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Diabetic Keto-acidosis

September 18, 2014 by Imagine_David 2 Comments

Is the hospital diabetes plan complete, holistic?

Diabetic ketoacidosis (DKA) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death.

From the Intensive Care Unit of the Nepean Hospital Penrith NSW Australia: LINK: http://intensivecare.hsnet.nsw.gov.au/five/doc/education_packages/nepean/nepean_guide_DKA_2007.pdf

“Hyperglycaemic Emergencies derive from an absolute or relative insulin deficiency that leads to insufficient glucose uptake into the cells and concurrent breakdown of glycogen stores and new formation of glucose in the liver. Hyperglycaemic emergencies are life-threatening, and require immediate treatment in hospital, often with an admission to an intensive care unit (ICU)”

From The Royal Childrens Hospital, Melbourne:

“Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes.

All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l should have blood ketones tested. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available.

The biochemical criteria for DKA are:

Venous pH < 7.3 or bicarbonate <15 mmol/l
Presence of blood or urinary ketones

If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin” LINK: http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_Mellitus/

What is DKA? Simply….

When your cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones.

Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick.

High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2.

Treatment

Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly.

What are the Warning Signs of DKA?

DKA usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following:

Thirst or a very dry mouth
Frequent urination
High blood glucose (blood sugar) levels
High levels of ketones in the urine

Then, other symptoms appear:

Constantly feeling tired
Dry or flushed skin
Nausea, vomiting, or abdominal pain (Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting seek medical advice)
Difficulty breathing
Fruity odor on breath
A hard time paying attention, or confusion

Ketoacidosis (DKA) is dangerous and serious

If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital.

How Do I Check for Ketones?

Ideally you will be measuring your blood ketone level with strips similar to a blood testing strip. If unable to test you blood for ketones, test your urine.

Talk to your team and plan a sick day protocol: how often to test your blood for ketones if you are sick; when to go to hospital; etc.

Also, check for ketones when you have any symptoms of DKA.

What If I Find Higher-than-normal Levels of Ketones?

If your health care provider has not told you what levels of ketones are dangerous, then call when you find moderate amounts after more than one test. Often, your health care provider can tell you what to do over the phone. Sometimes this will help to keep you out of hospital. Sometimes it is the best thing to go to hospital. In any situation with ketones present, seek medical advice.

Call your health care provider at once if you experience the following conditions:

Your ketone tests show high levels of ketones.
Your ketone tests show high levels of ketones and your blood glucose level is high.
Your ketone tests show high levels of ketones and you have vomited.

Do NOT exercise when you have ketones and your blood glucose is high. High levels of ketones and high blood glucose levels can mean your diabetes is out of control.

Be Pro-active: Have a ‘sick day plan’ prepared before you need it. It may also be helpful to have a family member or friend be aware of your sick day plan.

What Causes DKA?

Here are three basic reasons for moderate or large amounts of ketones:

Not enough insulin Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness.
Not enough food When you’re sick, you often don’t feel like eating, sometimes resulting in high ketone levels. High levels may also occur when you miss a meal.

Hypo (low blood glucose) If testing shows high ketone levels in the morning, you may have had a hypo while asleep.

Hospital

Ideally, you will have a family member of friend with you who understands your diabetes well enough to be an advocate for you.

It may be an idea to have a small ‘hospital’ kit bag at home and at work. This bag can contain your plan for going to hospital: your sick day plan; names and numbers of support people; names and numbers of your usual health care team.

If you go to your local hospital with signs of keto-acidosis be prepared for health professionals who do not have a lot of experience with this situation. In hospitals there are a range of nurses and doctors: some with a good sound knowledge of diabetes, some with basic knowledge (and occasionally inaccurate knowldge) about diabetes.

Before you need it…

…make contact with your local hospital and request a copy of their DKA (Diabetic Keto-acidosis) policy / protocols.

Links to this type of document here:

http://www.chw.edu.au/about/policies/pdf/2008-8061.pdf

http://content.lib.utah.edu/utils/getfile/collection/ehsl-gradnu/id/74/filename/32.pdf

http://www.bimcmedicine.org/storage/files/pdfs/BIMC%20Adult%20DKA%20Protocol%202012.pdf

EMERGENCY ROOM

If you are familiar with the processes then you can ask for the staff looking after you when you arrive to follow their own hospital’s protocols.

It may be helpful to you also to take a printed copy and show the staff you have some knowledge of the correct thing to do.

On arriving at emergency ask these questions:

Would you please measure my ketones and BGL? I have type 1 diabetes and I am trying to avoid an intensive care admission. Before I left home my ketone level was….. My health care team (if you have one, give the name of your endocrinologist) advised me to come to emergency when my ketone levels reached….. or, if I gave (for example) 2 or more extra doses of inuslin at home and still had ketones present
Is it less expensive for the hospital to keep treat me here in emergency for a few hours than it is to end up sicker and in intensive care?
Could you please ask one of the endocrine team to assess me.
The names of the people who you see – and write them down.
If you feel that you are not being treated appropriately, ask firstly for the person in charge – usually the nurse unit manager (or most senior nurse on duty). If you are still not satisfied, then the next step is to ask for the contact details of the ‘client liaison officer’ or similar person who your complaint/s can be directed to.

Your health is of prime importance in this situation, which, as mentioned above can be life threatening.

Stay Safe: Plan Ahead

Regards,

David, Diabetes Educator @ Diabetes Counselling Online

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Juggling Wellness and Diabetes

September 15, 2014 by Sally Leave a Comment

I’m writing this personal kind of blog on a Saturday. I love Saturdays. They encompass lots of things I love to do which all contribute to my wellbeing. This morning I was out on my run and because it’s Saturday and lovely Spring weather lots of my neighbours were also out and about. Nearly everyone I ‘ran’ into made the comment about how well I looked. I had at least 3 such comments this morning and they inspired me to share with you what I believe to be the key to being well with diabetes, or what works for me anyway.

This is important to me because I have diabetes and I’m turning 50 next year, so I know that if I don’t focus on being well myself I’m in a higher risk group to lose my wellness that is so important to me. I want to do all I can to hold onto it for as long as I can, so I can enjoy more of this wonderful life. I’m also passionate about helping others to be well too to the best of their ability, so here goes!

Sleep

Every Saturday I get to sleep in. Yay! To catch up on a few hours I may have missed through the busy-ness of my week. Time to give my body a chance to repair and relax. I usually get to sleep in until around 8am, which is a big improvement on my 6-6.30am starts on other days of the week. The only thing that stops me from doing this is waking early with a hypo, but this morning my BGLs behaved themselves. This week I found an awesome article in The Conversation on the importance of sleep which I encourage you to read. It’s just so important for our wellbeing, and especially so for us with diabetes.

Eating Well

As a dietitian you would know that I am particularly passionate on this topic! This is the only topic in today’s blog that I’m qualified to talk about as a health professional, and it’s such an important one! The Australian Dietary Guidelines that we follow actually makes the comment, “Diet is arguably the single most important behavioural risk factor that can be improved to have a significant impact on health.” It is something that I think about, read up on and focus on every day.

Today I started with my fibre rich, low-GI and high nutrient breakfast, a combination of two cereals that enjoy eating together topped with skim milk. I had a banana for morning tea and a delicious bowl of vegetable and low-GI carb rich Minestrone soup. This afternoon I’ll probably have a snack of a handful of nuts and another piece of fruit. We have a delicious lean meat and vegetable rich stir-fry planned which we’ll serve with plain Basmati rice, and I’ve marked out my favourite Black Cherry yogurt for dessert.

I know that I’m getting the nutrients I need to be well each day, and I’m sure it must also reflect in my outward appearance when I’m out on my run, makeup free in my daggy running shorts too lol

Regular Exercise

Nice segway to the exercise! Also lots of evidence here to support wellbeing, reducing inflammation, improving mental health and keeping our BGLs more stable. You may know that I’m a golfer. I try to play 18 holes in a comp twice a week, and 9 holes if I have time as a break in my day on a Friday. On the days I’m not golfing I do my best to get in at least the minimum recommended 30 minutes of moderate physical activity. Usually I try for 45 minutes. Since I’ve been doing this I have noticed a big improvement in the stability of my glycemic control as my fitness has improved. It’s so worth the effort even when you don’t really feel like it!

Family Time/Love

I’m incredibly fortunate to have so much love and support from my family, but I guess it works both ways in that I also love and support them! I believe that love and giving love is an important part of wellbeing. We hug each other a lot in our household, and in the wider family too. Have you hugged someone today and told them you love them?

Being sociable

Although I was out on my run, I enjoy stopping along the way on a Saturday as I have more time available to me to chat with my lovely neighbours in the suburb I live in. I chat with the children, and the parents, and the older people, and the neighbours who are my friends. To me this is important as I feel loved within my community too, and I know that I’m helping some of these people to feel loved too <3

Hard Work

I enjoy working. It keeps my brain active. It gives me a purpose and keeps me inspired each day to stay well and make the most of my life. The lovely Helen Wilde called me a workaholic this week, which made me think. You know I probably am a workaholic, but that’s because I love what I do and it makes me happy to help other people to be well. But I honestly try very hard to keep a balance with the other important factors in my life.

For those of you who are lucky to be retired or not have to ‘work’ as such I would encourage some kind of volunteer role as it can really be so rewarding and contribute to your wellness. We have some awesome volunteers who help us out at Diabetes Counselling Online. You can read more about our team and some of our ambassadors here. They’re so important in making our charitable organisation what it is.

Keeping the Balance

Of course, being Saturday, I also have household chores to do, preparation cooking for the week ahead, and I might even fit in a quiet hour of reading a book. It’s always a good day, and means I really relax and enjoy myself on my day of rest (and golf) Sunday.

If you try to imagine all these aspects (including any others you may have yourself) as a number of balls that you’re juggling, I believe that remaining well is all about keeping a balance amongst them. Sometimes you need to drop one ball to keep the others going smoothly, but don’t forget it and go back to collect it as soon as you can. I don’t see diabetes as one of those balls – it’s just part of me and often influences how I manage some of those balls/aspects.

Hopefully some of this will inspire you to focus on keeping your balls in the juggle, and know where you can make some positive changes to improve your own wellness. Diabetes Counselling Online actually has a whole section on the website on Diabetes & Wellbeing. Check it out!

You know we’re here to help. With love, 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 list of all Sally’s Diabetes Counselling Online blogs here.

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Healthy d-baking with guest Joan Bailey

September 8, 2014 by Sally Leave a Comment

One of our wonderful Diabetes Counselling Online volunteers, Joan Bailey, has type 2 diabetes. She also has two young daughters who both have coeliac disease. Joan loves to bake them yummy, homemade meals and treats for their lunchboxes. She also works hard to control her blood glucose levels and remain fit so that she’ll be healthy to look after her family in years to come. And she also enjoys the food that she creates for the rest of the family. This means that she needs to consider all the diabetes factors in recipes as well as making them gluten free and delicious.

In today’s blog Joan demonstrates how she does this and explains that often these healthier options are even more delicious than the original recipes. If you’re not gluten free, don’t worry as Joan has included gluten containing options too in her tips for healthier swaps

Over to you Joan:

Thanks Sally. I hope this blog highlights that for those of us who enjoy baking that it is still possible!

Today many low glycemic index (GI) recipes are available but sometimes a family favourite is hard to give up and obviously we still want to enjoy them at the end of the day.

So the only option is to identify the potentially high GI, high fat and high sodium elements within the recipe and swap them for diabetes friendly ingredients.

I personally think that taste-wise the healthier versions can taste even nicer and be more filling and satisfying!

Making the conversion

As we’ve learned through listening to Sally and other dietitians, when converting a recipe for diabetes the main components that should be addressed are the carbohydrate components (the sugars and the flours) as well as the total and saturated fat levels and the salt (sodium) content.

Once you get the proportions correct and the correct substitutions it is easy to do.

It does take a bit of trial and error, so it’s a top idea to write things down as you go. And just like anything you do, the more practice you get, the better you’ll be at making your original ‘guesstimations’ for the substitutions.

Beginning with a Brownie recipe

Let’s start with a basic brownie recipe and look at converting each component. This table shows what a difference the changes can make!

Original recipe	Amount of Nutrient	Substituted with	Amount of nutrient	% Difference
1.5 cups self-raising flour (337g)	Carb = 246g	1.5 cups chickpea (besan flour) plus a teaspoon of baking powder (225g)	Carb = 104.4g	-57.6%
½ cup sugar (225g)	Carb = 224.5g	½ cup Stevia	Carb = 0g	-100%
1 cup water		1 cup water
¼ cup cacao		¼ cup cacao
1 tblspn vinegar		1 tblspn vinegar
60mL full cream milk	Per 100gFat Total = 4.4gSaturated = 2.9	60 mL low fat milk	Per 100gFat Total – 1.2gSaturated 0.8	-73%-72%
1 tsp vanilla essence		1 tsp vanilla essence
6 tblspns sunflower oil	Per 100gFat Total = 100gSaturated = 11g	6 tblspns low fat yogurt	Per 100gFat Total = 0.3gSaturated 0.2g	-99.7%-98%

Now, this table took me a little while to put together, but I think it’s quite an eye opener as to the enormous differences we can make to help our health and wellbeing, just by making a few minor changes to the original recipe. Still looks and tastes as good as the original!

And just to further make the point, I put both recipes through the FSANZ Nutritional Panel calculator (following the directions in a past blog that Sally posted for Diabetes Counselling Online).

First is the original brownie recipe

And here’s my healthier version

Which would you rather have, especially when you know that this one tastes just as good as the original??

Are you amazed at the differences these changes have made?

And the taste also lived up to expections! My girls certainly enjoyed them – they didn’t last long!

Some other helpful ideas for your recipe conversions

Instead of icing sugar try low fat Philadelphia cream cheese thinned out with milk and sweetened with Stevia (cocoa – optional)
For pizza bases/pancakes/crumpets/muffins try swapping the plain white flour with chickpea flour, quinoa flour, buckwheat flour and spelt flour (for those who aren’t gluten intolerant). Coconut flour is also low carb, but I find its flavour spoils the flavour of the finished product.
Use low fat yoghurt! It makes a great alternative for mayonnaise, sourcream, ordinary cream and can directly replace oil in baking. Here is the link to an article that talks more about it.
Rolled outs and ground seeds also make an excellent substitution for flours. The calorie content does needs to be considered when using ground nuts and seeds. If one cannot have oats rolled quinoa could also be used. Love this Teresa Cutter recipe for Oatmeal Scones for when a special treat is in order.
I have not found a good replacement for syrups. I have tried dissolving Stevia in hot water and letting it cool down. (2tsp stevia to 1 cup water) this can be used in baking but the texture is not the same as syrup.
Sushi can be made with cauliflower rice or even quinoa if you wanted the low GI carbs
Quinoa can be substituted for cous cous to provide a lower carb amount (due more protein in the grain).

And now back to our Diabetes Counselling Online social media dietitian, Sally!

Wow Joan! Thanks so much for making such an effort to demonstrate just what a difference a little bit of thinking in your cooking can achieve. Those girls of yours are certainly fortunate to have a Mum who looks after them with good food for their wellbeing too!

Please add your comments below if you have other suggestions/tips that you’ve discovered that might interest some of our readers.

Sally

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Carb Counting Queen: am I really good at Maths, or is it an illusion?

September 5, 2014 by helwild Leave a Comment

I’m always so profoundly moved by what people are so prepared to share with me. Recently I received the following lovely piece of writing from one of the Parents in our ‘Parents of Kids with Diabetes’ group on Facebook. Check out the link if you are the parent, carer or grandparent of someone with diabetes.

Thanks to Maureen Campey for sharing of your thoughts. Fabulous writing Maureen. Yes, the tears come, even if in secret. There are the times we ALL feel like the ‘carb counting Queen’, whether we have a child with diabetes, or have diabetes ourselves! As you say, it helps to be able to see the funny side. I think it also celebrates our confidence in our skills & knowledge, a confidence that we need to stay sane.

“Sometimes I feel sad, but there are times when you just have to laugh at the craziness of life as a mum of a Type 1 child. We were at a friend’s bbq recently and when I came home, I started to write this. Do you feel like this too? I’m happy to share this and just give you a laugh. x

The Carb Counting Queen

I am the carb counting queen. No carb is too complex for my capabilities. This title, it has to be said, was totally uncontested. There was no bloody revolution. There is no pretender to the throne.

A Saturday afternoon bbq? Sure, we’d love to come! Watch me as I glide, seemingly effortlessly, towards the buffet. Greeting friends on either side, they are totally unaware of my inner calculations. Think synchronised swimmer – all smiles above the water, craze of activity below. If karma exists, my maths teacher would be rolling about laughing.

Ok, here we go! Salad, all good: nice and plain. A top ‘filler upper’! Protein, yip: lots of chicken, and sausages. Fine, but wait! Was the chicken marinated? Best stick to sausages! Which carbs though? At least a modicum of healthiness! Bingo! Corn on the cob! One exchange down!

I bet there’s a loaf of bread somewhere, hopefully wholegrain! Always a ‘failsafe’ but so, so boring. Can I check out the pantry without seeming like a crazy lady? Ah look! Potato bake! Now, how did I calculate carbs in that one I made at home? Get the Mobile ‘phone out and have a look. There might be one on the ‘Carb Counter App’ or my faithful knave the ‘Traffic Light Guide’.

Is there a dessert I wonder? Fruit? Maybe iceblocks for the kids? Which brand? Would it be rude to ask? Please let it be at least font size ten on the packaging! So unseemly scrambling about for those newly prescribed glasses.

All that in a ten metre walk! Pass me a glass of bubbly! Now for the rest of the family!”

Maureen Campey

If you have some thoughts you’d like to share about living with diabetes, we’d love to hear from you. Send your writing to: [email protected] OR just write your thoughts after this post in the Comments.

Regards

Helen Wilde

Helen is a Senior Counsellor with www.diabetescounselling.com.au She has been the mother of someone with Type 1 diabetes since 1979, and has lived with Type 2 diabetes herself since 2001.

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A fibre reminder – do you make the minimum?

September 1, 2014 by Sally Leave a Comment

Just recently the importance of fibre has been featuring in the news, mostly along the lines of improving our gut bacteria to help keep us well. So following on from that I thought it worthwhile to review a previous Diabetes Counselling Online blog on fibre and build on it by providing some examples of how you can build the fibre in your own diet to ensure you meet at least the minimum advised for people who live with chronic health conditions (in adults, 28g for women and 38g for men).

As a precursor to this encouragement to you to increase the amount of fibre in your diet, even aiming as much as 10g above the minimum, you need to do it gradually while drinking plenty of fluids (preferably water) and being physically active to get the greatest benefits.

More evidence is emerging relating to control of insulin resistance and protection of our immune systems being associated with increased fibre intakes. Additionally the Australian Dietary Guidelines discusses the evidence about fibre reducing fat absorption and risk of cardiovascular disease and bowel cancers. And then there’s the ‘traditional’ view about improved regularity in our bowel movements. It seems there’s no end to the potential benefits for increasing our fibre intakes, but so many of the people I see find it a challenge to do that.

When thinking about increasing our fibre intake, it’s also important to understand that there are three main types of fibre: soluble, insoluble and resistant starch. We need a healthy balance of all three as they all play particular roles. Read more about them here.

If you aim to include fibre-rich foods such as wholegrains, legumes, nuts, vegetables and fruit in each of your main meals, and follow the Australian Dietary Guidelines, especially in those 3 food groups, you should easily reach your target. Leaving the edible skins on your fruit and vegetables is also an awesome idea.

I thought if we make a table for four examples of each meal of the day and indicate how you can add fibre along the way, it might help you to find some ways to improve your own daily intake (data taken from Calorie King).

Example Breakfasts	Serving Size	Amount of fibre (grams)
Weetbix	2 biscuits	3.6
Traditional oats porridge	¾ cup cooked (170g)	2.9
Multigrain toast	2 slices (56g)	2.8
Baked beans	½ cup (140g)	6.7

Example Fibre Toppers	Serving Size	Amount of fibre (grams)
Wheatgerm	1 tablespoon (12g)	2.2
Psyllium Husk	1 tablespoon (6g)	4.9
LSA (nut) mix	1 tablespoon (20g)	4.6
Rice bran	1 tablespoon (12g)	3.1

Example Snacks	Serving size	Amount of fibre (grams)
Apple	1 medium w skin&core (138g)	3.3
Banana	1 medium (170g w skin)	3
Mixed nuts, dry roasted, no salt	A handful (30g)	2.7
Classic Fruit & Nut muesli bar	1 bar (45g)	3.0

Example Lunches	Serving size	Amount of fibre (grams)
Multigrain sandwich w tomato	2 slices plus 1 small tomato (100g)	4g
Salad with chickpeas	½ cup (100g) chickpeascarrot ½ cup gratedcelery ½ cup chopped capsicum ½ cup chopped 1 small tomato (100g)	4.72.10.8 1.1 1.2 (TOTAL 9.1)
Barleymax wrap	1 wrap	10
Campbells vegetable soup	½ tin	6.5

Example Dinner carbs	Serving size	Amount of fibre (grams)
Wholemeal pasta	1 cup cooked (150g)	8.3
Sweet corn	1 large cob (200g)	11.2
Basmati rice	1 cup cooked (125g)	1.4
Lentils	1 cup cooked (198g)	7.3

So if your meal choices through the day looked kind of like this day plan in the table below, you’d be getting at least 41g of fibre per day of all three sorts.

	Meal	Fibre (g)
Breakfast	½ cup baked beans on one slice of multigrain toast	8.1
Morning Tea	1 medium apple (skin on)	3.3
Lunch	1 Barleymax wrap with filling	10.1
Afternoon Tea	1 handful nuts (skin on)	3.0
Dinner	Wholemeal spag Bolognese and 2 cups salad	15
	TOTAL	41g

This is very basic and just designed to give you an idea of how you ensure you get the fibre you’re looking for each day. You’ll notice I haven’t made it a ‘balanced’ diet as my focus was just about fibre. You can read more here about that, but I have aimed for reasonable amounts of carbohydrate in each meal.

And using the toppers, you can easily add extra fibre to your breakfast cereal or your salads if you feel you need topping up. If you look in the health food isle in the supermarket there are lots of fibre topper products. Just remember to bear in mind the carbs for your diabetes, and watch the amounts of fat too if you’re watching your weight.

Make one yourself!

You can make up your own similar tables using the fibre per serve off the labels of the products you’re using and referring to www.calorieking.com.au for the ones without packets to guide you.

Hoping you’ve found this blog useful in working out how much fibre you’re getting each day and how to top up with some high fibre ideas that you may not have thought of. Remember that ideally you see your own Accredited Practising Dietitian for a personalised consultation to ensure that your diet reflects your nutritional requirement for your medical conditions.

Let me know if you have any questions and any tips on how you add fibre to your meals. 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 list of all Sally’s Diabetes Counselling Online blogs here.

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