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 labour. • 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 1 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 any other form of stress, illness can raise your blood glucose levels. Typical things that will upset your diabetes control can 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 1 diabetes 2013 Managing at home When you are 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. At these times it is important to keep taking your insulin. If you don’t, your blood glucose levels will keep rising and you will eventually develop diabetic ketoacidosis (DKA). You should try to drink plenty of unsweetened fluids and to rest, 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. It is important to monitor your blood glucose levels and you may need to increase the frequency of your glucose monitoring while you are unwell. Sometimes, high blood glucose levels can be the reason you are feeling unwell, rather than your actual illness. When to get medical help You should seek medical advice if: • 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 persistent ketones or large amounts of ketones in the urine • you have very low glucose levels. Testing for ketones If there is no glucose going into the cells, your body will start to burn its stores of fat as an alternative source of energy, producing an acidic by-product called ketones. Checking your urine with special test strips will indicate the level of ketones you had a few hours previously. These strips are available on prescription and you should always keep some in-date ones at home. ILlness & infections Some blood glucose monitors also measure ketones – this test uses a different strip and shows your current levels of ketones. If either test shows positive for ketones, seek medical advice. If the test is negative, you should retest your blood glucose levels after two hours to be sure your blood glucose levels have gone down. If they haven’t, check again for ketones. If you have high blood glucose levels and any signs of DKA (ketones in the blood/urine, abdominal pain, nausea/vomiting, rapid breathing), you must contact your diabetes healthcare team immediately. If DKA is left untreated it can lead to unconsciousness. But, if picked up early, it can easily be treated with extra insulin and fluid. 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 • 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, if possible take some with you to avoid delays and take your own diabetes equipment (insulin pens and meters) because they won’t 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 longer periods of inactivity might affect your blood glucose levels, so test more often. Even if you go to A&E as an emergency, you may have to wait to receive treatment. In this situation, you shouldn’t eat or drink anything in case you need surgery when you are seen. As soon as you arrive, tell a staff member that you have diabetes and may need to eat to avoid going hypo. If you feel that you do need to eat or drink, check with staff first. i See �Your diabetes care explained’, p24. tops tip Living with diabetes Diabetes when you’re ill 1 2 3 Continue to take your insulin even if you don’t feel like eating. Test your blood glucose levels more frequently. If your blood glucose levels are consistently above 15mmol/l, you may have to increase your insulin dose. Talk to your diabetes healthcare team about how much. 4 If you don’t feel like eating, 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 Drink 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 1 diabetes 79 Living with diabetes Work & discrimination An even playing field Unfortunately you may come across some discrimination at work. Here is some helpful advice that should help you deal with the situation, should it arise Your employer should work with you to make adjustments to your role 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 certain 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 1 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 day-today 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, 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 “ By being honest and showing how you cope with your diabetes, your employer is fully in the picture ” ACTION POINTS • Be honest with your employer, if they don’t know that 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 Citizens Advice Bureau (CAB), or the Equality and Human Rights Commission (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 supporting information and refer you on to other possible sources of support, if the CAB or EHRC can’t help. 2013 Type 1 diabetes 81 Living with diabetes DRIVING The road ahead Diabetes doesn’t stop you from driving. However extra care has to be taken Always check that you have a snack and hypo treatments in the car before a journey 82 Type 1 diabetes 2013 DRIVING I f you drive and you are on insulin you need to inform the Driver and Vehicle Licensing Agency (DVLA). You will be asked to fill in a medical questionnaire and give the name of the doctor who looks after your diabetes. If your diabetes is well controlled, with no complications and good awareness of hypos, you will 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 (free of charge). This is so your fitness to drive can be assessed on a regular basis – but you won’t be charged anything for the renewal. You also need to let your insurance company know that you have diabetes. Most companies won’t ask you for any further information and won’t charge you any more – but a few may ask what may feel like unnecessary questions, such as how much insulin you take. Even if they don’t ask about your diabetes, do tell them you have it, just in case you have an accident in the future. You don’t want to find any unknown small print if you come to make a claim. Group 2 licences Since November 2011, people with diabetes treated with insulin are able to hold a licence to drive a �Group 2’ vehicle (HGV and PCV). But you have to undergo an independent medical assessment every year to assess your fitness to drive and your management of your diabetes. You will need to monitor your blood glucose regularly and Living with diabetes store the results on a memory meter. For further details, see www.diabetes.org.uk/driving or contact the Diabetes UK Careline. Hypos and driving Having a hypo while driving can be fatal, not only for the driver, but for others as well. So it is essential you always have some form of hypo treatment and snacks with you in the car. Even a mild hypo, because of its effects on the brain, can seriously impair your ability to drive. Technically, you’re driving under the influence of a drug – insulin – and it’s an offence to drive while hypo. So always check your blood glucose levels before you start your journey. If you feel like you are going hypo, stop driving as soon as possible, 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 your journey. The DVLA recommends that you wait 45 minutes after the blood glucose levels have risen to above 4mmol/ before driving. Remember, you should not test blood glucose levels or treat a hypo while in the driver’s seat – and you must not start driving again until you have dealt with the hypo. i Visit www.diabetes.org.uk/ driving for more details. ACTION POINTS • Check blood glucose levels before driving. If below 5mmol/l have something to eat and wait 45 minutes before setting off. • Always have hypo treatments to hand. • 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 4mmol/l. 2013 Type 1 diabetes 83 Living with diabetes Travel your “Planning trip well in 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 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 in advance will give you 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 48 hours notice to prepare your prescriptions and, if you want to take extra supplies with you in case of loss or damage, then you must allow time to arrange this. 84 Type 1 diabetes 2013 • Shop around for travel insurance (see top tips for insurance, right). A • pply 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. • Ask your diabetes healthcare team for a letter explaining that you have diabetes and your treatment. You’ll need this if you’re flying, so you can carry sharp items (such as pen needles) and insulin in your hand luggage. • Arrange to have any vaccinations or malaria tablets you may need. • Check that your accommodation includes a fridge that you can store insulin in. advance will give you plenty of time to get organised ” A safe getaway If you’re flying, here are a few things to consider: • Don’t store your diabetes supplies in baggage that is going to be checked-in at the airport unless you absolutely have to – the low temperate in the hold can damage insulin and 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 have to store supplies in your suitcase, pack the insulin in a flask or bubble wrap and place it in the centre of a suitcase. • 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. • Carry plenty of snacks in your hand luggage, particularly when there’s Living with diabetes Travel no guarantee what time the in-flight meal will be served or, as with low budget airlines, you will have to buy food or drink on the aircraft. • Don’t feel like you have to order the diabetic meal rather than the standard one, ask for whatever you prefer. Airline meals tend to be low in carbohydrate, so the most important point is to match your insulin to your carbohydrate intake. • Test your blood glucose levels regularly, especially on a long flight. • Make sure you keep your hypo treatment close to hand. While you’re away • Keep insulin cool: – If your accommodation doesn’t include a fridge, store it in an 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. 3 • A hot climate and activities such as swimming in the pool or sea might cause your levels to drop lower than usual. Likewise, different foods or long periods lying around doing nothing might cause them to rise. Monitor your blood glucose levels regularly and consider whether you need to alter your insulin dose. • 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. Essentials to pack • Insulin. Also take some spare insulin as a precaution, in case it gets misplaced or is not available where you are travelling to (it may be available under a different brand, so check before you go). • Insulin injector pen/syringes • Open needles • BD Safe-clip (prescription available) to store used needles • Finger pricking device or lancets • Blood glucose meter • Glucose testing strips • Ketone testing strips • Ketone monitor (if you use one) • Hypo treatments (including Glucogel and GlucaGen Hypo Kit if you have these) • Letter about your diabetes • currency so you can buy food and drink on arrival, if necessary • Travel insurance emergency contact number • European Health Insurance Card (EHIC), if appropriate. tops tip Insurance 1   Buy your insurance at least two weeks before your holiday. 2  Don’t just buy on price and check the cover is what you need (read the small print). 3  Choose 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 condition 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! i Diabetes UK Insurance Services provides travel insurance Call 0800 731 7431 or visit www. diabetes.org.uk/travel for details. 2013 Type 1 diabetes 85 Living with diabetes religious holidays Fasts & Festivities R eligious holidays are an important part of many people’s lives. Most involve feasting and some also precede this with a period of fasting. So it is important to understand how this may affect your diabetes and what you can do to manage your blood glucose levels better, and reduce the chance of any problems. Here we take a look at how fasting features as part of some religions. Christianity Fasting is not obligatory but the major Christian festivals of Christmas and Easter usually involve not only eating more than usual but also feature high-fat treats such as nuts or chocolate, which you may not normally include in your diet. Having Type 1 diabetes doesn’t mean that you have to miss out. Being less active, over-indulging or changing your routine will cause your blood glucose levels to be higher than usual, so talk to your diabetes healthcare team about how to increase your insulin to cope with this. If you get back to your normal routine once the holiday is over, your long-term diabetes control or health shouldn’t be affected. Islam Total fasting (no food or water) between dawn and sunset in the month of Ramadan is one of the five pillars of Islam. Although people 86 Type 1 diabetes 2013 Fasts and feasts form significant parts of the annual calendar for several religious faiths, but care needs to be taken to ensure that your diabetes control is not affected with diabetes are exempt from this requirement, many people with Type 1 diabetes still wish to fast. If you do choose to fast, then you must talk to your diabetes healthcare team before Ramadan so that you can discuss how to change your insulin regimen or pump settings to minimise your risk of hypos. Before starting the fast, it might be helpful to include more slowly absorbed food (low GI – Glycaemic index), such as rice, pitta bread, chapattis and dhal, in your meal. Fruits, vegetables and salad should also be included. When you break the fast, watch portion sizes and limit the amount of sugary and fatty foods you eat, such as Indian sweets, cakes, samosas and puris. Be careful to give yourself enough insulin to cover the food you eat. It is important to have plenty of sugar-free drinks to avoid dehydration, too. Fasting increases the risk of hypoglycaemia. so if you feel hypo you must treat it in your usual way, followed by some starchy food. This breaking of the fast is permitted – religious laws state nobody should put their health at risk. you “When break the fast,watch your portion sizes ” to your “Talk diabetes healthcare team before fasting so you can discuss your insulin regimen ” Judaism A number of fasting days are observed in the Jewish faith. The most prominent day of fasting is Yom Kippur, known as The Day of Atonement and the holiest day of the Jewish calendar. The period of fasting on this day starts at sunset on the evening before Yom Kippur and is broken after nightfall on the following day. Because of the potential problems associated with fasting for more than 24 hours, people with diabetes may be allowed not to take part in the fasting. Talk to your diabetes healthcare team before fasting, so that you can discuss how to change your insulin regimen to minimise your risk of hypos. Once the fast is over, the celebration may involve high-fat and sugary foods, so blood glucose levels may be affected for a short period of time. Remember to adjust your insulin dose accordingly. religious holidays Living with diabetes Enjoy your religious festivities Sikhism Sikhism condemns blind rituals, such as fasting. There are four major festivals in the Sikh calendar where more high-fat and sugary foods may be eaten. A sweet-tasting food (Karah Prasad) is blessed and served at the Gurudwara (the Sikh place of worship). It’s made from semolina or wheat flour, sugar and ghee (clarified butter), so it may have an effect on your blood glucose level. Depending on the amount you eat you may need to adjust your insulin dose accordingly. A Langar meal is then shared from the free kitchen, which is lacto-vegetarian. Buddhism Every month, most Buddhists have special religious days, and many Buddhists go to temples to worship. Rather than fasting, Buddhists will meditate. Although there are no set dietary laws in Buddhism, many Buddhists are vegetarian as they follow the teaching �do no harm’ and so apply it to avoid killing animals. Buddhist self-restraint in dietary habits often means that even at feasting times, your diabetes would not be adversely affected. Hinduism Some Hindus practise the tradition of fasting during special occasions, such as holy days, new moon days and festivals. Hindus fast in various ways. Depending on the individual, they may choose to not eat at all during the fasting period, or to eat only once, eat only fruits or restrict themselves to a special diet of simple foods. Diwali (the festival of lights) is the best known of the Hindu festivals. It is a five-day festival and includes the exchanging of gifts, which are often sweets and dried fruits, and preparing festive meals. As these are usually high in fat and sugar, blood glucose levels will be raised, so care is needed to make sure that you adjsut your insulin dose accordingly and that you return to a normal pattern of eating as soon as possible. ACTION POINTS • Be aware of how a period of fasting can compromise your diabetes control. • Take care to get back to your usual routine as soon as you have finished fasting. 2013 Type 1 diabetes 87 Living with diabetes Alcohol, smoking & drugs positive changes Whether it’s a small change like cutting down on the amount of alcohol you consume each week or a bigger one like quitting smoking, the benefits can be huge W e all need to take time out to relax in a variety of different ways. However, when it comes to drinking, smoking or even using illegal drugs, there are a few things to bear in mind if you have been diagnosed with Type 1 diabetes. Alcohol Having diabetes doesn’t mean that you have to give up alcohol. The same rules of sensible drinking apply to someone with diabetes as for someone without the condition, which is no more than 2–3 units a day for women or 3–4 units a day for men. Also, ideally, try to have two alcohol-free days each week. Alcohol can interfere with the mechanism of the liver, which releases stored glucose when blood glucose levels drop. Because you are treated with insulin you are at greater risk of having a hypo – and 88 Type 1 diabetes 2013 this increased risk continues for some time after your last drink. Alcohol also alters perception, so you may miss the warning signs of a hypo and not be able to react appropriately when you need to. To avoid the possibility of people around you thinking that you’re just drunk because you smell of alcohol when in fact, you are having a hypo, it’s a good idea to tell the friends you are drinking with that you have diabetes and how they should treat a hypo. Also try to wear something very obvious that indicates that you have diabetes, such as an ID card, a medical necklace or a bracelet Visit https://shop.diabetes.org.uk for diabetes ID. Tips for a tipple • Don’t ever drink on an empty stomach. Eating starchy snacks, such as crisps, while you are drinking, will help reduce the risk of hypos. You should also have a starchy snack before going to bed. This could be cereal or toast, or even grab a pizza or chips on the way home, and drinking plenty of sugar-free fluids will help to prevent dehydration. • Don’t forget if you are on any other medication besides insulin, to check with your doctor that you can still drink when you are taking it. • The liver gets rid of alcohol at the rate of about one unit per hour, but this can vary. So if you drink more than a few units in an evening, you will have an increased risk of a hypo during the night and also part of the next day as the liver continues to get rid of the alcohol. • The next day try to have some breakfast. Even if you don’t feel like eating, it will help you get over the night before and will help your Alcohol, smoking & drugs A rough guide to alcohol units Units Beer, Lager, cider Pint2–3 Spirits (eg vodka, gin, whisky) Single pub measure (25ml) Wine (red or white) Standard glass (175ml) Large glass 250ml) 1 Up to 2.5 3 or more Important: over the years the alcohol content of most drinks has gone up – a drink can now contain more units than you think. blood glucose control. • If you are suffering with 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 straightaway. • If you can’t face food or if you are being sick, take as much fluid as you can, including some sugary fluids such as a non-diet drink or ordinary cola. Monitor your blood glucose levels regularly and never stop taking your medication. • You should be able to take over-the-counter remedies like paracetamol or antacids. Ask your pharmacist for individual advice. 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 Living with diabetes 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. 2013 Type 1 diabetes 89 Living with diabetes Alcohol, smoking & drugs 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. 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 – there is no such thing as 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 ACTION POINTS • If you can, quit smoking. The benefits of quitting are immense, while the costs of smoking are numerous. • Make sure you are aware of the amount of units of alcohol it is safe to consume each day and have at least two alcoholfree days a week. • Alcohol can cause a hypo. Make sure you and the people around you are aware of this. 90 Type 1 diabetes 2013 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. 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 hrs a day, 365 days a year). This is a free, confidential service or you can visit the website at www.talktofrank.com. Although they don’t talk about diabetes specifically, they give descriptions of the effects of each drug, so you can see the knock-on effect on your condition. you’re not alone with diabetes bECome a m em Join us tod ber ay 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. Join today. Call 0800 138 5605 and quote Begin1 or visit www.diabetes.org.uk/Begin1 Living with diabetes festivals Mud, rain & 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. Be prepared: • Visit the festival’s website and download a map. Work out where the first aid tent is – they may not carry your particular sort of insulin, but will be able to help if you feel unwell. • 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 can be very expensive to buy on site. • Check you’ve got all your diabetes equipment: 92 Type 1 diabetes 2013 Get a map of the site and familiarise yourself with the location of the main facilities – insulin and your delivery system (pen/pump syringe) – blood glucose monitoring kit – hypo treatments – snacks. What to take: • It may be a good idea to take some disposable insulin pens for the festival, even if you usually use a pen with refills or a pump. Your GP, practice nurse or diabetes healthcare team will be able to advise in case it fails. • Remember to take your insulin. You may want to put a reminder on your phone to let you know when to take your long-acting insulin. • 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 are too ill to tell them who to contact. • 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. • Keep your insulin cool - you could use a Frio pack they work by holding them under running water so they are very useful: www.friouk.com. • Carry your diabetes kit and hypo treatment with you when you are moving around the festival site. You may be a long walk from your tent. • 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 tops tip Staying safe 1 2 Carry some kind of diabetes ID. rink plenty of sugar-free fluids to D 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 5 6 7 M ake sure you always have something to treat a hypo with you. Keep plenty of carbohydrate-based snacks to hand. 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 p88. 8 Keep away from drugs, see p90. NEW EVENTS FOR 2013 A range of fundraising challenges to suit all abilities and tastes Ride London 100 London2Brighton 100km walk Thames Path Trans Pennine Walk Moonrider Series For information contact [email protected] or call 020 7424 1000 www.diabetes.org.uk/events A charity registered in England and Wales (215199) and in Scotland (SC039136). © Diabetes UK 2013 2013 Type 1 diabetes 93 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 94 Type 1 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 though. 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 cardiovascular disease, www.diabetes.org.uk/cvd Cardiovascular Disease Complications ACTION POINTS Steps you can take to to help prevent CVD • If you smoke, ask for help to stop. • Eat a healthy, balanced diet (see p36). • 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 p56). • 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 1 diabetes 95 Complications Complications retinopathy TESTIN 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) 96 Type 1 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 p82. 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 p23 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 any excess weight. • Eat a healthy, balanced diet. • If you smoke, ask for help to stop. • Attend your annual eye screening appointment. 2013 Type 1 diabetes 97 Complications TESTIN 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. 98 Type 1 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 • burns 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. Walking barefoot can lead to foot damage if you have neuropathy 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 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 simple tasks, such as fastening buttons • muscle wasting, where muscle tissue is lost due to lack of activity • muscle twitching and cramps. What do I do if I become impotent? Talk to your doctor, don’t hide away. There are a number of treatments available and if you also get your blood glucose well controlled, your problem may be resolved quite quickly. ACTION POINTS Steps you can take to avoid neuropathy •Keep your blood glucose within your target range (see p23). •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 1 diabetes 99 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 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 100 Type 1 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 way to prevent nephropathy developing is: • Keep your blood glucose and blood pressure levels within your target range (see p23). •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 1 diabetes 101 Further information 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: 0845 120 2960 Monday–Friday, 9am–5pm 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 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/Get_involved/Diabetes-Voices/Signup-for-Diabetes-Voices Care Events for children, young people and families A Diabetes UK Care Event is packed with fun activities and adventure. It also offers a unique opportunity to be among people who understand. For many people, it is the first step to managing their own diabetes. Diabetes UK also runs events for the whole family, committed to providing families who have a child with diabetes with support, information and the opportunities to share experiences and to discuss both emotional and practical issues around living with diabetes. At the same time, we offer safe and expert care for children when they are taking part in their own activities. For details, call Diabetes UK on 020 7424 1000 or visit www.diabetes.org.uk/careevents. Ready STEADY Shop! A selection of items for Diabetes UK. All funds raised come to the charity. Code 4222 Code 4235 Code 4236 Code 4238 Code 4239 Carbs & Cals Kids T-shirts £5.95+p&p Bearing the Diabetes UK logo, these great T-shirts come in a range of sizes: T-Shirts: Kids 12/13 Years – Youth X-Large T-Shirts: Kids 3/4 Years – Youth X-Small T-Shirt T-Shirts: Kids 7/8 Years – Youth-Med T-Shirt T Shirts: Kids 9/11 Years – Youth Large T-Shirts: Kids 5/6 Years – Youth Small An easy-to-understand visual guide to carb and calorie counting in diabetes management. Contains more than 1,200 photos of popular food and drink items, with the carbohydrate and calorie values clearly displayed above each photo. £12.99+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) DIABETES UK UMBRELLA Be prepared for a rainy day with this gold umbrella, which is great for outdoor events as well as everyday use. £12.99+p&p (code 4833) 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 shop.diabetes.org.uk or freephone 0800 585 088, Monday to Friday, 8am to 6pm. Please quote G100 when placing your order. (Postage is charged on some items.) Diabetes Management System Interactive pump therapy that fits into your lifestyle Easy Safe Discreet Easy to use bolus advisor & one stop electronic diary Multiple safety reminders & alarms Hand held remote control & blood glucose meter To request your insulin pump information pack please visit accu-chek.co.uk/infopack1 ACCU-CHEK, ACCU-CHEK AVIVA COMBO and ACCU-CHEK SPIRIT COMBO, are trademarks of Roche. The Bluetooth word mark and logos are registered trademarks owned by Bluetooth SIG, Inc., and any use of such marks by Roche is under license. © 2012 Roche Diagnostics Limited. Roche Diagnostics Limited, Charles Avenue, Burgess Hill, RH15 9RY. Company registration number: 571546 Accu-Chek Pump Careline: 0800 731 22 91
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