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1. Questions on Blood Sugar Level.
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Q. I don’t understand blood glucose control. Can you please explain it to me?
A. When you have diabetes, the most important thing you must do is control your blood glucose (‘blood sugar’) levels. If you are testing your blood glucose, you will have been told to try and keep your reading between 4 and 7 mmol/l. This is necessary either because your body has little or no ability to produce the hormone insulin which normally does this for us (type 1 diabetes); or else because your body does not produce enough insulin or the cells in your body have become resistant to the action of the insulin and are not able to use the glucose effectively (type 2 diabetes). Whatever the underlying cause of your diabetes, you must now regulate the amount of sugar in your blood, with the help of your treatment regimen.
Glucose is required by body tissue for energy, repair and sustenance. Insulin circulating in the blood helps transfer glucose from the blood stream to tissue cells. In someone with diabetes, the absence or ineffectiveness of the insulin does not allow this to happen which results in too much sugar remaining in the blood for too long. This, in turn, leads to tissue damage, which is often the first indication that someone has diabetes, for example where tissue in the eye has been affected.
Once diabetes has been diagnosed and a regimen established to control it, it is important to strive to maintain steady control, as too little sugar in the blood is dangerous too, leading to dizziness, faintness and, potentially, coma. People with type 1 diabetes must inject just enough insulin at meal times to balance the sugar that accumulates in their blood after eating. People with type 2 diabetes must at first control how much they eat (if they still have responsive insulin-producing cells in their pancreas), or use tablets to help balance their blood sugar (when less and less insulin works in their bodies to do this), and eventually may need to inject insulin to supplement what the body is able to produce.
Q. What is the difference between “hypoglycaemia” and “hyperglycaemia”?
A: These two words can often cause confusion. They are so similar in sound, yet are opposite in meaning. In derivation, hypo = low, and hyper = high, so “hypoglycaemia” means LOW blood sugar and “hyperglycaemia” means HIGH blood sugar. Hypoglycaemia. Technically, you are said to have hypoglycaemia if your blood glucose (BG) falls below 3.5mmol/L. However, some people experience a ‘hypo’ at 5.0mmol/L and others only at 2.0mmol/L.
Hypoglycaemia can be caused by: increased medication; missed meals or too little food; increased exercise levels; alcohol or stress.
Symptoms are: sweating, headache, being irritable or aggressive (mood swings), confusion or lack of concentration, blurred vision and palpitations. Be aware that hypoglycaemia can also lead to unconsciousness and potentially coma.
Action to take: Have a sugary drink or some glucose tablets; OR have a high carbohydrate meal or snack; AND check your BG levels to make sure they are coming back to normal. If the person with diabetes is unconscious, place Hypostop gel in the mouth and massage it into the cheeks; OR give Glucagon (reverses the action of insulin). Call for medical assistance if necessary.
Hyperglcaemia is diagnosed as a blood glucose level of over 12.0mmol/L. It is caused by: under-treatment of diabetes or forgetting to take medication; too much food or the wrong type of food; infections and illness; reduction in usual activity levels; other medications such as steroid tablets and weight increase.
Symptoms can be mild and unspecific, such as feeling tired all the time, excessive thirst, passing more urine than usual, more frequent infections, and thrush.
Hyperglycaemia may not appear as dangerous as hypoglycaemia, but in the long-term it is harmful to blood vessels and underlies all the complications of diabetes.
therefore it is vital that you quickly take steps to lower your blood glucose levels.
Action to take: If hyperglycaemia is not severe the symptoms can be accepted as ‘normal’, eg due to overwork or late nights, but if they are recognised frequently and you haven’t been diagnosed with diabetes, ask your doctor for a diabetes test. If the hyperglycaemia is severe (perhaps where a diagnosis of Type 1 is delayed), hospital treatment is likely.
If you know you have diabetes and recognise the symptoms of hyperglycaemia, it is important that you take the necessary medication or exercise to lower your blood glucose levels.
Maintaining steady blood glucose levels as near to normal as possible, will greatly reduce the risk of these conditions and the long-term complications of diabetes. In other words, strive for NORMOglycaemia. This is best achieved by adhering to the treatment prescribed, exercising, eating healthily and by having regular check-ups.
Q: How can I bring down my blood glucose? I monitor it morning and night and it remains at about 14. My doctor says to exercise and watch my diet, but I am an HGV driver and find it difficult to exercise.
A: I am sorry to hear that you are having problems controlling your blood sugars. As you probably know, a blood sugar of between 4 and 8 mmol/l is normal and is what you need to aim for.
Being an HGV driver is a good incentive to work hard at improving your control, as people on insulin cannot drive HGV vehicles for safety reasons.
I suggest you take your tablets regularly and try not to eat fried or fatty foods.
Cheese is a worst culprit in making it difficult to lose weight!
As for exercise - it does appear to be the key to getting the sugars down. A brisk walk for half an hour every day is certainly recommended - why not give it a go?
You ask about heart rate - I do not have any evidence that insulin has an effect on heart rate or sleep patterns. Patients often say they sleep better once their control has improved because they don't have to get up to go to the loo at night.
Q: I would like to monitor my blood sugar. I take urine tests but I don’t think the results are accurate. In fact, for two months, my urine tests have been negative – but three-monthly clinical tests tell a different story.
A: You are certainly right that blood glucose tests are more accurate than urine tests. The problem with urine testing is that it is retrospective and it is telling you what your blood glucose result was three hours ago. It’s a little bit like driving with your speedometer telling you what your speed was three hours ago!
Urine testing can also be a bit misleading because your ‘renal threshold’ can change. This means that whereas in most people a blood sugar of 10mmols will show as a trace of sugar in your urine, some people show no evidence of sugar in their urine until their blood is more than 10mmols. This means you can sometimes be lulled into a sense of false security with negative urine tests.
2. Questions on Diet.
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Q. I have recently been diagnosed with diabetes, can I still drink alcohol?
A. In the past there has been a tendency for health professionals to advise people with diabetes to give up alcohol and other things they enjoy but recent evidence shows that small quantities of alcohol (less than 4 units a day for men and 3 for women) can have a beneficial effect. It can improve metabolic control as well as the vascular complications of diabetes, particularly angina and stroke. Without question, the drinking of large amounts of alcohol is hazardous and should be avoided, because it can lead to hypoglycaemia. As a guide: 1 unit of alcohol = ½ pint beer; or 1 measure spirits, sherry, liqueur; or 1 standard glass wine.
Avoid drinking on an empty stomach; have something to eat with your drink.
Choose low alcohol drinks but avoid special ‘diabetic’ beers and lagers as they have a higher alcohol content.
Use slimline/sugar-free mixers
Drink less alcohol if you are trying to lose weight
If you count your carbohydrates, don’t include the carbohydrate from alcoholic drinks, especially if you are drinking spirits.
Q. Is there any general dietary advice applicable to people with diabetes?
A. People with diabetes who keep good control of their blood glucose levels feel better and are less likely to develop complications associated with diabetes. There are two ways to maintain good control of blood glucose levels – diet and exercise.
For most people with type 2 diabetes, diet is a first line treatment. However, a good diet for people with diabetes is a good diet for everyone. It involves eating: MORE fruit, vegetables, pulses, and carbohydrates (such as bread, rice and potatoes) and LESS high-fat and high-sugar foods, and dairy products (such as cheese).
Use the ‘Balance of Good Health’ diagram as a model for determining what you should eat and in what proportions. The plate is divided into five food groups: starchy foods - bread, other cereals and potatoes; fruit and vegetables; milk and dairy foods; meat, fish and alternatives; foods containing fat and foods containing sugar.
Modern dietary thinking has also now turned to the Glycaemic Index. GI is a food ranking based upon how quickly or slowly foods affect blood glucose levels. Understanding GI allows you to make dietary choices which best maintain steady blood glucose levels – ask your dietitian for more information.
Teaching people how food and insulin work together is one of the most necessary starting points for people diagnosed with type 1 diabetes. Such knowledge means improved glycaemic control (blood sugars), fewer hypoglycaemic
episodes, and greater flexibility of daily living. People with type 1
diabetes need to have the confidence to adjust their insulin doses to
their lifestyle. Avoid all quick-fix diets. There is no healthy way to lose weight fast, and missing meals or trying to lose weight too fast can have psychological pitfalls and be positively demotivating. Be patient. It took time to put the weight on; getting it off will take time too, and being patient will help you keep it off
Q. Will losing weight help me control my diabetes?
A. Obesity is an important predictor of type 2 diabetes and is the major cause of cardiovascular (heart) disease. Obesity also contributes to hypertension, another risk factor for heart disease. If you are greatly over your ideal weight, your diabetes team will ask you to lose weight. The ideal way of losing weight is to do it slowly and consistently, using a healthy eating programme combined with physical activity.
Obesity is usually gauged by an index termed Body Mass Index – BMI. This assesses a person’s weight in relation to height. BMI is not altered by age or sex. You can calculate your BMI by dividing your weight (kg) by your height (m2). [BMI = kg/m2].
· BMI of 25.0 – 29.9 means you are overweight.
· BMI of 30.0 – 34.9 means you are obese.
· BMI of 35 or more means you are severely obese.
Help may eventually be available in the form of drugs or surgery, but the challenge is to change your way of living so that weight gain does not become inevitable. For those who are already overweight, adopting a lifestyle that encourages weight loss, including a healthy diet and greater physical activity, will have short and long-term benefits.
Studies show that obesity is the main cause of the continuing rise in type 2 diabetes worldwide, and the evidence is overwhelming that tackling obesity is the key to preventing type 2 diabetes.
Q: Does coconut contain fat and high cholesterol? And I’ve heard conflicting views about whether nuts are good for you or whether they are fattening. Which is true?
A: Nuts, in general, tend to be high in fat but are a good source of protein. One exception is chestnuts, which are low in both fat and protein. Nuts contain virtually no cholesterol; they are a reasonable source of vitamin E and contain moderate amounts of fibre.
We should try to cut down on the amount of fat in our diet, regardless of whether it is saturated fat or mono- and polyunsaturated.
It is recommended that fat should make up no more than 35 per cent of our daily food intake. Nuts are generally high in calories and fat and therefore could not be described as ‘slimmer’s food’. However, the average person would eat only perhaps a handful of nuts at a time. On an occasional basis and in small portions, they can be eaten and enjoyed like any other food.
Coconut is very similar in composition to nuts, but with a lower protein content. It contains no cholesterol.
3. Questions on Medication.
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Q: I have Type 2 diabetes and I keep myself very healthy and eat a well balanced diet. I think that I have quite good blood glucose control, my levels always fall between 3.9 and 6mmol/l and my diabetes is currently regulated by tablets.
A new specialist at the hospital who I haven’t seen before wants me to change the tablets I am on or even start injecting insulin. Why is this? I thought my diabetes was well controlled.
A: I would suggest that you find out from your diabetes specialist the reasons why your medication may need to be changed. I wonder if there has been some other blood test result such as an HbA1C. This is a long-term measure of blood glucose control. If that is raised or other tests have been taken you need to find out. I feel that you need a little more information. You can ask to see your diabetes specialist nurse for more information too, and if insulin is necessary, I am sure your anxieties will be allayed once you understand how easy it can be.
Q: Two years ago my mother was diagnosed with diabetes. She is a very independent lady and won’t take any notice of me when I tell her that just taking aspirin won’t help and she needs to take her prescribed medication. Please advise.
A: Being diagnosed with diabetes often means having to make many changes to lifestyle and sometimes it is easier to tackle them one stage at a time.
I would suggest you consult a dietitian so that a full diet history can be taken and supplements suggested if necessary.
Regarding her diabetes medication, it is important that any medication is taken regularly and at the appropriate times. It is also important to obtain good blood sugar levels to ensure the long-term complications associated with diabetes do not develop.
Eating regularly and taking diabetes medication is essential to achieve this.
4. Questions on Exercise.
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Q. Why am I always being told to exercise more?
A. Exercise is beneficial to everyone but especially to people with diabetes. Done regularly, it improves fitness as the heart becomes stronger and begins to work more efficiently, reducing the risk of developing diabetic complications. It can also help you manage your blood glucose control effectively.
Exercise doesn’t have to mean going jogging or to the gym. Studies have shown that even very light daily exercise has beneficial effects on health. Just doing the housework at a brisk pace, using stairs instead of a lift and gardening are all good ways to start being more active.
If you are up to it, aerobic activity has tremendous benefits to health. It involves an exercise routine that uses large muscle groups, is maintained for a sustained period of time, and is rhythmic in nature. Examples are: cycling, jogging, swimming, cross-country skiing, ball sports, skipping, dancing, brisk walking. An aerobic workout can also be achieved in a class at a gym (bikes, treadmills, stair-steppers, rowing machines etc). In addition to the benefits to the cardiovascular system, aerobic exercise can:
· Increase levels of the good HDL cholesterol, which is known to reduce the risk of heart disease.
· Help control and reduce body fat, in conjunction with healthy eating.
· Increase resistance to fatigue and give you more energy.
· Improve mood and reduce depression and anxiety.
· Improve the quality of sleep.
· Reduce certain types of cancer (colon, breast and ovarian).
Remember, you should always speak to your diabetes doctor before embarking on a new exercise programme. If you are just beginning an aerobic workout regimen, it might take several months before you reach fitness. Stick with it and gradually increase the frequency, duration and intensity of your workouts. Don’t forget to include a warm-up and a cool-down period to avoid the likelihood of injury. Warming up prepares the body by slowly raising the heart rate and muscle temperature. Cooling down allows the heart rate to return to normal and gets the blood circulating freely back to the heart. Never abruptly stop an aerobic activity or you could become dizzy and faint. If you are unable to maintain the pace of an aerobic workout, simply slow down and walk around for a few minutes before stopping.
Q: My sister has diabetes and also angina. Could you tell me of any specific exercises that would be suitable for her?
A: Exercise is an important aspect of diabetes treatment, it helps to reduce blood glucose levels by improving the efficiency of insulin. It can help control weight and blood pressure, and improve circulation.
While there are no specific exercises for people with diabetes. It is essential that your sister checks with her doctor before starting to exercise. It would be important not to start with exercises that would leave her short of breath. Walking, gardening, even dancing, are good forms of gentle exercise. It is helpful to choose exercise that she enjoys and can fit into her daily routine.
Your sister should ensure her diet is low in fat and that every meal contains some form of carbohydrate, such as cereals, bread, rice or pasta or potatoes, which will help control her diabetes.
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