Diabetes Education Archives - Diabetes Counselling Online

Why So High?

February 24, 2015 by Imagine_David 1 Comment

So often I hear ‘why so high’ from my clients, people living with diabetes.

So often I hear no diabetes specialised health care professionals asking ‘why so high’ when a person living with diabetes is in a bed in pain following an infection requiring a surgical procedure.

So often I hear ‘Its all too hard, Im not going to bother with this diabetes stuff, its all so confusing’ – diabetes burnout! arrrghhhh!

“Diabetes is not a death sentence, but it can feel like a life one. It can really shake up your world. After diagnosis, day-to-day activities that were once simple and straightforward such as eating, exercising, even enjoying a late night out with a few glasses of red, suddenly require greater attention, forward planning and consideration.

After a while it can feel like there is never time out from diabetes management, which like an octopus, sends its tentacles into every area of your life. Sometimes you will feel totally in control of this juggle and marvel at how well you manage. At other times, monitoring your blood glucose levels (BGLs), medication and insulin on top of the hurdles of everyday life, will become a time-sucking intrusion in your day. In particular, when you are overloaded with lots of other responsibilities and tasks, or when diabetes is not ‘playing fair’, your daily ‘must do’ diabetes management list can become an exhausting marathon. In your lowest moments, this can weigh heavily and feel an enormous burden, even a curse.” from our eBook Put the Brakes on Diabetes Burnout

Up and down we go!

So, the next tome you have a question like ‘why so high’ consider some of the things here in this chart:

Causes	Ask These Questions	Take Action
		If your answers to the questions are yes, follow these suggestions.
Food	Have you increased your portion sizes? Have you changed your eating habits or food choices? Have you eaten too many high-fat foods?	You may need to measure food more accurately to check portion control. If you think your eating pattern is changing, your medication or exercise plan may need to change.
Activity	Have you decreased or eliminated your usual activity? Are you doing too little physical activity?	Physical activity is a key to blood glucose control. Ask your healthcare team about starting a program.
Medication	Have you been taking the prescribed doses? Have you been taking the medication at the right time?Do you have “spoiled” insulin? Does your insulin look different? Was your insulin exposed to very hot or cold temperatures? Has your insulin expired?	Take the right dose at the right time. If you have any questions ask a diabetes educator. Throw away the bottle and open a new bottle. Check the expiration date on bottle.
Monitoring	Is the drop of blood too small? Are you using the correct technique? Could your meter be dirty? Have your strips expired? Have your strips been exposed to very hot or cold temperatures or not been kept in an airtight, dry, container? Is your meter calibrated to the current bottle of strips?	See a nurse educator to be sure your technique is correct and your meter is functioning the right way. Learn how to clean the meter.Throw away the strips and get a new bottle. Check the code on the strip bottle.
Illness, infection, injury and surgery	Are you feeling well? Do you have any infections?	Follow sick day rules. Contact your healthcare team for questions or help.

Some of my clients have found it helpful when visiting their health care professionals to share their knowledge about diabetes. You might find it helpful to download and complete this DIABETES KNOWLEDGE QUESTIONNAIRE (old rtf format) and take it with you to your next doctor and/or diabetes educator and/or dietitian appointment.

One of the problems for people living with diabetes of course is not FEELING the high blood glucose level. A blood glucose level of 10-15mmols is likely NOT to cause the symptoms of:

Being excessively thirsty
Need to wee more often than normal
Feeling tired and lethargic
Always feeling hungry
Having cuts that heal slowly
Itching, skin infections
Blurred vision
Gradually putting on weight
Mood swings
Headaches
Feeling dizzy
Leg cramps

However, just because you feel ok doesn’t mean that things are healthy.

Treatment of High BLOOD GLUCOSE LEVEL

For Type 1 diabetes

Plan ahead. Work with your doctor or Diabetes Educator for advice about increasing your dose of short acting insulin in this situation – before you need to.

You may need extra doses on top of your usual dose, and also you may need insulin (e.g. 2-4 units every 2 hours).

Test your blood glucose levels frequently. Measure your ketone level if the blood glucose level is over 15 mmols.

Drink extra water or low calorie fluids to keep up with fluid lost by passing more urine.

Contact your doctor or go to hospital if:

Vomiting stops you from drinking and makes eating difficult
Blood glucose levels remain high
Moderate to large ketones are present in the urine.

In type 1 diabetes, high blood glucose levels can progress to a serious condition called Ketoacidosis.

For Type 2 diabetes

Even for people NOT living with diabetes it is normal for blood glucose levels to go up and down throughout the day.

And an occasional high blood glucose level is not a problem.

However, if your blood glucose level remains high for a few days or if you are sick, enable your sick day plan and seek medical advice if unsure of what to do.

Further sick day plans can be found here:

MedlinePLus (USA)

Australian Diabetes Educators Association

Royal Australian College of General Practitioners

******* If in doubt always consult your health care professional *********

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Case Study: George Mellows (Part 4) – A visit to the Diabetes Educator

February 18, 2015 by Imagine_David 3 Comments

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.

*** Previous Posts: Part 1 here ; Part 2 here ; Part 3 here ***

George has now had diabetes 3 months. He has had a consultation with his dietitian and found some healthy choices to make that not only fit with his diabetes self care plan but also things he enjoys!

This past 2 weeks George has been measuring his blood glucose level with a view of discussing the results with the diabetes educator. George feels confident that he can identify the causes of hyperglycaemia

On diagnosis, George’s doctor commenced George on Metformin 500mg in the evening with dinner. This has not changed.

The table below is his most recent blood glucose levels. George has highlighted the blood glucose levels that are over his target in red.

The Visit

“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

Tools

On arrival in the consultation room George was asked by the receptionist to complete:

* The Diabetes Distress Scale (download here DDS and HERE )

* The Diabetes Knowledge Questionnaire (download here DIABETES KNOWLEDGE QUESTIONNAIRE (old rtf format) )

George felt a little uncomfortable initially using these ‘tools‘ to complete these ‘tests’. However, the diabetes educator saw George acting a little uncomfortable in the waiting room and explained that the purpose of these tools would be to individualise the visit based on the knowledge and needs of George.

George felt more comfortable with this explanation, and managed to complete both before the visit started in person. *He also felt that it might have been good to complete these at home before the visit.*

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

“How did you feel about completing those tools George?” the diabetes educator asked as they sat down to start the session.

” At first it was a little like being in school; but when you saw I was puzzled about them, and explained how we could use them in this session, I felt like I was going to be listened to, not just spoken at and told what I should and shouldn’t do” replied George.

The diabetes educator then used these with George to open and lead the session. George was also a little surprised at this, expecting the diabetes educator to be focussed on his blood glucose levels.

The diabetes educator started with the knowledge questionnaire, only asking George about the question he had gotten incorrect. By the end of the first 20minutes George was feeling that he was learning new things despite al of the reading and research he had been doing on the internet.

George hadn’t even considered the importance of foot-care, despite being aware that diabetes can effect the nerves and the blood supply to parts of the body.

Diabetes Distress

Diabetes may lead to specific problems and increased stress, which we often call “diabetes distress”.

Daily life and general stress levels can affect your diabetes control. How well your diabetes is going can in turn affect your general stress levels – so it is a bit of a chicken and egg. It is very important to get the general stress in your life under control, as this will assist with your diabetes management. Likewise, feeling settled with your diabetes management will decrease your overall stress.

If you are struggling with stress at work, or in your personal life, it can be harder to manage diabetes and it suffers. We all experience stress and life would be boring without some stress! People say they would rather not have stress in their lives, but in fact we need a balance between just enough stress and not too much, to keep us alive and active. Not all stress is bad believe it or not.

Some of the things that can lead to diabetes distress are:

Worry about food changes
Management of blood glucose levels
Weight management
Going onto insulin/medication
Hypos (low BGL)
Depression & mood swings – have been shown to be higher in people with diabetes
Relationship & sexual problems
Work stress, discrimination in relation to your diabetes
Disclosure – wondering if you should tell people about your diabetes
Lack of understanding or support from family/friends
Guilt, fear, worry, panic & anxiety about diabetes and your future
Risk of Complications
Feeling alone and isolated
Seeing or hearing about all the things that can go wrong
Feeling out of control
Other mental health problems such as an eating disorder
Feeling overwhelmed and exhausted
Lack of information

Blood Glucose Levels

Towards the end of the session the diabetes educator and George decided to take a careful look at the blood glucose levels that George had been measuring.

The diabetes educator asked “George, why do you test your blood glucose level?”

George was a little taken aback by this question. He thought that everybody just had to, that it was a part of having diabetes.

After a moment he said: ” To determine if my diabetes self care plan is working well, or if there needs to be some changes to my meal planning, or my exercise, or to my diabetes medication.”

George identified clearly the things that would impact on his blood glucose level, and also identified that weekdays at lunchtimes when he didn’t move very much was a problem for him.

Future Planning

The plan at the end of the session was to make an appointment with an exercise physiologist and a podiatrist, and then return to the diabetes educator in 6 months (unless he felt the need to return sooner).

George also had a plan to talk with his manager to have 60 minutes for lunch and go for a 20 minute walk each working day after he had eaten. This meant that he would have to work back an extra 30 minutes. But he also felt it was well worth it if it meant having a better quality of life, and potentially a longer working life (by minimising the risks to his health caused by high blood glucose levels).

George felt that he had achieved quite a lot in his first few months of living with diabetes, but was also aware that this was only the beginning of a lifelong journey.

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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.

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

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.

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.

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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Diabetic Nerve Damage: Neuropathy

January 11, 2015 by Imagine_David Leave a Comment

Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood glucose can injure nerve fibers throughout your body, but diabetic neuropathy most often damages nerves in your legs and feet.

Depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in your extremities to problems with your digestive system, urinary tract, blood vessels and heart. For some people, these symptoms are mild; for others, diabetic neuropathy can be painful, disabling and even fatal.

Diabetic neuropathy is a common serious complication of diabetes. Yet you can often prevent diabetic neuropathy or slow its progress with tight blood glucose management, and a healthy lifestyle.

Clinical context

Pain and paraesthesia are common peripheral neuropathic symptoms, and if the autonomic nervous system is involved, gastrointestinal, bladder and sexual problems arise.

Diabetic neuropathic complications increase the burden of self-care and overall management.

The clinical focus is on prevention via good glycaemic control, and early recognition facilitated by good history and routine sensory testing.

New modalities are arriving to assist in the management of diabetic neuropathies.

Before any treatment is instigated, exclusion of non-diabetic causes of neuropathy is suggested. This includes assessment for vitamin B12 deficiency, hypothyroidism, renal disease and review of neurotoxic drugs including excessive alcohol consumption.

Autonomic neuropathy

Autonomic neuropathy may result in:

orthostatic hypotension (also called postural hypotension, is a form of low blood pressure that can cause dizziness. It happens when the blood vessels do not constrict (tighten) as you stand up, which makes you feel dizzy) with >20 mmHg drop
impaired and unpredictable gastric emptying (gastroparesis), which can cause a person’s blood glucose levels to be erratic and difficult to control. Pro-kinetic agents such as metoclopramide, domperidone or erythromycin may improve symptoms
diarrhoea
delayed/incomplete bladder emptying
erectile dysfunction and retrograde ejaculation in males
reduced vaginal lubrication with arousal in women
loss of cardiac pain, ‘silent’ ischaemia or infarction
sudden, unexpected cardiorespiratory arrest especially under anaesthetic or treatment with respiratory depressant medications
difficulty recognising hypoglycaemia
unexplained ankle oedema.

Cardiovascular autonomic neuropathy should be suspected by resting tachycardia (>100 bpm) or orthostatic reduction in BP (a fall in SBP >20 mmHg on standing without an appropriate heart rate response). This applies to people not currently on antihypertensive agents that may cause variations in BP responsiveness such as beta blockers. It is associated with increased cardiac event rates.

Diagnosis

The diagnosis of diabetic neuropathy may include:

taking a medical history for symptoms typical of neuropathy
checking your feet and legs for responses to stimuli such as temperature, light touch, pain, movement and vibration
checking the reflexes at your ankles and knees
tests to exclude other possible causes of neuropathy (such as low vitamin B₁or thiamine levels).

Treatment

Damaged nerves cannot be repaired. However, the risk of further complications in the feet can be reduced by:

vigilance – regular inspection of the feet for early signs of trouble or potential problem areas (such as breaks in skin, signs of infection or deformity
getting help at the first sign of trouble – early treatment of foot ulcers gives the best chance that they will heal
good foot and nail hygiene
choosing appropriate socks and shoes properly fitted to the shape of your foot
avoiding activities that may injure the feet. Check shoes for stones, sticks and other foreign objects that might hurt your feet every time before putting your shoes on.

A referral to a podiatrist may be appropriate for assessment and ongoing preventive management of foot complications.

Treatment for painful neuropathy

Appropriate pain management can significantly improve the lives of people with diabetes and painful neuropathy. A number of different medications are available, which produce comparable effects.

Most people would begin with one of either:

serotonin-norepinephrine reuptake inhibitors (such as venlafaxine, duloxetine)
tricyclics antidepressants (such as amityptiline)
anti-epileptics (such as gabapentin, pregabalin).

If one type fails to provide the response required, it is usual to switch to or add another. If all three agents alone or in combination fail, then opioid analgesics and tramadol may be used as second-line treatments.

Prevention of diabetic neuropathy

Be guided by your doctor, but general suggestions to reduce the risk of diabetic neuropathy include:

Maintain blood glucose levels within the target ranges.
Exercise regularly.
Maintain a healthy weight for your height.
Stop smoking.
Reduce your blood pressure and lipid (fat) levels through diet and lifestyle changes, and medication where appropriate
Consult your doctor promptly if you have symptoms including pain, numbness or tingling in your hands or feet.
Have your feet checked at least yearly by your doctor, podiatrist or diabetes educator, or more often if you have signs of problems with your feet or other complications of your diabetes.

Although, potential health complications due to diabetes may happen; don not live in fear, by watching the amount and types of food you eat, exercising, and taking any necessary medications, you may be able to prevent short and long-term diabetes complications.

Keeping blood glucose close to normal can help prevent the long-term complications of diabetes.
Manage high blood pressure.
Monitor your blood sugar level and A1c.
Have regular reviews with your diabetes care team.

Talk to your health care professional team: ask questions and get answers that you understand….. prevention is better than a decreased quality of life.

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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