How to stand up to the fear of diabetes

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I was thinking the other day that if someone could just come up with a way to check blood glucose that does not require turning your fingers into blackened stubs, where multiple areas bleed when you squeeze for one blood test, and they could eliminate hypos, I would be ok with having diabetes.

There are many parts of it I dislike, but these are two of my most hated. In fact the hypos thing is probably the biggest fear for me. And that is the bottom line toughest part of life with diabetes when we break it all down isn’t it, the fear.

It is not that you have to eat healthy, be active, get your rest, plenty of sunshine, check your feet, visit more doctors than usual and reduce your stress. These are all good for you. It is not that you have to take medications or have multiple daily injections or lived attached to a machine, even though that is annoying and sometimes frustrating. It is not even the fact you have a chronic disease that can’t be cured. It is the cold hard fear.

It’s waking up in the morning with a high blood glucose level and having to decide whether to eat breakfast or wait, worrying about whether you are going to end up higher and feel like crap, or dive into a hypo from your correction dose of insulin, and feel like crap….It is sitting up late at night when everyone else is in bed, waiting to see if your levels are going to settle as they have been too high or too low. It’s managing the swings and ups and downs, often alone and not knowing when it will stop.

It is going out on a run, to the gym, dancing, drinking, on holidays, hiking, skiing, having sex, even a walk around the block – and not knowing if you might end up low or high. It is the fear of the unknown. And the fear of the known. The fear that gets drilled into you when you get diagnosed and reminded to you every time you look at a national diabetes week, or world diabetes day poster. It’s sleeping, waking, eating, fasting, sitting, standing, lying, existing – with FEAR.

It’s exhaustion. Which makes fear worse.

It’s all those things that can go wrong, break, stop working, fall off or be chopped off. It is blindness and dialysis and horrible feet. It’s not having babies, or having babies and then trying not to breathe the entire time you are pregnant in case it messes up your blood sugar and harms your precious baby.

It’s working hard in your career and your life dreams and not knowing if your diabetes will cause a problem you don’t want your colleagues to find out about. It’s failing exams because your levels were so high you couldn’t think straight. The stress of losing your license when your job is driving trucks. Losing your ability to make love. Losing your partner. Losing your grip.

Yes indeed, diabetes is a whole lot about fear and a whole lot less about the mechanics of it all, a whole lot less about the actual act of caring for your diabetes. People will tell you that you are “non compliant”, not managing well, not getting it. That is bullshit. You are probably scared. You are probably confused. You are probably exhausted.

Fear creeps up on you, takes hold of you, hangs around in dark corners, jumps out at you from under the bed.

Fear is a bitch.

And if someone could only take away that fear for me, I would be pretty ok with having diabetes, it is not the worst thing to have. The truth is, nobody is going to do that for you but YOU. If you are like me, and fear has a grip on your life with diabetes at times, the only way we can stand up to that fear is together, and alone.

We must take time to notice these fears, to pull them out from under the covers. We must take time to shine a light on them, share them – please don’t suffer fear in silence. Learn how to be more mindful, how to manage fears, how to be more centered, more peaceful. You don’t need to learn how to be more brave – people with diabetes are some of the bravest people I have ever had the pleasure of knowing – and trust me over 15 years working in diabetes I have known many thousands.http://www.dreamstime.com/royalty-free-stock-photo-fear-concept-choice-acronym-bravery-life-image44534735

By sharing these fears we reduce them. We feel safer, as there is safety in numbers. Fear will always be part of life with diabetes. It is scary. But we can reduce how much it impacts on our daily lives by setting up networks of support, help when we need it, talking about it and facing it head on. And in those moments when you are scared shitless, just remember we are all here holding your hand. We have your back and you CAN do it.

What do you fear most about life with diabetes – please share and get these things out into the spotlight

Helen

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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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Diabetic Nerve Damage: Neuropathy

Diabetic Nerve Damage: Neuropathy

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.

Everything is Possible
Everything is Possible

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 B1 or 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.

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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

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

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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
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

Insulin: The Comes a Time
Some evidence shows people living with diabetes are at an increased risk of some level of hearing loss
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
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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Navigating the Australian Health System

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Health care in Australia is divided between Federal and State responsibility.

To make the most of the system it is wise to understand how to navigate these systems, so you can get the best ‘value’ to enable your diabetes self care plan to be most efficiently and affordably implemented.

The International Diabetes Foundation recognises that “People with diabetes have the right to understand their disease, make informed choices and receive care based on best practice. They must be part of the team that manages their condition.This can only be achieved if interdisciplinary teams and people with diabetes have the information and tools to make changes based on best practice and recognized improvement strategies are used to support meaningful system change.”

All too often people living with diabetes do not get the opportunity to have the specialist input from a diabetes educator or dietitian.

To make your diabetes self care plan most effective it is in your best interest to have an appropriate level of diabetes self management education.

A diabetes educator provides diabetes self-management education for people with diabetes. They play a major role in self-empowering the person with diabetes by focusing on an individual’s needs, providing knowledge, motivation and support to aid the prevention of diabetes related health complications.

Diabetes Educators have many years experience (some living with diabetes themselves) and can provide you with tailored education, upon the following:
  • Self blood glucose monitoring.
  • Oral hypoglycaemic agents.
  • Insulin initiation and titration.
  • Sick day guidelines.
  • Hypoglycaemia recognition and management.
  • Complication risk management.
Accredited Practising Dietitians can, in addition, provide you with a nutritional assessment and advice tailored to your individual needs, in addition to education upon the following:
  • Influence of nutrition on blood glucose control.
  • Carbohydrate counting and information.
  • Weight management.
  • Blood lipid management.
  • Related health issues.
  • Complication management.
  • Hypoglycaemia recognition and management.

State Health Systems:

State health systems often provide services such a diabetes self management education courses at community health centres or in public hospitals.

These courses may be a combination of individual and group self management education sessions, usually run by a diabetes educator and a dietitian. These diabetes self management programs are usually free.

Whatever type of diabetes you have been diagnosed with, this is a good place to start.

To find out more about what is available in your area make contact with your local hospital or community health service.

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Navigating the System to Better Health

Another way to find your local diabetes self management programs is via Diabetes Australia or ADEA.

What’s Next

By initially connecting with these state funded health care professionals, you can then navigate the Medicare system with your GP to connect in an affordable manner with other members of your health care team. e.g. podiatrist, exercise physiologist, psychologist/counsellor etc (ALL of whom are covered by the Medicare system).

Medicare – Federal Government Funding

Talk with your GP about the Medicare system, whats available to people with chronic health issues like diabetes.

The Chronic Disease Management (formerly Enhanced Primary Care or EPC) — GP services on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke. There is no list of eligible conditions; however, the CDM items are designed for patients who require a structured approach, including those requiring ongoing care from a multidisciplinary team.

Whether a patient is eligible for CDM services is a clinical judgement for the GP, taking into account the patient’s medical condition and care needs, as well as the general guidance set out in the MBS.

Patients who have a chronic medical condition and complex care needs and are being managed by their GP under a GP Management Plan (item 721) and Team Care Arrangements (item 723) are eligible for Medicare rebates for certain allied health services on referral from their GP.

In summary:
  • Maximum of five (5) services per patient each calendar year
  • Medicare rebate of $48.95 per service, with out-of-pocket costs counting towards the extended Medicare safety net
  • Patient must have an Enhanced Primary Care (EPC) plan prepared by their GP (your GP is paid to produce this for you)
  • GP refers to allied health professional (referral NOT required if that health care professionals happens to be available for free in the State health care system)
  • Allied health professional must report back to the referring GP

CAUTION: In creating the Chronic Disease Management Plan ensure YOU and your GP knows who is available in the State health system for you to enable the best use of this plan.

Team Care Arrangements (item 723)

  • Provides a rebate for a GP to coordinate the preparation of TCAs for a patient who has a chronic or terminal medical condition and also requires ongoing care from a multidisciplinary team of at least three health or care providers.
  • In most cases the patient will already have a GPMP in place (but this is not mandatory).
  • The minimum claiming period is once every twelve months, supported by regular review services.
  • Involves the GP collaborating with the other participating providers on required treatment/services, agreeing to arrangements with the patient, documenting the arrangements and a review date in the patient’s TCAs, and providing copies of the relevant document to the collaborating providers.
With good self care knowledge everything is possible.
With good self care knowledge everything is possible.

A Diabetes Self-Management Plan Review form can be downloaded here Diabetes. This document shows a guide to the goals made in collaboration between the doctor and the person living with diabetes.

CAUTION: If you have more than one of these in place, e.g 2 different doctors making 2 different plans for you, your health care provider may end up out of pocket and may charge you the full fee for service – with no rebate owing to you.

Any questions? Please ask, even the smallest of questions.

Kind Regards,

David, Diabetes Educator @ Diabetes Counselling Online

 

 

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