diabetes control
by Jenny Bryan
Anyone with diabetes who has ever missed a meal and had a hypo will recognise the first symptoms: trembling, sweating, blurred vision and tingly lips.
© C4/intuitis
'Everyone's a bit different,' explains Amanda Vezey, from Diabetes UK. 'Some people get hypos when they exercise more than they'd planned, others when they don't eat enough after taking their insulin.'
'More severe symptoms include personality changes, irrational behaviour and even unconsciousness, but these are less common. Most people learn to recognise mild symptoms and do something about them before they become more severe,' she adds.
too little glucose
Hypoglycaemia means there is too little glucose in your bloodstream to give your body the energy it needs to keep working properly.
Most people don't have to think about glucose control because their pancreas does it for them. It produces two hormones – glucagon which increases glucose levels in the bloodstream and insulin which brings them down.
As there's more glucose around during a meal, insulin levels increase and glucagon production falls. The insulin ensures that glucose is transported to muscle cells for energy and stored as glycogen in the liver. Between meals, glucagon raids the glycogen stores in the liver so there's enough glucose in the system until the next meal.
People with diabetes don't make enough insulin in their pancreas (type 1 diabetes) and/or their muscle, liver and other cells no longer respond to it properly (type 2 diabetes).
too much glucose
It is the lack of insulin or resistance to it that is the biggest problem for people with diabetes. Prolonged, high levels of glucose in their bloodstream lead to heart disease and serious nerve, kidney and eye problems. Diabetes treatment is therefore aimed at keeping blood glucose levels within the normal range .
For type 1 diabetes this means not eating too much fatty or sweet food, together with regular insulin injections. Some people with type 2 diabetes can regain control of their blood glucose by losing weight and sticking to a healthier diet, while others need tablets and possibly insulin injections.
what to do about hypos
If you have diabetes, you're sure to get hypos from time to time, says Amanda Vezey. It's something to be aware of, but not scared about.
'Some people who are newly diagnosed find them a threat but once they know the symptoms and what to do they aren't so worried,' Amanda explains.
warning, warning!
People who have regular mild hypos may lose the warning symptoms that tell them they need to drink or eat something sweet. As a result, they start getting severe hypos – blacking out before they realise that anything is wrong.
Fortunately, it is possible to restore hypo warning signs by easing up on glucose control for two or three months, and not letting levels get below 4 before meals or above 10 afterwards.
She advises people to have a sweet drink, such as Lucozade, as soon as they get hypo symptoms, but not a diet drink. Three or four glucose tablets or barley sugar sweets or a chocolate bar are other options. Once the immediate symptoms have disappeared, it's advisable to check your blood sugar level and follow up with a sandwich, biscuits and milk or a bowl of cereal.
'The sugary drink or sweets are short acting carbohydrates so it's important to follow up with longer acting carbohydrate so that your glucose level doesn't dip down again,' says Amanda.
If a hypo is severe enough to cause a loss of consciousness, giving people a sugary drink or food is likely to make them choke. Instead, they should have an injection of glucagon to kick-start their liver into making more glucose.
DAFNE may reduce hypo risk
Hypos occur because most people with diabetes control their blood sugar with regular doses of insulin or other drugs, taken at set times of the day. Once the drug is in their body, it can't come out. So, if they miss a meal, use up more energy than they had expected or get dehydrated, for example after drinking too much alcohol, they may suddenly find themselves low on glucose.
Ironically, hypos may be getting more common as people with diabetes try to control their blood sugar more effectively in order to reduce their risk of complications.
Diabetes UK has funded research into a new approach to diabetes treatment called Dose Adjustment For Normal Eating (DAFNE). This teaches people with type 1 diabetes to adjust their dose of insulin to fit their life and diet rather than the other way around. During a five-day education programme, they learn to match their insulin dose to the amount of carbohydrate they are eating or exercise they are taking. It allows them to lead a much more flexible lifestyle, with fewer restrictions on what they can eat.
The results of the DAFNE study were published in the BMJ in 2002, and revealed that participating in DAFNE results in improved glyceamic control, without the increased risk of severe hypoglycaemia, improved quality of life and improved satisfaction with treatment. Only 4 of the 141 participants in the study did not derive some benefit from DAFNE.
Specialists such as Dr Simon Heller, who took part in the study, have been impressed with what they've seen:
'We found that, not only were people getting better glucose control, they felt very liberated. The course isn't a panacea, but we think that this type of training may increase the number of people who adjust their insulin dose to suit their lifestyle from about 1 in 20 at present to perhaps 50%,' he predicts.
As Dr Heller points out, the DAFNE approach is very much in line with government philosophy that we should all be taking more control of our health. Unfortunately, intensive courses like DAFNE don't come cheap. They require a lot of time from doctors, nurses and others involved in diabetes treatment. But, if they work, they may prevent expensive complications of diabetes and emergency treatment for hypos. As a result, DAFNE is the only programme endorsed in National Institute for Clinical Excellence (NICE) guidance as an example of high-quality structured education for people with type 1 diabetes.
can insulin pumps provide better control?
Insulin pumps may provide the high-tech route to better glucose control in people with type 1 diabetes. Already widely used in the USA, insulin pumps are offering a growing band of committed users in the UK a solution to the highs and lows of glucose control.
Worn externally on a belt or in a pocket, the most sophisticated insulin pumps are about the size of a pager and can be programmed to deliver insulin through a needle or cannula inserted under the skin, usually on the abdomen.
Between meals the device provides a background, basal rate of insulin around the clock, but allows users to deliver a larger dose before meals, matched to the amount of food they will eat. If necessary, the basal rate can be changed, for example, if the user is taking exercise and needs extra glucose or is ill and needs to reduce their glucose level.
Insulin pump users can't just put them on and forget about them. Considerable training is needed before switching to a pump and users must commit to testing their blood sugar three or four times a day and changing their infusion set every few days. Not least, users need to be able to distinguish between high blood sugar levels caused by over-eating and those arising from mechanical problems with the pump not releasing sufficient insulin.
The reward for many pump users is tighter glucose control, fewer symptoms and diabetic complications, and greater freedom to get on with busy lives. However, some people find the pump routine too demanding and prefer to return to regular injections. Getting an insulin pump on the NHS isn't easy – they tend to be reserved for those with special problems in controlling their diabetes. But if you think you might benefit, you can find out more from your diabetes specialist. For those who wish to buy a pump privately, the cost is usually around £2,000 for the pump, and about £1,000 per year in running costs.
find out more
The INsulin PUmp Therapy (INPUT) group is a patient led support group for diabetics using insulin pumps, and is run by pump users and their families (see help and info below). It provides information for people seeking facts about insulin pumps, their use and how to obtain and fund them. An independent organisation, INPUT's prime objectives are to increase the awareness and understanding of insulin pump therapy, and to have it funded by the Department of Health.
Two manufacturers currently market insulin pumps in the UK – Disetronic and MiniMed. Their pumps work in similar ways but the Disetronic pump is designed to last for two years while the MiniMed pumps have an open-ended life expectancy.
MiniMed sell one pump (model 508) which has a remote control and can store extensive data on insulin usage over a 90 day period.
Patients who choose Disetronic's H-TRON plus V100 buy two insulin pumps at a total cost of £2,000. Each pump lasts two years, giving a total life expectancy for the devices of four years. Various warnings alert users when the pump is nearing the end of its life. Like the MiniMed devices, the Disetronic pump offers an extensive range of programmes for administering insulin.
D-TRON is the name of their newest pump and it is one of the most technologically advanced pumps in the world, being the only insulin pump which takes the prefilled 3ml Humalog cartridge from Lilly (the cartridge being available on prescription). This is a one pump system with a four-year life span and guarantee and, as before, various alarms are given as the pump nears the end of its life. The pump also features extended and scroll bolus, backlight, vibrating alarm, and two different programmable basal rates.
help and info
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organisations
Diabetes UK
Careline: 0845 120 2960 (Mon-Fri 9am-5pm)
Textphone: 020 7424 1031
E-mail: careline@diabetes.org.uk
Website: www.diabetes.org.uk
Campaigns on behalf of people with diabetes, provides support and information, and funds research. The Careline has trained counsellors who can be contacted for support and current information on diabetes, however they cannot give individual medical advice. Also operates an e-mail enquiry service.
For the Diabetes UK position statement on pump therapy please visit:
www.diabetes.org.uk/infocentre/state/pump.htm
Diabetes Research & Wellness Foundation (DRWF)
Tel: 023 92 637 808
E-mail: enquiries@drwf.org.uk
Website: www.diabeteswellnessnet.org.uk
Established to fund research and offer support to people living with diabetes. DRWF brings professionals, patients, their parents and friends together in a 'Diabetes Wellness Network,' providing information to help improve diabetes self-management through newsletters, advice leaflets and a programme of patient events.
Juvenile Diabetes Research Foundation
Tel: 020 7713 2030
E-mail: info@jdrf.org.uk
Website: www.jdrf.org.uk
Funds research to find a cure for diabetes, and provides information on diabetes, new developments in treatment and research. A range of leaflets on living with diabetes and its complications are available free of charge.
NHS Direct
Helpline: 0845 4647 (24 hours)
Website: www.nhsdirect.nhs.uk
The NHS 24-hour service provides expert health advice from trained nurses. An extensive database of medical information is available on the website.
websites
Best Treatments: hyperglycaemia and hypoglycaemia
www.besttreatments.co.uk/btuk/conditions/ ..
Information on hyperglycaemia and hypoglycaemia, how to recognise them and what to do.
BUPA: type 2 diabetes
http://hcd2.bupa.co.uk/fact_sheets/html/diabetes2.html
Information on type 2 diabetes from BUPA including a PDF factsheet to download.
Children with Diabetes
www.childrenwithdiabetes.com/index_cwd.htm
A US-based site geared towards promoting understanding of the care and treatment of diabetes, especially in children. Described as an 'online community for kids, families and adults with diabetes.'
DAFNE
www.dafne.uk.com
Contains up-to-date information on DAFNE both for people living with Type 1 diabetes and for healthcare professionals, including personal accounts of the benefits of DAFNE, details of the costs of the programme and training dates.
Diabetes Insight
www.diabetes-insight.info
UK website aiming to provide information to people with diabetes in a positive manner, to help them live an active life. Operates an e-mail support group and an online discussion forum, Diabetes Support.
Disetronic
www.disetronic.com
Disetronic produce programmable insulin pumps to allow patients to continuously administer insulin doses according to their individual needs.
INPUT
www.webshowcase.net/input
An independent, patient-led support group for diabetics using insulin pumps run by pump users and their families. Provide information for people seeking facts about insulin pumps, their use and how to obtain and fund them.
Medtronic: Diabetes Overview
www.medtronic.co.uk/UK/health/diabetes/ ..
Information about diabetes, treatment options and pump therapy.
reading
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Parenting a Child with Diabetes by Gloria Loring (Contemporary Books, 2000) |
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When Diabetes Complicates Your Life: Controlling Diabetes and Related Complications by Joseph Juliano (John Wiley and Sons Inc, 1998) |
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(January 2002, resources updated January 2005)
