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Case Study 1: George Mellows (1)

January 21, 2015 by Imagine_David Leave a Comment

Some things you can Control. Diabetes you can manage.

"Enjoying a good quality of life is my goal" George — “Enjoying a good quality of life is my goal”

George Mellows is aged 55. He lives with his wife and his two teenage children, aged 15 and 19.

George works Monday to Friday 8.30 am until 4.30 pm . He works at a desk in a sedentary role, getting minimal activity in his working day. George has not played any sport for some time, but he does enjoy playing lawn bowls.

4 weeks ago George was:

feeling excessively thirsty
was peeing more than normal
was feeling tired and lethargic
and was always feeling hungry

So, George went to visit his doctor. He described the symptoms, and his doctor sent him for a glucose tolerance test to test for diabetes. The results of this test confirmed a diagnosis of type 2 diabetes .

George was a little shocked as he has nobody in the family with diabetes, only a history of heart disease.

Until this diagnosis of type 2 diabetes George had no identified health problems.

Since his doctor discovered diabetes George has had some further blood work and had been found to have high cholesterol.

Measuring the Blood Glucose Level

George decided to start measuring his blood glucose levels as he was still feeling some symptoms, despite the doctor commencing George on Metformin 500mg in the evening with dinner. Table 1 below shows George’s blood glucose level test results.

George has yet to see a diabetes educator, dietitian, exercise physiologist or podiatrist.

Since starting the blood glucose level measurement George identifies, that despite commencing on Metformin, his blood glucose levels are above target.

Below is a table from the RACGP (Royal Australian College of General Practitioners) identifying the target blood glucose levels in type 2 diabetes. *Note: target blood glucose levels need to be individualised.

Targets for self-monitored glycaemic control in type 2 diabetes *

FBG (mmol/L)	Pre-prandial blood glucose (mmol/L)	Postprandial blood glucose (mmol/L)	Comment
6.0–8.0	6.0–8.0	6.0–10.0	NHMRC values

Based on his blood glucose levels after meal, George is concerned. He thought that taking his Metformin would be all that he needed to do. Now, he feels like he has failed.

George joined several groups of people living with diabetes on Facebook ( https://www.facebook.com/diabetes.counselling ) to see if he could glean some further understanding of diabetes self management.

“Self-management means having a daily management plan, setting goals, solving problems and taking responsibility. But it certainly does not mean you are on your own. Mutual trust and respect between yourself and your doctor and other members of the health care team, as well as regular communication with them, are vital to effective self-management.

Previously, traditional care was based on doctors and health professionals being seen as the experts responsible for the diagnosis and management of care. It was accepted that people’s lives should be fitted around their diabetes with goals set by the health professionals.

But this approach is not effective. Diabetes requires daily management. Doctors are not available every day, leaving responsibility for day-to-day care on the patient and the family.

In addition, good results are difficult to achieve if the person involved is not an active participant or does not understand the reasons behind management decisions.

Patient Empowerment takes a new approach. It moves the focus from the doctor to the patient. It involves fitting diabetes into your lifestyle with you making the choices and taking charge of your management and the consequences.” Diabetes Australia

Georges Plan:

Research diabetes and prepare questions for doctor, diabetes educator, dietitian.
Meet with diabetes educator:
“Diabetes educators are healthcare professionals who focus on helping people with and at risk for diabetes and related conditions achieve behavior change goals which, in turn, lead to better clinical outcomes and improved health status. Diabetes educators apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and education to provide self-management education/self- management training.” American Diabetes Association

“Diabetes educators specialise in the provision of diabetes self-management education for people with diabetes.

They provide support for people with diabetes, including gestational diabetes, integrating clinical care, self-management education, skills training and disease specific information to motivate patients to:
- Understand diabetes and make informed lifestyle and treatment choices
- Incorporate physical activity into daily life
- Use their medicines effectively and safely
- Monitor and interpret their blood glucose patterns” Allied Health Professions Australia
Meet with dietitian: appointment booked
Meet with doctor: appointment booked

George plans to ask about different treatment options.

Here are some questions George has prepared for his team:

Is this the best medication for me?

If I get any side effects what do I do? If this medication does not work, what’s next?

Do you mean ….. ? Is there anything I should not be doing?

How soon should treatment start ?

Can the treatment start next month when I am back from holidays?

Can I stop the treatment when I can’t afford it?

How much will the treatment cost?

What can I do to prevent further problems?

What can I do to keep my condition from getting worse?

How will making a change to my habits help me?

Are there support groups or community services that might help me?

Which other HCP’s will be able to help me manage this health issue?

Hand in hand with your health care professionals you van achieve a good quality of life with diabetes — Hand in hand with your health care professionals you can achieve a good quality of life when living with diabetes

Over to You

What advice would you give to George?

What was your experiences of being diagnosed with type 2 diabetes ?

How did you access your diabetes educator, dietitian, counsellor etc?

**** Added January 26: Part 2 HERE *****

Next time we visit George, we shall see how he is progressing with his diabetes self care plan http://www.diabetescounselling.com.au/choices-in-diabetes-management/

In the meantime, healthy days to you.

Kind Regards,

David, Diabetes Educator @ Diabetes Counselling Online

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Making Rice Nice for Diabetes

January 12, 2015 by Sally Leave a Comment

Rice is one of those grains that can be problematic for people with diabetes, so I thought it might help if we explain a little of why that is, why different rices have varying effects on our BGLs and ways to make rice more diabetes friendly.

You may know that, generally speaking, a quarter of a cup of cooked rice is one carb serve. You can see that in this snip from CalorieKing showing that half a cup of boiled rice = 28.8g carb (or 2 carb serves).

And this photo shows you what half a cup of cooked rice (2 carb serves) looks like on a plate.

You may also know that, particularly for us with diabetes, we’re better having rice that breaks down more slowly to glucose in our bloodstream, or low-GI rice. The main types in Australia of low GI rices are long grain rices including Basmati and Doongara. Even when choosing brown rice for the extra fibre, we’re best to choose brown Basmati or Doongara.

This mini-table gives you a feel for the glycemic indexes of various rice products.

Source: Low GI Diet Shoppers Guide 2014

Rice type	Glycemic Index	Glycemic Index rating
Aborio/risotto rice, boiled, SunRice	69	Medium
Basmati white rice, boiled, SunRice	59	Medium
Basmati white rice, SunRice, microwave pouch	52	Low
Calrose rice, brown, medium-grain, boiled	76	High
Calrose rice, white, medium-grain, boiled	87	High
Japanese style sushi rice, SunRice	89	High
Jasmine fragrant rice, SunRice	73	High
Long-grain rice, white, boiled 15 mins, Mahatma	50	Low
Low-GI Long-Grain rice, Brown, SunRice	54	Low

This is only a snapshot, but it indicates that there’s quite a difference in how quickly the different rice types break down to glucose in our bloodstream. It’s also worth bearing in mind that the longer you cook any rice the higher it’s GI rating will become, so try to keep it tender, not mushy.

What makes these rices different in GI is the type of starches they contain combined with the shape of the grains. The two main starches found in rice varieties are amylose and amylopectin. Wikipedia explains that high-amylose varieties of rice, the less sticky long-grain rice, have a much lower glycemic load. It’s to do with the chemical structure of the starches.

Nutritionally rice is mostly starch (80-90%). This snip from Wikipedia shows the nutritional content of Rice, white, long-grain, raw, and demonstrates that it doesn’t add a whole lot of nutrients to our meals other than carbohydrate.

By keeping your portion sizes reasonable, consuming protein foods and vegetables with your rice meal will add nutrients and lower the overall GI of the meal.

And dishes that you’ve previously always used rice in can be nutritionally enhanced by swapping in other forms of more nutritious grains such as barley, quinoa and cracked wheat. Why not do an experiment and try some swaps out for yourself? One of my dietitian colleagues makes her sushi with quinoa, and barley risotto is amazing! Here’s a recipe from Taste.com.au for it.

One trick with rice is to combine it with other grains for added fibre and nutrients and to further lower the glycemic index and improve that nutritional profile.

Fortunately more and more options are available to us.

The Australian company, SunRice, has a great range of ‘Health & Wellbeing’ rices and rice blends that you may like to consider trying.

And Coles also has recently launched some similar products that are all high in fibre and have a low glycemic index too. The varieties available are:

Brown Rice and Quinoa
Brown Rice and Chia seeds
7 Ancient Grains – a combination of brown rice, green lentils, millet, quinoa, sorghum, amaranth and chia seeds (the highest fibre variety).

These microwaveable packs usually contain 2 serves per pack. You should check the Total Carb per Serve column to check how many carb serves a ‘serve’ contains. It’s usually about two. They’re very convenient quality carb options to keep in your pantry.

Resistant starch

Just a reminder while we’re on the subject of starches, that cooked and cooled starches develop a crystalline structure which makes them resistant to digestion (hence their name) which lowers their glycemic index. So adding cooked and cooled rice to your salads is a great way of adding a serve or two of low-GI carbs to your meal to help manage your blood glucose levels and provide the many benefits associated with including low-GI carbs in each meal. The theory of resistant starch goes that if the starch resists digestion it will end up in the large bowel to feed the good bacteria which in turn improve our immunity and overall wellbeing. You can read more in the blog on fibre if you’re interested.

So I hope you learned how to make rice work better for you. Please let us know if you have any questions. Sally

Sally is the Social Media Dietitian with Diabetes Counselling Online, owner of her private practice (Marchini Nutrition), and has had type 1 diabetes for close to 40 years and coeliac disease for many years too. You can access a linked list of all Sally’s Diabetes Counselling Online blogs here.

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Hypoglycaemia at School

January 7, 2015 by Imagine_David Leave a Comment

Children of all ages require a safe and effective plan for those times when not under their parents supervision

‘Hypo’ or a low blood glucose level is one of the fears for all people living with diabetes.

A low blood glucose level will often occur unexpectedly, sometimes without an obvious cause.

For the child with diabetes, a low blood glucose level may lead to loss of concentration and behaviour change – possibly disruptive behaviours.

Talk to your child’s school about diabetes to help your child attain an education without discrimination

Education and Care Services National Act and Regulations: Australia

“In January 2012 new national legislation (Education and Care Services National Act and Regulations) requires a type 1 diabetes policy for all services providing or intending to provide education and care on a regular basis to children under the age of 13 years. This includes outside school hours programs. More information on the medical conditions section of this legislation can be found on the Australian Children’s Education and Care Authority website http://www.acecqa.gov.au/national-regulations” from HERE (Diabetes Australia Victoria)

As a parent of a child living with diabetes it is in your best interest to communicate with the headmaster of your childs school before or at enrolment

Duty of Care

Schools have a legal responsibility to provide:

a safe environment
adequate supervision

When the school knows that certain students have diabetes, staff (including relief staff) need to know enough about diabetes to ensure the safety of those students (especially in regard to hypoglycaemia and safety in sport). Parents/guardians have a responsibility to advise the school of their child’s medical condition and the particular requirements for the management of their child’s diabetes. For children with special requirements, a written individual management plan incorporating medical recommendations should be developed with the school in collaboration with the parents/guardians and doctor. This should be attached to the student’s records. from Diabetes Australia

Hypoglycaemia Symptoms

A very good multimedia presentation from the Royal Childrens Hospital, Melbourne, can be found HERE

Managing Hypo

Managing hypoglycaemia

Hypoglycaemia (“Hypo”) means a low level of glucose in the blood. This is a blood glucose value of less than 4.0 mmol/L.

Hypoglycaemia can be caused by:

Too much insulin
Vigorous exercise without extra carbohydrate
Missing or delayed meals
Not eating all serves of carbohydrate
Alcohol intake

If you would like to share, or debrief, about your experiences please visit our Forum or Facebook

Research

“The management of type 1 diabetes in Australian Primary Schools” by Diabetes Nurse Practitioner, Associate Lecturer UWS Anne Marks HERE

Children using insulin pump therapy were more likely (97%) to receive insulin at school than children using injections (55%)
Children in the study who were able to self-administer insulin were more likely to receive insulin (93%) at school than children who were unable to self-administer insulin (65%)

Parent Concerns:

62% reported that they had current concerns about diabetes management at school

Difficulty participating in school activities

Inclusion at meal times

Lack of independence

Missing school, classroom activities or time with peers

Safety

Lack of staff to assist with care

Impact on parental employment

Increased workload of teachers who are willing to assist with care

Other Resources

Helping the Student with Diabetes to Succeed

sample-emergency-care-plans-for-hypoglycemia-and-hyperglycemia-508

Kind Regards,

David, Diabetes Educator @ Diabetes Counselling Online

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Diabetes and Hearing Loss

December 23, 2014 by Imagine_David Leave a Comment

**Some evidence shows people living with diabetes are at an increased risk of some level of hearing loss**

As people living with diabetes are at a greater risk of developing hearing loss, audiological tests to monitor auditory (hearing) function should be introduced into comprehensive packages of care provided by diabetes services.

The American Diabetes Association report, ‘Standards of medical care in diabetes – 2014’ recommends that hearing impairment be assessed and addressed as one of the common comorbid conditions that may complicate the management of diabetes.

The Australian RCGP Microvascular disease risks does not includehearing loss as a risk

Renal (kidney) impairment and CKD
Neuropathy (nerve damage)– peripheral, autonomic
Retinopathy (damage to the eye) more HEAR

Further research and evidence-based outcomes may support the introduction of indicators to identify hearing difficulties in the diabetes population. More HEAR

In one research paper, sensorineural hearing loss was more common in people living with diabetes than in the control nondiabetic patients, and severity of hearing loss seemed to correlate with progression of disease as reflected in serum creatinine. This may have been due to microangiopathic (small blood vessel) disease in the inner ear.

A review of the literature by these authors, and their study, suggests a moderate link between poor blood glucose control and progression of hearing loss.

Because audiologic data from patients with diabetes not experiencing hearing loss was not available, the exact impact of diabetes on hearing loss is still not clear.

However, this study does demonstrate that data mining can be used to identify poorly defined disease relationships and suggests that screening all patients with diabetes for hearing loss in a prospective manner may be useful for a clearer understanding of this disease process. More HEAR

Don't wait for your wheels to fall off..... talk to your doctor about having your hearing tested — ***Don’t wait for your wheels to fall off….. talk to your doctor about having your hearing tested***

The American Speech Language and Hearing Association comments that “building epidemiological evidence depends on a robust definition of a condition, so that results can be compared across studies.

For hearing impairment, however, no definitive definition has been established. Recently, using audiometric data from the National Health and Nutrition Examination Study, investigators evaluated hearing impairment using high-frequency (3000-, 4000-, 6000-, and 8000-Hz) as well as low- or middle-frequency (500-, 1000-, and 2000-Hz) averages, at two levels of severity (>25 and >40 dB HL), in both the worse and better ear (Bainbridge, Hoffman, & Cowie, 2008).

The results demonstrated that the prevalence of hearing impairment depends on how the condition is defined, but a greater prevalence of hearing impairment was observed among adults with diagnosed diabetes than without, regardless of the definition used”

**Talk to your doctor about having your hearing tested**

The data also suggest that people living with diabetes may experience hearing loss at earlier ages.

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Sleep & Diabetes

December 17, 2014 by Imagine_David Leave a Comment

“I slept so badly last night; I simply have no energy to exercise.” — **“I slept so badly last night; I simply have no energy to function.”**

How are you sleeping at night? All too often, the answer is the same: not well.

Diabetes and sleep problems often go hand in hand. Diabetes can cause sleep loss, and there’s evidence that not sleeping well can increase the risk of developing diabetes.

Symptoms

Symptoms associated with insufficient sleep include feeling tired, irritability, slurred speech, blurred vision, memory loss, inability to concentrate, episodes of confusion, hallucinations, nausea, impotence and reduced sexual drive. Extreme sleep deprivation can cause psychosis and death. However, there are no documented cases of a healthy human dying from sleep deprivation (although mortality from accidents does occur). Before death occurs in healthy, sleep-deprived humans, the brain forces itself to have ‘micro-sleeps’.

Evidence

In the past decade, there has been growing evidence that too little sleep can affect hormones and metabolism in ways that promote diabetes.

Current data suggests that the relationship between sleep restriction, weight gain and diabetes risk may involve at least three pathways: 1. alterations in glucose metabolism; 2. upregulation of appetite; 3. decreased energy expenditure. from The Metabolic Consequences of Sleep Deprivation

A 1999 Lancet study at the University of Chicago – the researchers monitored the blood glucose levels of 11 healthy young men who were allowed only four hours of sleep per night — from 1 a.m. to 5 a.m. — for six nights.

That study showed that after only a week of short bedtimes, their glucose tolerance was impaired. There could be dramatic effects even after only a week.

After 6 nights of little sleep, the men had higher-than-normal blood glucose levels. (The levels were not high enough to be diagnosed as diabetes, however). The effects went away once the men were back on their normal sleep schedule.

Experts also believe that chronic sleep deprivation may lead to elevated levels of the stress hormone, cortisol. Elevated cortisol may in turn promote insulin resistance, in which the body can’t use the hormone insulin properly to help move glucose into cells for energy.

Low Sleep = High Blood Sugar?

High blood glucose level is a red flag for sleep problems among people with diabetes.

Diabetes and sleep problems often go hand in hand. Diabetes can cause sleep loss.

If the blood glucose level is high the kidneys want to pass this excess glucose out in the urine. Getting up to pee in the middle of the night disturbs the sleep.

People who are tired will eat more because they want to get energy from somewhere. That may mean over-eating during the day > higher blood glucose level at night> getting up to pee>poor sleep etc etc.

Eating well throughout the day – having a safe and effective diabetes self care plan – to have your blood glucose level on target may have you be able to sleep better at night.

Low Sleep = Low Blood Sugar?

Conversely, having a hypo during the night is likely to wake you and destabilise your sleep.

A wise action to take would be to measure your blood glucose level occasionally at 2-3 am in order to exclude overnight hypoglycaemia.

The Link Between Lack of Sleep and Weight

Some studies show that people who get less sleep tend to be heavier than those who sleep well. People who are tired will eat more because they want to get energy from somewhere. That may mean over-eating during the day > higher blood glucose level at night> getting up to pee>poor sleep etc etc.

Sleep loss could also affect energy expenditure via its impact on the levels of leptin and ghrelin. Since several human studies have demonstrated reduced levels of leptin after sleep loss, it is possible that the reduction in leptin is associated with a reduction in energy expenditure. Similarly, the increase in ghrelin after partial sleep restriction could be associated with a decrease in NEAT (Non-exercise activity thermogenesis). *Experimental evidence is currently lacking to support either hypothesis*

Sleep Apnea?

There is also a link between diabetes and sleep apnea, a sleep disorder marked by loud snoring and pauses in breathing while you sleep. The culprit may be excess weight, which can cause fat deposits around the upper airway that obstruct breathing. So being overweight or obese is a risk factor for sleep apnea as well as diabetes.

If you have diabetes, are overweight, and snore, tell your doctor. You may need a sleep study.

Sleep apnea can prevent a person from getting a good night sleep, which can worsen diabetes. In sleep studies, you are monitored while you sleep for sleep disorders such sleep apnea.

There are many effective treatments for sleep apnea. These include lifestyle changes such as weight loss for mild cases and devices to open up blocked airways for more significant cases.

Sleep: How Important?

In general, people living with diabetes have to be very careful about sleep. Anything that throws off your routine can make you feel a lack of energy and fatigue. The more fatigued you feel, the more your motor is running, and the more likely you are to develop insulin deficiencies.

How Much Sleep?

On average, we need 7.5 hours per night, but your sleep requirement is genetically determined and varies.

It can be about four hours on the short end to 10 or 11 on the long end.

Want to know if you are sleep-deprived? The answer is simple…..If you use an alarm clock, you are. If you were getting adequate sleep, your brain would awaken you before the alarm goes off.

HELP

Improve your sleep habits: SNORE Australia

MJA (Medical Journal of Australia) Sleep Disorder Supplement

Australasian Sleep Association

So, turn off your electronic device…. and go get some sleep!

Kind Regards,

David,

Diabetes Educator @ Diabetes Counselling Online

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