20 things I hate about diabetes

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couple hands

bgl rouletteSometimes I get sick of telling people that their diabetes will be ok, and they will be ok, and everything will be ok. Not because I don’t believe that to be true, I do. I think everything WILL be ok. But damn it, diabetes is NOT always ok. I am exhausted at the moment- are you? It is that whole end of year , nearly at Christmas, we can see the finish line thing.

My 6 year old Maxwell got up today and fell asleep on the couch for a minute or two, and then jumped awake shouting, “I wasn’t asleep!”He gets that from his Dad. :)

And my 15 year old couldn’t manage day 4 of work experience. I know his problem.

The thing is, not only am I exhausted from working bloody hard and sleeping very little all year. I am exhausted from managing diabetes. Do you know what I mean? It has NOT been ok. I have had swings from highs to lows and sudden hypos that freaked me out and stubborn highs. My gut problems from gastroparesis continue to play with me. And some days lately I have felt like maybe it WON’T be ok…..

So here are 20 things I hate about diabetes (coz we all have to get this crap out sometimes – try it, it helps!) Feel free to share and comment if you feel the same or want to add to the list

1) It’s so damn unpredictable and never ending

2) Finding spots for finger pricks after 35 years and up to 20 tests a day is pretty hard – you should see my fingers, they are a mess…..

3) There are no perfectly 100 % accurate blood glucose monitors and do you KNOW how much difference a 1 or 2 mmol reading can make to some of us with type 1??

4) My skin is stuffed and finding sites for my pump continues to be a delight of each and every day

5) Hypos, especially sudden ones where I go under 3 mmol freak me out

6) Hypers, especially unexpected ones where I go over 16 mmol freak me out

7) People ask me all the time in airports to “take the pager off” as I go through the scanner

8) It is exhausting

9) The general public don’t get it. They think it is simple.

10) It has damaged areas of my body that I am terrified will just get worse…

11) Exercise is a debacle, you need a PhD and even then your theories will be challenged every time you go out for a run

12) There is no spontaneity

13) Leaving home to go out involves lugging a suitcase with you

14) Carbs Carbs Carbs you are such a challenge – can’t live with em, can’t live without em

15) I worry that my children will get diabetes

16) I worry about losing my blood machine or breaking my pump, or forgetting to put it on after a shower – being reliant on machines to keep you alive is stressful

17) It costs a LOT and we should have a concession card- all of our lives

18) It keeps me awake at night- sometimes sitting up to make sure my levels are not too high or too low before going to sleep

19) All the “I quit sugar” people give me the shits

20) It is for life. It isn’t going anywhere fast. The promised cures never come. This is IT.

Rant over.

Oh and you know it WILL be ok. It always is in the end. But sometimes you just gotta get this stuff out. If you are feeling like me- please comment and share. You will feel better trust me and at least we know we are all in it together next time you are sitting up at night, or screaming at your blood glucose machine.

Helen

xx

Helen Edwards has lived with type 1 diabetes since 1979. She is Mum to 3 sons, the founder of Diabetes Counselling Online, a diabetes educator, social worker and PhD Candidate studying diabetes distress in pregnancy for women with type 1 diabetes. She is also a successful Interiors Blogger and Stylist at www.recycledinteriors.org and runs creative workshops, an online store and studio in Adelaide – just for a life outside of diabetes.

 

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Blood Glucose Level in Hospital

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Teamwork ....will get you everywhere ... especially home sooner from hospital

Australian Diabetes Society (ADS) produced the document ‘Guidelines for Routine Glucose Control in Hospital 2012‘

In hospital different situations require specialist guidance
In hospital different situations require specialist guidance

The aim of this document is to provide guidance for the management of hyperglycaemia in a range of hospital situations.

As a people living with diabetes you an use this guide to ask about your care when admitted to hospital, or as a part of your sick day management plan (in the event of an urgent hospital admission).

The ADS has focused on the management of hyperglycaemia in people with myocardial infarction and stroke, on general hospital wards, and other matters they may be admitted to hospital with.

The optimal means of achieving tight blood glucose management, the role of the specialist inpatient diabetes team, inpatient management of insulin pump therapy, and general measures for diabetes management have also been examined.

The document also provides guidance for the follow‐up of people who have been newly discovered hyperglycaemia.

The recommendations were based on evidence obtained from systematic reviews where trials had been performed; otherwise they were made by consensus.

 

What Glucose Target Should be Aimed for in Acute Myocardial Infarction (heart attack)?

Studies indicate that persistent hyperglycaemia, even if mild, is also associated with increased mortality following myocardial infarction.

Recommendations and Practice Points

  1. Patients admitted to hospital with myocardial infarction who have hyperglycaemia, should be treated to achieve and maintain glucose levels less than 10 mmol/L.
  2. Hypoglycaemia must be avoided. It would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.
  3. Insulin infusion therapy may allow for tighter targets but this requires frequent monitoring and high level staff training.

What Glucose Target Should be Aimed for in Acute Stroke

Recommendations and Practice Points

  1. Patients admitted to hospital with acute thrombotic stroke who have hyperglycaemia, should be treated to achieve and maintain glucose levels less than 10 mmol/L.
  2. Hypoglycaemia must be avoided, and therefore it would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.

What are Appropriate Glucose Targets for Patients in General Hospital Wards?

Recommendations and Practice Points

  1. Most patients in general hospital wards with hyperglycaemia should be treated to achieve and maintain glucose levels less than 10 mmol/L.
  2. Hypoglycaemia must be avoided. It would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.
  3. To achieve tight glucose control safely, frequent glucose monitoring is recommended
Is the hospital diabetes plan complete, holistic?
Is the hospital diabetes plan complete, holistic?

How is Steroid‐Induced Hyperglycaemia Best Managed?

Recommendations and Practice Points

  1. In patients receiving glucocorticoids, undiagnosed diabetes should be excluded. Those free of diabetes should be screened for the development of hyperglycaemia by random blood glucose monitoring performed in the afternoon following morning administration of GC.
  2. Hyperglycaemia is best managed with insulin: basal insulin as isophane type insulin, and rapid acting analogue with meals as required.
  3. In individuals already on insulin the likely need for increased insulin should be recognised. Dose requirements need to be individualised and require daily review.

What is the Optimal Means of Achieving and Maintaining Glycaemic Control in Hospitalised Patients who are not Critically Ill?

Recommendations and Practice Points

  1. Sliding scale insulin should not be used to optimise glucose control in the inpatient general medical or surgical setting.
  2. Oral hypoglycaemic agents or pre‐mixed insulin can be used in certain stable hospitalised patients who are eating regularly. Supplemental insulin should be written up in addition.
  3. Insulin therapy in hospitalised patients should otherwise consist of a basal insulin, prandial and supplemental insulin. **Effective use of basal bolus insulin requires frequent and regular blood glucose monitoring (at least 4 and preferably 6‐8 times daily)

How Should Patients on Insulin Pump Therapy be Managed in Hospital?

Recommendations and Practice Points

  1. In general, CSII should be continued in hospital where the patient can competently and safely self-manage the pump and self‐dosing.
  2. Details of pump therapy should be documented, and supported by the endocrine team
  3. CSII may be continued for short operative procedures if those responsible for the patient’s intraoperative care are comfortable with its use.

 

What is the Role of a Specialist Inpatient Diabetes Team?

Consultant Service.

The traditional hospital model of care, whereby specialised diabetes services are invited, at the discretion of the admitting team, to assist with specific patients’ diabetes management.

There is no evidence that improving this model has resulted in any substantial benefits. Anecdotal evidence suggests that this is akin to “shutting the gate once the horse has bolted”.

Systematic Hospital‐wide Diabetes Programme

These programmes aim to improve the identification of patients with diabetes and to enhance the diabetes management skills of all staff, by education and implementation of diabetes management and prescription guidelines. The responsibility of managing the patient’s diabetes remains with the admitting team.

The evidence supporting such an institution‐wide approach in improving diabetes‐related outcomes is limited to one comparative study162 which demonstrated a reduction in length of stay of 1.8 days for patients with primary diabetes following the intervention.

Specialist Diabetes Inpatient Management Team

This involves a multidisciplinary team approach, with the role of the Inpatient Diabetes Management Team varying from an advisory function to active management of the patient’s diabetes, for all patients with diabetes and usually commences at the time of the patient’s admission.

Several comparative trials (4‐9) have shown reductions in ALOS of 0.26‐5.6 days following intervention by an inpatient diabetes management team, primarily involving a specialist diabetes nurse (some with prescribing capabilities).

# Diabetes inpatient specialist nurse service: Mean excess bed days for diabetes admissions reduced from 1.9 days to 1.2 days after introduction of the service.

# Diabetes Specialist Nurse with prescribing rights: Reduction in medication errors from median 6 to 4 (p<0.01); Reduction in Length Of Stay from median from 9 to 7 days (p<0.05)

#Endocrinologist, diabetes nurse specialist, junior doctor: Reduction in average Length Of Stay for all patients with diabetes from 9.39 to 3.76 days.

role-of-health-care-professionals-in-hospitla
Click to enlarge

*****Want to get out of hospital asap – ask to see a member of the diabetes inpatient management team*****

For more detail in this document go HERE

How has your experience of hospital admissions effected the way you manage your diabetes at home? Or during subsequent hospital admissions?

Kind Regards,

David

Diabetes Educator @ Diabetes Counselling Online

 

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“I forgot to measure my BGL ….. “

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Exercise: you may find your blood glucose level has gone up immediately following exercise.

Do you use your blood glucose level meter like a compass, giving you some direction with your diabetes self care plan?

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So, is missing an occasional blood glucose level a problem?

At a meeting of diabetes health care professional specialists a few years ago I met an endocrinologist specialising in the diabetes management of young people living with diabetes. This specialist stated that she didn’t really mind if her patients measured their blood glucose level between visits…… except for the 2 weeks immediately prior to the visit. For these measurements were the current ones – that bgls that she would base any treatment changes on.

Testing

Among other things, a measured pattern of your blood glucose levels will help you to:

Develop confidence in your diabetes self care plan

Develop a improved understand of the relationship between your blood glucose levels the factors that effect them: e.g. physical activity, food you eat, stress and illness.

Explore if your diabetes medication, if used, is safe and effective in helping you reach your blood glucose level targets.

Assess in critical situations if your blood glucose levels are in the extremes and require immediate management

Your meal choices are ONLY one factor that will effect your blood glucose level
Your meal choices are ONLY one factor that will effect your blood glucose level

Frequency

For any individual with diabetes, personalised education by qualified and experienced health care professionals in appropriate blood glucose targets and timing of SMBG, interpretation of documented SMBG serial profiles and trends across and between days, is essential.

Suggested patterns of testing could be :

1) You may test before and 2 hours after meals on 3-4 consecutive days to establish your current pattern. If you identify that your blood glucose levels are off target, more testing maybe required in order to make appropriate adjustments to your diabetes self care plan.

2) For people with type 2 diabetes – You test once per day moving the test each day forwards by one appropriate time e.g Monday before breakfast, Tuedsay after breakfast, Wednesday after lunch, Thurdsay after dinner, Friday before breakfast and so on. After a few weeks you can then assess the pattern.

3) Before and after a new meal: this will give you some idea of how your body is adjusting to this new meal. You may have changed the type of food you eat, or the volume of the carbohydrate in your meal based on advice from your dietitian.

4) Before, after, during exercise: assessing your risk of hypoglycaemia and your bodies reaction to the exercise.

Exercise: you may find your blood glucose level has gone up immediately following exercise.
Exercise: you may find your blood glucose level has gone up immediately following exercise.

If your bgls are on target you may the test less frequently, or/and only when you are thinking you may be hypoglycaemia or sick.

*For people with type 1 diabetes, avoiding DKA is essential when sick – in this situation follow your sick day plan.*

What’s Recommended?

Blood glucose targets: from HERE – Australasian Paediatric Endorcine Group, 2011

For adults in the intensively treated group of the DCCT, blood glucose targets were:

  • Before meals 3.9 to 6.7 mmol/L
  • After meals 5 to 10 mmol/L
  • At 3am (weekly) above 3.6 mmol/L

For young people with type 1 diabetes, targets are (Ambler and Cameron 2010):

  • Before meals 4 to 7 mmol/L
  • After meals 5 to 10 mmol/L
  • At bed time 6 to 10 mmol/L
  • At 3am 5 to 8mmol/L

Blood glucose targets may be set higher for infants and young children:

  • Before meals 5 to 10 mmol/L
  • After meals 6 to 10 mmol/L
  • At bed time 6 to 12 mmol/L
** It is emphasised that blood glucose targets need to be individualised for each person with type 1 diabetes. Clinical trials targeting intensive blood glucose control such as the DCCT typically exclude people at highest risk of severe hypoglycaemia, with advanced end‐stage diabetes complications, with poor adherence to therapy or with major intercurrent medical conditions (DCCT Research Group 1993). The average duration of diabetes was only 2.6 years at study entry in the intensive treatment arm of the DCCT, for the average 6.5 years’ study duration. Thus, the DCCT and EDIC mainly examined the importance of tight glycaemic control in the first 10 years after diabetes diagnosis. In contrast, glycaemic control typically becomes more difficult to achieve safely with increasing diabetes duration of, and both a lack of hypoglycaemia awareness and severe hypoglycaemia become increasingly common.

“A 2012 Cochrane review75 on the effect of SMBG in patients with type 2 diabetes not using insulin found limited clinical benefit as measured by HbA1c from SMBG and no evidence that SMBG affects patient satisfaction, general wellbeing or general health-related quality of life.

Self-monitoring is usually recommended:

  • for patients on insulin and oral hypoglycaemic agents (OHAs) that can cause hypoglycaemia
  • when monitoring hyperglycaemia arising from illness
  • with pregnancy, as well as pre-pregnancy planning
  • when changes in treatment, lifestyle or other conditions requires data on glycaemic patterns
  • when HbA1c estimations are unreliable (e.g. haemoglobinopathies).

The method and frequency of monitoring need to reflect individual circumstances and therapeutic aims and where the person with diabetes and their healthcare providers have the knowledge, skills and willingness to incorporate self monitoring of blood glucose levels and therapy adjustments into diabetes care plans.

In practice

Recommendations Reference Grade*
Blood glucose control should be optimised because of its beneficial effects on the development and progression of microvascular complications (71)
NHMRC, 2009		 A
The potential harmful effects of optimising blood glucose control in people with type 2 diabetes should be considered when setting individual glycaemic targets (71)
NHMRC, 2009		 A
The general HbA1c target in people with type 2 diabetes is ≤7% (≤53 mmol/mol). Adjustments to diabetes treatment should be considered when HbA1c is above this level (71)
NHMRC, 2009		 A
Targets for SMBG levels are 6–8 mmol/L fasting and pre-prandial, and 6–10 mmol/L 2 h postprandial (71)
NHMRC, 2009		 C

” from HERE – RACGP General Practice management of type 2 diabetes 2014-15

Goals

What are your goals? For most people goals are very ‘soft’ e.g “I want normal blood glucose level’s”

Something more specific may be “I want to avoid hypoglycaemia” or “I don’t want any blood glucose levels over 15 mmols”

You may want to consider how to write effective goals that are specific and time limited. For example:

“In the next 3 months, (between now and my next HbA1c test) I shall measure my blood glucose level every week for 3 days when I wake up, and also before and after each meal. If my bgls are over target I shall test daily for a week and show the results to my GP”

Missing an occasional test is not going to change this goal. The more information you can provide to yourself the more likely it is that your diabetes self care plan will be safe and effective.

 

Regular assessment of your blood glucose level can help you with your quality of life
Regular assessment of your blood glucose level can help you with your quality of life

Kind Regards,

David

Diabetes Educator @ Diabetes Counselling Online

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A fresh look at The Christmas Meal

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xmas table

My family celebrated Christmas Day a month early this year because we’ll all be in different parts of the world on 25th December, and we value our annual family get together. I thought it was a good opportunity to remind you how easy it is to provide a delicious and nutritious lunch, especially for us in Australia with the hot weather, that won’t disrupt your usual diabetes routine too much whilst still enjoying your Christmas celebrations. I’ve also included a few of our family recipes for your enjoyment. :)

Ours was held at my brother’s home in Sydney. We had 20 family members expected, including 7 children under the age of 14. Our Christmas foods tradition follows a Red, White and Green theme to look Christmassy. My Mum is the organiser and she delegates one dish to each of the family groups, so not all the preparation and cooking is left to one person (although you’ll notice that she does more than her own fair share!). Sharing that load really does minimise the stress often associated with these large family gatherings.

Xmas 2014 table decorations

The basic idea is to include more plant-based foods, and provide a treat or two that you save for these such special occasions.

We arrived to bowls of pistachio nuts – perfect as each nut must be opened first, thereby minimising overeating potential – and olives. Perfect with a glass of bubbly to get us all in the mood for our Christmas feast ahead! :)

First course are the cold green and red soups.

I made the green zucchini soup which is so easy (6 zucchini, 1 onion lightly sautéed. Add 1 litre chicken stock, one chopped potato and some fresh dried tarragon with salt and pepper to taste. Simmer for 15 mins or until potato is cooked through. Allow to cool. Blend and refrigerate).

zucchini soup cooking

One of my Sister-in-laws made the red tomato gazpacho which is just pureed tomatoes with an onion/ lemon juice flavour added, plus diced cucumber and ham (from the main event).

Both these soups are very popular across the whole family. The children tend to love the zucchini soup the best. I like to indulge in a small bowl of both so I can enjoy both yummy flavours.

Buffet in the kitchen.

Our centre piece is a whole ham that my Mum makes a glaze for and bakes. It’s served at room temperature as there usually no room in the fridge, and that’s where the salt comes into its own as a preservative until there’s room to get it into the refrigerator.

whole glazed ham

Of course, the ham in your meal could be replaced with any protein source that you and your family enjoy including the traditional favourites of turkey and seafood.

Traditionally we’ve had cold baby potatoes tossed in fresh herbs and olive oil for our carb salad (excellent for resistant starch and glycemic management), however this year Mum found a recipe for a quinoa and cannellini bean salad that was also full of fresh herbs. It was very delicious, but also more work than the potatoes.

Quinoa and canellini bean salad

Then the non-starchy salads – we have a tomato salad, a green avocado salad and asparagus with parmesan, so there are plenty of plant foods to fill up on.

avocado green saladasparagus and parmesan

tomato christmas salad

This year Mum found an unusual tomato recipe that had pomegranate seeds and lots of fresh herbs. Again it was very delicious but I think she underestimated how long it would take to dice up all those coloured tomatoes. It was flavoured with lots of chopped garlic, fresh herbs and olive oil. Usually we do sliced beefsteak tomatoes with mozzarella cheese and fresh basil leaves on top, drizzled with extra virgin olive oil. I don’t think you can beat that one for simplicity and flavour!

Desserts

We don’t really enjoy the richness of the traditional Christmas desserts in our family. This year another of my Sister-in-laws and one of my Aunts were asked to bring a dessert with no guidelines so we ended up with a pavlova topped with lovely fresh fruit, and a light lemon ricotta cheesecake that my Sister-in-Law found on a blog called ‘Marley & Lockyer’ with you as it’s so easy and suitable for us with diabetes.

Source: Marley & Lockyer blog
Source: Marley & Lockyer blog

We served ours with low-fat icecream, but you could also use low-fat Greek yogurt rather than cream.

For those of you who really enjoy the Christmas puddings and mince pies, the December 2014 issue of Australian Healthy Food Guide magazine included a feature called ’10 of the best Christmas treats – enjoy your favourite sweets for fewer kJs!’ which I encourage you to read. In there they rate the ‘Best Mince Pie’ as a bite-size Woolworths Free From Gluten Fruit Mince Bit as a ‘real taste of Christmas’ for only 522kJ (125cal).

Reminders

I hope you found some healthy inspirations here for your Christmas main meal. I’d remind you to have a read of the blog I wrote for Diabetes Counselling Online entitled ‘Five tips for managing diabetes at events where food choices are likely to be poor’ and remember these tips when you’re at your own Christmas food celebration.

Healthy Eating Plate

I’d also encourage others of you to share your own healthy and special favourite Christmas dishes in the comments below please!

Wishing you all compliments of the season with a reminder about enjoying everything in moderation, except the love and goodwill that we can all enjoy in excess across the Christmas season. 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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Basal Bolus Insulin: Is It For You?

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"Now I have started insulin I feel like exercising; I have so much more energy"

“Almost all patients with type 2 diabetes will eventually fail to respond adequately to oral hypoglycaemic drugs and will require insulin therapy. A regimen of bedtime intermediate-acting insulin in combination with daytime oral drugs is acceptable to patients, simple to start and results in rapid improvement in glycaemic control. It can be started safely in general practice and is the most practical way of implementing insulin in the face of a worldwide epidemic of type 2 diabetes.” Source HERE

 

A basal-bolus injection regimen involves taking a number of injections through the day. If you are using a mixed insulin twice a day, did you realise that you are injecting 4 does of insulin?

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“My life is so much more social since I started on a basal bolus regimen”

A basal-bolus regimen, which includes an injection at each meal, attempts to roughly emulate how a non-diabetic person’s body delivers insulin.

That is, the normal response of the body when carbohydrates are ingested is for the pancreas to produce and release insulin into the blood stream so that the glucose can be shifted into the muscle tissue for use as a source of fuel. See Link for Life: Insulin

A basal-bolus regimen may be applicable to people with type 1 and type 2 diabetes.

"My days are irregular, this might be just what I need"
“My days are irregular, this might be just what I need”

What is a basal-bolus insulin regimen?

A basal-bolus routine involves taking a 1) longer acting form of insulin in an attempt to keep blood glucose levels on target through periods of fasting and 2) separate injections of shorter acting insulin to manage meals.

What is basal insulin?

The role of basal insulin, sometimes refrred to as ‘background’ insulin, is aimed at keeping blood glucose levels at steady levels during periods of fasting.

When fasting (time when not eating e.g. overnight or between meals), the liver releases glucose into the blood and into our bloodstream, with a purpose of fueling our body’s cells.

Basal insulin is therefore used to help keep blood glucose levels on target, and to allow the cells to take in the glucose released by the liver for energy. Basal insulin is usually taken once or twice a day depending on the insulin.

Basal insulin acts over a relatively long period of time – usually between 12 and 24 hours.

If you are an Australian resident you can obtain FREE diabetes counselling and education HERE

What is bolus insulin?

A bolus dose is insulin that is usually taken immediately before a meal in an attempt to keep blood glucose levels on target following a meal. Bolus insulin needs to act rapidly as the meal starts to be digested. The actions of these type of insulin is usually a) it starts working to lower the bgl within 15 minutes of being injected – mimicking the role of the pancreas for people without diabetes b) last in duration for between 2-4 hours.

Bolus insulin is most often taken before meals, but it is also possible to take some during or just after a meal if the appetite is hindered by illness or e.g. the inability to predict the meals carb content if eating out.

If you think that this type of insulin regimen is for you, then talk to your diabetes educator or endocrinologist about the pros and cons for you.

Some of the advantages of a basal-bolus regimen

  • One of the main advantages of a basal-bolus regimen is that it allows you to fairly closely match how your own body would release insulin if it was able to.
  • It can allow you to give less insulin over the course of the day relative to a mixed dose of insulin.
  • It may assist with weight management.
  • If your day is irregular or you work shifts, this regimen may be helpful for you.
  • If you like to count our carbs and eat different amounts of carbs relative to your situation, appetite and time restraints

Disadvantages of a basal-bolus regimen

  • One notable disadvantage is that a basal-bolus regimen involves taking more insulin injections each day.
  • This may prove problematic for some people more than others.

everything-is-possible-2

Have you asked yourself how you can improve your diabetes self care plan with your medication?

Talking to your doctor or diabetes educator about this type of insulin use may be just the thing you need.

“…..once insulin therapy is started, a plan needs to be in place for the appropriate adjustment of insulin”

More information ca be found HERE & HERE & HERE

 

Kind Regards,

David

Diabetes Educator @ Diabetes Counselling Online

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