All posts in Hypoglycemia or low sugar levels

Understanding insulin

Understanding insulin

There are many types of insulin each working in its own unique manner, some types of insulin are suitable  for one but not for another. Normally basal insulin acting for almost 24 hours is used once at night and rapid acting insulin used with the main meals is used thrice or twice as the case warrants. Most insulin preparations come either in pen delivery devices which are disposable or refill pens. Some preparations of insulin still come in vials or small bottles. The pen delivery devices are easy to use and for those who are visually handicapped there are audible clicks while turning the dose dialer to help know the dose. The basal insulin is clear looking insulin. This acts for 16 hours to 36 hours. Normally does not cause low sugar spells and can be taken before or after food. The dose is usually dependent upon the fasting sugar levels. There is also premixed insulin preparations available which is a combination of short acting and intermediate acting insulin.

The commonly available basal insulin ( long acting) preparations in Oman are: Insulatard®, Detemir ( under brand name Levemir®), Glargine 100 units/ml( under brand name Lantus®), ultra long acting Degludec (under brand name Tresiba®) and ultra long acting Glargine 300 units/ml (under the brand name Toujeo®).

The bolus insulin (rapid acting insulin) comes either in small bottles or vials or pen delivery devices (either as disposables pens or those which can be refilled with cartridges) This insulin is clear looking insulin. This is generally taken 15 minutes to half an hour before the main meals.

The commonly available brands in Oman are Human Actrapid®( which can also be given into the veins in the hospitals when sugar levels are really high) Humalog Lispro®, Novorapid ® and Glulisisne ( under the brand name,Apidra®).

The basal ( long acting) insulin is preferably injected on the thigh and the rapid acting insulin on the abdominal wall avoiding 2 finger breadths around the navel or belly button.

The commonly available premixed insulin preparations available in Oman are Human Mixtard 30/70®, Humalog Mix 25/75®, Humalog Mix 50/50®, Novomix 30/70® and Novomix 50/50®. Because there is a clear and a milky insulin as the constituents, the insulin preparation bearing vial or cartridge will have to be shaken before use.

There are some barriers facing the patients and the treating doctors when advising insulin. The fear of low blood sugar levels, the fear of the pain associated with the needle prick, the need for having to check the sugar levels frequently, the cost of the insulin, the possible negative impact insulin can have on ones social and married life, the scary feel associated with the insulin, the impact insulin has on ones friends are the common barriers. There are some who have seen their near or dear ones die or having developed a kidney failure or having amputated a limb after staring insulin. They feel the insulin was responsible for all this. The uncontrolled sugar levels can damage the eyes, the nerves, the blood flow to the legs, the heart, the brain, kidneys and once the damage has set in, insulin cannot help reverse the damage, but can help further worsen the damage. The insulin can cause weight gain, might cause allergy or numbness for some and episodes of low sugar when the patient has taken too high a dose and either exercised or taken less food.

Insulin is safe during pregnancy, in those with very advanced kidney failure and heart failure.

There are however some points to be considered while using insulin:

  • Insulin is to be stored either in a cool room. It is never to be frozen by placing in the freezer. If frozen by any chance, it cannot be thawed and is best discarded.
  • Insulin can be taken along while traveling by carrying it wrapped in between ice packs or by using cooled gel holders. Sometimes you might need a certificate while traveling to be allowed in the cabin bag.
  • Never leave insulin in the car especially during the summer as it can get damaged and lose its efficiency.
  • Always check the expiry date especially while buying large amounts of insulin.
  • Do not inject cold insulin. Roll the pen between the palms of the hand for six to seven times to lightly warm it.
  • Rotate the site every time you inject.
  • The site to be injected must be lightly cleaned with a swab. Check the site of injection for small swellings or bumps. These sites are to be avoided as the insulin will not act well if injected into those areas.
  • The dose to be injected is dialed if using a pen insulin delivery system.
  • Inject perpendicular to the skin after the needle is plunged fully. Plunge the dialer button to deliver the insulin.
  • After the dose has been delivered, count to five and remove the pen, lightly wipe the injection site and cap the pen again to place it back in the refrigerator or in a cool room away from direct sunlight. Sometimes a drop of blood is seen coming after the injection. Light pressure to that site for half a minute will help.
  • There is no need for a vigorous massaging of the site after the injection has been given.
  • You will need to have the food consumed within ten to fifteen minutes of the rapid or premix insulin shots to prevent low sugar levels.
  • Dispose the needles in a sharps container. It is advisable to change the needles after every injection.
  • Do not wipe the needles with an alcohol swab as it removes the silicone coating on the needles and makes the injections painful.
  • The dose of insulin will have to modified when traveling by long haul flights involving more than 15 hours either towards the East or the West.

 

Some precautions:

  • If going for a party at night, it is safe to take the long acting insulin before the party if the patient is on a mix of short and long acting insulin. Take the rapid acting insulin after you come back home, and checking the sugar levels. Taking the rapid insulin before the party can lead to low sugar levels as there will be a delay in eating the food. Moreover, one is not sure of the kind of food either and how much one would consume.
  • During Ramadan, please consult with your doctor on how best to take insulin.

Some myths:

  • The dose of insulin always remain the same. The dose of insulin depends upon the sugar levels while checking.
  • If I am sick and have not taken food, I do not need to take my insulin shots. When sick, though the appetite is compromised, the sugar levels will be high in response to the body`s defense mechanisms. Check the sugar levels and inject accordingly after consulting with your doctor. You might need either a smaller dose or higher dose depending upon the sugar levels.

Normally one unit of rapid acting insulin corrects sugar spike caused by intake of 10-15 gm of carbohydrate. (this is called the insulin to carbohydrate ratio) The carbohydrate content of food can be understood by referring to apps available on the smartphones or by checking on some sites such as www.carbsandcals.com

Another number to known is the insulin sensitivity factor. If you divide 1800 by the total dose of insulin taken in a day it will give the insulin sensitivity factor. Suppose you inject 50 units of insulin a day ( add all the insulin doses taken on a day), divide 1800 by 50 to get 36. This means by injecting one unit of insulin 36 mg/dL or 2 mmol/L of sugar comes down. This number will vary from person to person.

There are so many new insulin preparations and combinations being researched and soon to come into the market.

Points to consider while exercising if you are on Insulin:

Please check the sugar levels before exercising. If sugar level is < 5 mmol/L or 90 mg/dL, take 20 g carbohydrate, wait till the sugar levels reach 7 mmol/L ( 126 mg) . If sugar levels are between 10-15 mmol/L( 180-270 mg/dL) you can still exercise but be reminded that the sugar levels go up while exercising. If sugar levels before exercising are above 15 mmol/L (more than 270 mg/dL), check ketone levels in blood( there are blood ketone meters available with Freestyle® which uses a test strip for ketone like using the glucose test strip) If the blood ketone is between 0.6 to 1.4 mmol/L, you can do moderate intensity exercise and drink more fluids for half an hour. If the blood ketone levels are more than 1.5 mmol/L, you need to meet the doctor for correction of the sugar and ketone levels with insulin and IV fluids. Upper abdominal pain and nausea or vomiting can be sign of high blood sugar levels.

During the exercise you might need to snack in between depending upon the duration . An exercise time of not more than an hour needs no carbohydrate replacement, if the exercise duration is between an hour to 2 hours, take 30-60 gm carbohydrate snack and some water. If the exercise duration is more than 2 hours, take 30 gm carbohydrate every 20 minutes with water.

Prevention of low sugar levels after exercise : If doing exercise 2 hours after taking basal insulin, reduce the dose of basal insulin by 20%. If doing the exercise in the late afternoon or evening, reduce the dose of basal insulin by 20% at night to prevent low sugar episodes. A short sprint before or after the exercises causes a spike in sugar levels which prevent getting low sugar following the exercise regime. A proper cooling down after exercise can prevent the high sugar levels soon after exercising.

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Updates in insulin delivery devices and glucose monitoring

Updates in insulin delivery devices and glucose monitoring

New insulin delivery devices .

  • LifeScan One Touch Via®

index

This is a super slim pump device which delivers only bolus (rapid acting ) insulin. The cartridge can store 200 units which means less frequent refilling of the insulin. Squeezing 2 buttons simultaneously on the pump allows 2 units bolus dosing.

  • Companion Medical`s InPen®
  • In pen

This is the first insulin pen with in-built Bluetooth- sends the dose data to a phone and app automatically. This calculates and recommends the optimal dosing of insulin, tracks the history and timing of the dose, monitors the temperature of insulin, displays the last dose and insulin on board available. This can even send reports to the health care team if synchronized.

  • OneDrop Premium®-

One-Drop 2

 

This a Bluetooth enabled meter which helps in diabetes education by paying an annual fee besides monitoring sugar levels and administering insulin.

 

  • Tandems T Slim X2, OmniPod Dash System also are soon to hit the markets.

Image Slim X2     Omnipod 2

 

 

 

 

 

 

 

 

 

 

 

Some new glucose monitoring devices:

  • Abbots Lifestyle Libre Pro®-

LibrePro 1   LibrePro 2

 

After the sensor is applied on to the body, there is no need for the patient to interact with the system. There is no need for the finger stick calibration. This can monitor 2 weeks of continuous glucose monitoring.

 

  • Google Contact Lens®-

google contact

This is a contact lens with a reader device which can check the sugar levels from the eye tears. The lens has a wireless chip and a miniaturized glucose sensing device. A tiny pin hole in the contact lens helps the tear drop to seep in for glucose sensing. The electronic connections lie outside of the normal eye thus not harming the normal eye. There is a wireless antenna inside the contact which is thinner than the human hair and this helps to communicate the information to the wireless device.

  • Medtronics MiniMed Pro Infusion®-

MiniMed

 

This has a very small catheter and has lesser tendency for blockage. The tubing has a side port which be used for insulin delivery even if the main port is blocked.

  • Medtronics 630G®-

MiniMed 630

 

This calculates and recommends precise bolus dose. This prompts the patient to take action by predicting low levels. This has an inbuilt continuous glucose monitoring devise. The insulin can be delivered every 5 minutes, if set to deliver so.

 

 

 

 

 

 

 

 

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Exercise tips in cold weather

Exercise tips in cold weather

 

Tai chi

It is a welcome change in the climate after months of scorching heat in the middle East. This might last for a couple of months before the scorching heat picks up again. It is the time for outdoor partying, smell of inviting barbeques and probably increase in bad cholesterol levels !!!!! It is also the time for contracting viral fevers. Have you had your annual flu shot? The Flu Vaccine at least helps against many of the strains of virus which are getting more complex with each passing year.

Losing weight is something the doctor always stresses on. Interestingly, you might notice that the males are generally reluctant to address the obesity as well as their female counterparts. Moreover, weight loss is slower among those with diabetes due to the medicines they are on and also due to diabetic dysregulation. But , that cannot be used as an excuse for losing weight or even trying to.!!!! There is always a weight loss plateau that is to be expected and that should not deter yourself from continuing, but will need a self assessment as how to overcome the plateau.

Many now blame the cold weather and cold breeze and wish to remain cuddled under the blankets or remain indoors and try eating more to keep the body heat.

Impulsive eating can occur when stressed ( positive stress is during a vacation and negative stress during a personal tragedy) , when angry, when depressed or when worried about an upcoming event or even when stewing over a conflict at office or work. This often leads to impulsive eating followed by the guilt and again feeling low followed by eating again which gets you nowhere healthy !!!

Bed time snacking

People might keep on snacking to give them the so called energy while staying up awake while working late hours. There are certain occasions when you are allowed to snack especially when having an early light dinner and sleeping late. But, there are certain things to be known while snacking.

  • Warm milk contains tryptophan and helps in sleep
  • A bowl of cereal with milk or a glass of labaan( butter milk) , crackers or bread and cheese all can cause sleep due to the carbohydrate content.
  • Sources of hidden caffeine and fatty food such as burgers can impair with sleep.
  • Alcohol ( nightcap) might cause nightmares, frequent awakening, night sweats  and headache for some which can impair with sleep. Drink plenty of water after the sleep.
  • Protein rich and high fat food will cause problems in digestion which can impair sleep.
  • Spicy food and smoking can impair with digestion.

So make healthy choices while snacking. Snack is just a small meal and not another meal.

The winter months are a cause for celebrations and family outings . The smell of barbeque fills the air after the sun sets. People might eat more of meat and prawns which might increase the cholesterol levels. You can however go a walk outside as the climate is much better than the hot humid summer climate.

Generally sugar levels and cholesterol levels rise with the increased food and alcohol consumption during the winter months.

 


      image 3                                                    aqua aerobics 2

You can safely exercise indoors if the weather outside is not to your liking. Tai Chi, Pilates, using the Hula Hoop, dancing to music,  yoga, skipping rope or just spot jumping helps burn calories. Zumba or kick boxing are options that needs a trainer to help you out. For the fitness freaks who like to sweat it out in a gym, try something new at the gym or use resistance bands. You can swim or do any exercise in the pool as water is kind to the joints. Aqua aerobics is catching up in a big way as it is entertaining and kind on the joints as well. One can enjoy shopping by walking in the malls and doing window shopping !!!! Walking is still a good exercise. Take care of your footwear and use proper clothing if walking outdoors. Cover your head and neck if very chilly. The new form of play station using the X box helps you engage in interactive games and helps you combine entertainment with exercise and it can be enjoyable when performed with either family of friends.

For those who are interested in resistance training using small weights, remember to always warm up, stretch and do repetitions of ten to twelve in a smooth controlled motion. The muscles might ache at the beginning, Give a rest in a between and try these on alternate days to help the muscles to recover.

How to overcome barriers to exercise?

  • Break the times of exercise to smaller periods if it not practical to spend 30 minutes a day for five days a week.
  • Identify causes of waste of time such as watching the television, lying on the sofa. See if these can be overcome.
  • Reframe the concept of exercise such as walking the dog or taking the kids for playing, playing ball on the beach or even dancing, walking in a mall, walking around a large airport terminal while waiting for the flight.
  • Join a group who can motivate you.
  • Watch the television or listen to music while exercising.
  • Take stairs instead of the lift or escalators.
  • When ill, do not exercise.

There are numerous apps which can be downloaded from the app store if you have a smartphone. These can monitor the progress and can even motivate you to get moving.

Ask yourself why you want to lose weight:

Questions Yes No
Look better
Feel better
Feel comfortable in clothes
Improve self image and confidence
Improve physical stamina
Improve energy levels
Improve sleep
Be a role model for my family
Improve the blood pressure, cholesterol and diabetes
Reduce joint pain
Improve life expectancy

 

You might want to add more…..such as want to look good at a function or don those clothes which you outsized and so on…..

 

Write down the challenges and obstacles you face towards achieving the goals. The more honest you are with yourself, both in recognizing the obstacles and coming up with realistic strategies, greater are your chances at succeeding. Let that be your New Year resolution.

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Type 1 diabetes mellitus

Type 1 diabetes mellitus

type 1

 

Cause of type 1 diabetes:
Type 1 Diabetes is due to an absence of insulin secretion by the pancreas from birth. Most of the cases of type 1 diabetes are caused by unknown triggers which results in varying amounts of destruction of beta cells in a genetically susceptible person. However, in some cases the pancreas can be damaged by auto immune diseases in which the body cells are destroyed by some cells due to unknown causes. A simple viral fever may cause the virus to attack the heart or pancreas leading onto diabetes.
Younger adults will show slower destruction of the β cells in comparison to younger children .
There are plenty of Type 1 Diabetic patients who are living well into the nineties. They all  went through a tough time when diabetes management was at a very primitive stage. There were no sophisticated blood glucose monitors, no good hospitals or technology to support them, no education materials, no support groups or no insulin as well. People had to monitor the urine and be on a starvation diet to try and find a cure for this. Insulin changed the way these patients handled life. The people who have lived long to see the 2 world wars, have told they have learned this from life: “ Learn to live in spite of having Diabetes” and “take one step at a time” and “Live life to its fullest- enjoy every moment of it and thank the Almighty”.
Today there are so many advances in the field of science which brought about the discovery of insulin, the glucometer devices which could even store data of previous readings, smart phones which could guide one to monitor ones diet, remind to take medicines and even plot their progress, have alternate sources to deliver insulin, alternate devices to check sugar levels painlessly and stem cell therapy and transplantation of the pancreas.
Type 1 diabetes mellitus used to be called insulin dependent diabetes mellitus. It used to be associated with children alone. There are a lot of young people and adults who are being diagnosed as having type 1 diabetes.

 

Clinical findings:
Those people who lose weight dramatically, do not thrive properly, get admitted for vomiting and abdominal pain are found to have diabetes mellitus type 1. It is generally seen younger the patient at time of diagnosis of diabetes, higher the chances of having type 1 diabetes. There are some people who are diagnosed with diabetes when they visit the hospital with either failing vision or kidney problems. There is a higher incidence of young adult presenting with type 2 diabetes as well.

Diagnostic tests:
g1

 

Blood tests such as GAD 65 antibodies ( Glutamate acid decarboxylase), IAA ( Insulin auto antibodies), ICA ( Islet cell antibodies) , are some of the commonly used tests run to diagnose type 1 diabetes. However, all these may not be positive in the early stages as that depends on the damage to the islet cells of pancreas. The estimation of Insulin levels and its precursor, C peptide done in fasting and after food are also used to define type 1 diabetes.
Though many genetic markers have been identified, the widespread use of genetic screening is yet to be justified and implemented
Insulin still remains the mainstay of treatment and is usually a lifelong. There is no magic cure yet for Type 1. However, research is still on to the efficacy of a stem cell therapy. Islet cell transplantation and pancreas transplantation have also been done at selected centers round the world, but the prohibitive costs, the post transplantation medications to reduce the rejection and the uncertainty of life long cure have not led to much enthusiasm.
There are advances coming up in the self monitoring devices and also novel ways to administer insulin.
Young adults or children must be informed about a partial remission of the diabetes where either a low dose of insulin or no insulin may be needed in the early phase. This is called the “honeymoon” phase of diabetes when there will be some activity of the pancreas but not enough to maintain sugar levels.

 

Insulin :

insulin

 

One has to take multiple injections a day to match the food intake just because the pancreas refuses to secrete insulin which keeps the sugars down. Some may need to take a combination of long acting insulin at night time and one with each main meal of the day. There different insulin preparations which have been detailed in the post titled,”insulin in diabetes”. Insulin can be given by pens which are easy to use and have small needles. Some patients may need multiple doses. Some may need insulin to be administered by a pump which delivers insulin in small doses based on food intake and physical activity.

 

  • Insulin has to be stored in the refrigerator ( not the freezer compartment) when not in use.
  • Never skip a dose of insulin as the sugars may increase and cause even an unconscious state which can kill if not treated in time.
  • Likewise, if you inject too much, the sugars can drop to dangerously low levels and can make you unconscious and can kill.
  • Have a sugary drink or sugar at hand always.
  • When you feel sweating or shivering, it can mean the sugars are low.
  • Remember to change the needles daily.
  • Rotate the site of injection daily. These can be given on the thighs and abdomen. Pinch a fold of skin and inject at right angles. Do not inject if the skin is too hard on pinching or dark in color. Normally the rapid acting insulin is given on the abdomen and the long acting given on the thighs.
  • When sick, it is a common mistake to either reduce the dose of insulin or omit the dose as there is reduced food intake. However when sick, the hyperglycemia demands a slightly higher dose of insulin.
  • Teenage girls can have eating disorders and may omit the dose of insulin with a hope to control their weight, with grave consequences.
  • As you grow up or have stress during exams, job interviews, marriage or family matters, the sugar levels can increase. As you grow up, the insulin levels will also increase.
  • If having a party or attending a buffet, you are allowed to take insulin in two separate doses like 30% before the party and 70% after the party. If you take 30 units at night of rapid insulin, take 10 units before the party and 20 units after the party to cover the food intake.
  • Be careful of alcohol intake and dancing after that as the sugars can drop down.

Advantages of insulin pumps over multiple daily injections :
• Ease of calculation
• Less insulin stacking
• More reliable
• Very low doses 0.01U to 0.025 can be given in those using the pump.
• Fewer skipped doses
• Less hassles with time zones
• Discreet insulin delivery

Requirements before embarking on insulin pumps:
• Should be willing to check blood glucose many times and should be able to count carbohydrates
• In toddlers, the pump can be placed between the shoulder blades or butt.
• The tip of the cannula of the infusion tubing can be blocked by the inflammatory cells causing errors in dosing.
• The settings in a young child should have high and wider range, in those with hypo unawareness, set the hypoglycemic setting higher, and those who are pregnant, set the narrower and lower range.

The accessories have to be changed once every 3 days. This is a costly matter.

Checking the blood glucose:

glucometer 5
You need to check sugar levels quite frequently. Ideally, a pre meal and 2 hour post meal sugar check will be needed.( 7 tests a day) This will have to be done at the initial stages till you know the “signals” your body sends. Some have to check their sugars when they have had a new food or while at a party. There are machines that require a lot of blood sample for the testing and some which need very less. The finger pricks are done at the tips ( in medical terms, the pulp) of the fingers. This is a very sensitive area and the repeated pricks for the rest of your lives can affect the sensation of these wonderful parts. You will need to have a glucometer machine that will check the blood sugar and blood ketones as well. Most of the machines have data storage facilities and also some can be connected to a network and data can be transferred to a remote system such as ones parents or doctors or nurse. ( Read more of this in the post titled, Diabetes and Digital age )
Self monitoring of blood glucose can help detect low sugar or high sugar levels, help titrate the dose of insulin, can be used to assess sugar levels when sick or pregnant and also to check how the levels are after a workout.
Earlier good control of sugar levels will delay the onset of the feared complications of diabetes such as the retinopathy ( eye) , neuropathy( nerves), nephropathy( kidney), heart disease.
The variability in sugar readings are more important than a stray high reading.

Good sugar control will lead an improvement of
• 76% in incidence of retinopathy
• 47-54% reduction in progression to severe eye problems
• 39% reduction in onset of microalbuminuria
• 54% reduction in onset of kidney diseases
• 60% reduction I onset of developing neuropathy
• 42-57% reduction in onset of heart related diseases.

Barriers to achieving good control:
• Fear of hypoglycemia ( low sugar)
• Complexity of day to day management
• Need for frequent self check of sugar levels
• Lack of social and family support
• Lack of specialized care access
• Increased costs
• Psychological factors- depression and anxiety
Educational programs such as DAFNE ( Dose Adjustment For Normal Eating habits) help in flexible plans for diet which help to overcome the rigid dietary control and fixed doses of insulin. There are many such good educational tools. The Conversation Maps© by Lilly is an interactive tool which helps understanding the disease well.

Periodic Check up:
The parents will accompany the child to get more understanding of the management. It is important to have the eyes checked, the feet checked and urine checked for microalbumin leak once annually after the age of 12 years. It is important to check the blood pressure and lipid profile if above 12 years of age. The 3 month average of sugar, HbA1C is to be done thrice a year. The most recent guidelines state a 3 month average sugar level of 7.5% for any age of child till the age of 18. The values were higher in the previous years.

Complications:

complications of diabetes

The complications are the same as those which a person with type 2 diabetes can have. The success of the quality of life depends on the near normal levels one can attain. It can get frustrating and depressing at times and definitely may even lead to quarrels with parents. They are concerned about the good health, though some parents may become over protective. Having high blood glucose can poison the body and slow it down! It can affect studies as well. Diabetes can affect the kidneys, eyes, heart, nerves and sensation of the limbs. Maintaining near normal sugars is the key to success to prevent these complications. Regular check up with the doctor or nurse can help lead a near normal life. If there is a problem such as difficulty in seeing while at class, please inform the teacher or parents. They may not understand the magnitude of the problem and may think it is way of escapism. Most of the schools have a medical wing having a trained nurse. A note from the health care provider can help the school authorities to take care. The child should be allowed to snack if low sugar levels are detected while in class, must have their parents notified in an emergency, but must not be restricted from regular playing and activities.
Take care of the feet- use footwear all the time even while on the beach. You may accidentally cut yourself which can take a long time to heal. Check your feet daily. Use cotton socks and use one size extra large footwear. Use a moisturizing cream on the feet taking care not to apply it between the toes. If you cannot feel either hot or cold sensations, please mention to your doctor or nurse urgently.

Take care of the eyes and tell your parents or your teacher if there is a problem. They can guide you to the doctor or nurse. Remember that eyes can get cloudy when the sugar levels increase.
Brush the teeth well and take care of them by visiting the dentist once annually.

Exercise:

yogaYou can exercise like other people. You may tire easily. Before exercising, check your sugar levels , if high, check on blood ketone levels as well. Do not exercise if low sugar levels are seen on checking. If blood ketone levels are more than 1.5 mmol/L, give yourself 15% of the basal insulin with a pen separately. Drink a glass of non sugar drink every hour. Check again after an hour. If not feeling well, losing consciousness or dehydrated or vomiting with abdominal pain, go immediately to the hospital.
Do not exercise immediately after injecting insulin as it can get absorbed soon and cause low sugars. It depends on which part of the body you inject and which group of muscles you exercise. If you inject onto thighs and go for jogging, it will be absorbed faster. If sugars are low before the exercise, have a carb snack ( biscuits or juice) before the program. Do not give bolus injections for the snacks taken to prevent low sugars.
Warm up for 5 minutes, stretch for 5 minutes and then go into activity for about 20 minutes and allow 5 minutes for cooling down. You are to drink non sugary fluids every half an hour. You can have a carbohydrate snack- a biscuit or a fruit juice to bring up low sugars. CHOCOLATES DO NOT INCREASE THE SUGAR LEVELS INSTANTLY DUE TO ITS HIGH FAT CONTENT. Preferably do not use heavy weights while exercising as it increases the pressure in your eyes which can cause a bleed into the eyes. If you go for a sprint( high intense exercise), the sugars will increase! This is due to the increase in some hormones which increase the sugar levels.
If the doctor says you have retinopathy ( eyes are affected by Diabetes), avoid lifting heavy weights and strenuous workouts.

Read more in the blog: Exercise and Diabetes

 

If having high blood sugar:
emotional-adulthood1

This is a medical emergency. If the blood sugars are high and if there are ketones in the blood the following can be done before going to the hospital.

Blood glucose                Blood ketones                                Insulin dosage
>200mg%                      <0.6 mmol/L                         One unit Rapid  insulin for each 50mg%above 100 Mg%

>200 mg%                       0.6-1.5 mmol/L                    10% of TDD of rapid  insulin
>200mg%                       >1.5 mmol/L                          20% of TDD as rapid  insulin

TDD means total daily dose. To convert sugar in mg% to mmol/L divide by 18

If the blood sugar is 345 mg%, the extra insulin has to be calculated as follows:
345- 100 = 245 mg%
Give one unit for each 50mg% above 100mg%
This means you have to give 5 units of rapid acting insulin ( 245/ 50)

Check sugar and blood ketones every hour till normal. You can use the Freestyle Optium Xceed meter for this. You can place blood as for checking the sugar on the strips for ketones and sugar.

For example, if the blood glucose is 22 mmol/L, the excess is 16.5 mmol( 22-5.5) You have to give one unit rapid for each 2.7 mmol excess. This means, 16.5 / 2.7 which is equal to 6 units.

 

Blood sugar In mmol/L                Excess sugar above 5.5 mmol/ 2.7                Extra  Rapid Insulin to be given
15                                                                   9.5/2.7                                                                          3.5 units (3 u)
16                                                                   10.5/2.7                                                                        3.8 units ( 3 u)
17                                                                    11.5/2.7                                                                          4.25 ( 4 u)
18                                                                    12.5/2.7                                                                        4.6 ( 4 u)
19                                                                    13.5/2.7                                                                         5 ( 5 u)
20                                                                    14.5/2.7                                                                         5.3 ( 5 u)
21                                                                     15.5/2.7                                                                          5.7 ( 5 u)
25                                                                     19.5/ 2.7                                                                        7. 2 ( 7 u)

Remember that the first 5.5 mmol of sugar is not counted for correction. The value above that is used for calculation. So please do not give a rough 10 units for any emergency at home. The aim is to correct the excess sugar. Do not feed the child after this dose of insulin. At this dose of insulin, the child will not go into low sugar. Make the child drink water hourly. Check the sugar every 15 minutes. If vomiting or abdominal pain or losing consciousness, get the child to hospital immediately.

The TDD means the total daily dose of rapid taken in a day. If it is 6+12+8, the total is 26 units. 10% of this is 2.6 units
20% of the total daily dose is 6+12+8= 26 and 20% of this is 5.2 units.

This needs some quick calculation. The best will be to give something like 4 units insulin, then calculate the exact amount.
If hypoglycemia ( when sugar levels fall down) develops, drink orange juice or take sugar or dates. In somecountries glucose tablets are available.  Wait for half an hour. Recheck and if needed take more orange juice. You can have a handful of raisins( dry grapes) also if needed.

Glucagon kits will be available in the pharmacy. This is used for treatment of low sugar levels before reaching the hospital.
If less than 8 years of age or weighing less than 25 kg give 500 mcg of glucagon Intramuscularly. If weighing more than 25 kg or more than 8 years of age, give 1 mg of glucagon intra muscularly. Check sugar levels again in 10 minutes. Take to the hospital if not better.

Adventure sports

  • Having type 1 diabetes does not prevent you from enjoying life to the fullest.
  • Never go for adventure sports alone.
  • If going for high altitude trekking, remember high altitude trips mimic mountain sickness ( headache, intestinal discomfort and fatigue)
  • Increased blood sugar and insulin resistance can occur at high altitudes. Sugar levels can fall with the increased activity.
  • Glucometers may not be accurate at cold temperature; the insulin may freeze as well.

Deep sea diving:
In those who dive deep, no unconsciousness has been reported. However, it is better to check the sugar levels an hour, half an hour and just before diving.

The transition from a child to an adult
grown up

 

• Kids just want to be kids. Child is a child first. Diabetes comes second.
• They strive for a little more independence each year. They do not want to stand out from the crowd. How the child accepts diabetes will depend on how, you as a parent, look at it. If you feel diabetes is a tragedy, the child will feel that way as well. However if you look at it as a fact of life that requires attention and discipline, the child will be prepared for a healthier future.
• Checking sugar frequently is painful but the child will gradually understand the importance.
• Remind them to be snacking in between playing hours.
• Remind independence comes with responsibility as they grow from a child to a teen.
• If your child reports a high blood sugar, do not scold them. They may be trying their best. Shower them with praise when they do well. Remember that nobody is perfect.
• Ups and downs of sugar levels are part of growing up and changes in body hormones as they grow into their teens.
• It is worthwhile checking how each food affects the sugar before and after eating and before and after exercise.

 

 

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Fasting during Ramadaan

Fasting during Ramadaan

ramadaan feasting                                                                             ramadaan feasting 2

Fasting from dawn to dusk in the holy month of Ramadan for healthy adult Muslims has been ordained and physically sick Muslims are exempt from it. However many Muslims with mild to moderate Diabetes, Hypertension and other medical conditions do want to fast.

The purpose of this presentation is make some recommendations how one can fast safely in light of research on fasting. Many are concerned they cannot fast when they have diabetes mellitus . Please consult with your doctor.

Some people may need some tests to be done to assess fitness for fasting.
The salient features of fasting are :
 It is a voluntary undertaking rather than being ordered by a physician
 There is no selective food intake i.e. protein only, juice only, fruit only , water only etc
 There is no total calorie malnutrition i.e. it not a semi starvation diet.
 An exercise in self discipline i.e. from constant nibbling , drinking, smoking etc
 Psychological effect on the body and additional prayer give additional peace.
People who should ideally not fast, but can fast under supervision
 Diabetes Mellitus Type 1
 Those who get recurrent low sugar levels.
 Chronic Renal Failure including Renal Transplant
 Severe heart and lung conditions
 Severe Epilepsy
 Severe Migraine
 Physically sick ( Quran 2: 184-185)
 Traveler on a journey
 Women during menstruation
 Pregnant and lactating women
 pre pubertal children

Do you know?
 Blood glucose and Insulin levels will fall during the fast.
 The first few days will take some adjustment. If in doubt( headache, sweating, dizziness) check sugar or blood pressure.
What to do during the fasting:
 Beware the sweets and the fried food.
 Remember that by eating throughout the night will not help one tide over the next day. Instead indigestion and gas related problems may set in.
 Fluid intake must be adequate during the night to make up for the reduced intake during the day
 Having too much of sweets or fried food during the Sahoor can lead to dryness of the mouth which can be a cause of concern during the fast.
Points to remember while breaking the fast at Ifthaar:

  • Drink enough water, butter milk or juice. A glass of water melon juice, butter milk or tender coconut water will be a good option to break the fast. One need not add glucose. Water melon juice is sweet by itself and usually people add more sugar. Water melon has a higher glycemic index.
  • Try to be careful with the fried and sweet food. Take them in moderation.
  • Have a good Ifthaar or Isha meal. Have your prayers and then go for a walk to allow digestion.
  • Have some fruit at about midnight if need be. Have a good Sahoor of needed.
  • Avoid too salty food at Sahoor as that can make the mouth dry forcing more fluid intake.
  • Check the sugar level 2 hours after Ifthaar to decide whether  any additional dose of medicines is needed.

Exercise and Ramadhaan
 One can exercise during the month. Please check the sugar before exercise. One can exercise lightly before Isha or after the heavy meal.
 Try to avoid strenuous workouts as the body may be tired due to the lengthy fast.
 Those who want to exercise before Iftaar should check their sugar before exercise. If sugar is below 100mg(5.5 mmol/L) avoid exercising.
 Those with type 1 diabetes are exempt from fasting as their sugar levels are dependant on insulin. However, there are some who do fasting alternate days only. This is depending on your health status.

Some more tips

 Check sugar levels just before Ifthaar and before the Sahoor meal.
 One can check the sugar levels at 7 am before going to work. If the sugar levels are either too low or too high, it is wise to seek medical advice immediately. You may be advised to forego the fast that day.
 Time your medicines between Iftaar and 1am.
 If on long acting insulin such as Glargine or detemir, it is advised to take 20% less either at Ifthaar or Sahoor time
 Normally the doses of most of the medicines could be reduced during the month.
 The medicines have to be tailored in such a way that there is no hypoglycemia
 Be careful of sulphonyl ureas and rapid acting insulin
 Among the sulphonyl ureas, gliclazide is safe in that the chances  of hypoglycemia is lesser and the weight gain is minimal.
 Intermediate acting insulin are avoided during the month due to the 10-12 hour action which can go into the period of fasting

 

The essence of Ramadhaan is the same all over the world, but the flavors may differ.

Have a blessed Ramadhaan

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Winter and Diabetes

Winter and Diabetes

Winter-Snowman (1)winter

 

Normally during the cold winter months, the levels of HbA1C, the 3 month average of sugar, can be higher due to higher food quantity consumed to combat the cold, the frequent outdoor barbeques and probably excess liquor consumption with the co incident Christmas and New Year festivities. People spend more time indoors in places where the weather is extreme. Lack of adequate physical activity and excess sleeping hours cuddled up under the warm blankets add more insult. It is quite natural to gain 5-6 kilos during the winter.

Blood Sugar Testing

GlucometerThe finger tips may be cold and so warm them by rubbing them together or wrapping them around a hot mug before pricking the finger for testing. In places where it snows, the glucometer kit has to be kept warm in covered bags so that errors do not come in the readings

 

 

 

Exercising

It is difficult to work up a sweat while exercising during this time and one may feel cold after the exercise due to the evaporation. Remember to dress adequately while going for outdoor exercises. Hydration with adequate amounts of fluids is still important even in the colder months. Dehydration can increase the sugar levels.

yoga       Tai Chi

 

 

Hula Hoop             swimming

Exercise such as skipping rope, doing the Hula Hoop, aerobics, dancing, yoga, swimming in thermal controlled swimming pools or working out in an indoor gymnasium do wonders. The benefits of exercise are the same whether done during winter or summer!!

Some blame the cold for exercising outdoors, but then they also blame the summer heat and humidity when that sets in.

Care of Skin

It is important to take good care of the skin as it can dry quite fast. Adequate and generous application of moisturising creams, and sunscreen if going to winter sports such as skiing or snow surfing or those just trekking in the snow laden mountains are very important. Adequate hydration keeps the skin shining and hydrated.

Those with neuropathy ( where the nerves of the feet are not working properly) may have difficulty in gauging the heat of water used for bathing.

Take care of the feet. Do not use hot water bags to keep yourself warm. Use multiple layers of clothing or socks at night to the feet. In some countries warm fireplaces keep the rooms warm, but beware the carbon monoxide accumulation.

Food & Beverages

Alcohol may cause a sense of warmth caused by dilatation of blood vessels, but the same may be lost after some time. Manage the consumption of alcohol wisely. Try to take hot beverages and easily digestible food such as soups, oats, porridge, steamed food and some fruits. Black tea with crushed ginger and black pepper is a good drink to even soothe the throat. Remember that excess red meat consumption can lead to high cholesterol levels in some races. The temperature can get quite low at night and it is natural people may eat more to raise their body temperature. Remember you do not need that much food at dinner whether it is summer or winter. It is healthier to sleep on a lighter stomach.

Frequent respiratory infections , mostly viral, are quite common. It is wise to have a Flu vaccine taken once a year rather than have to take multiple courses of antibiotics and medications to combat the infection. The elder adults should have a shot of pneumococcal vaccine once in their life.

It is also quite common to get infections due to food poisoning from eating out .

Use tissues, frequent washing of hands  using soap and water or sanitizers especially before shaking hands with others help to prevent transmission.

Gargling of the throat with warm saline helps. So also does steam inhalation.

Fizzy cool sugary drinks do not help whether it is summer or winter.

Enjoy the winter because you will wish it was like this when summer blasts in.

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glycemic index

glycemic index

glycemic-index-chart

Glycemic index ( GI )of a food is the increase in blood glucose ( above fasting glucose) 2 hours after ingestion of a constant amount of food divided by a reference food( usually glucose).

To make this easy to understand, if the GI of a particular food is 72, this means that 72% of the ingested food is converted to glucose within the body after 2 hours of consumption.

GI reflects the rate at which carbohydrate is absorbed and digested by the body. Try to aim for low GI food combined with medium or high GI food rather than have more of high GI food. Whatever be the diet chosen, the dietary management has to be combined with physical activity for maximum benefit. A diet which suits one person may not suit all. It is advisable to see which food increases the sugar levels by checking the sugar levels after each food ( this is painful, but this can help to decide which food suits a person).
Low GI food stuff with the GI levels
Yoghurt low fat 14             Milk chocolate 24             Multi grain bread 48          Broccoli 15            Spaghetti 27              Parboiled rice 48                      Celery 15                              Skimmed milk 32                 Carrot juice 45               Bell peppers 15          Fat free milk 32   Jams and marmalade 49            Spinach 15                         Apple 38                         Low fat ice cream 50            Tomato 15                      Plum 38                   Orange juice 52                       Soya beans boiled 16             Pears 38               Kiwi 53                          Artichoke 15           Apricots dried 31                     Banana 54                            Asparagus 15

Black beans 41               Sweet potato 54              Cauliflower 15          Boiled lentils 29                  Egg plant 15                Boiled kidney beans 29      Lettuce 15                                 Green beans 15                          Peanuts 15                             Cucumber 15

 

Medium GI food with their GI levels

Oat bran 55                       Rye-flour bread 64                        Rice, brown 55                 Apricots (tinned in syrup) 64         Fruit cocktail 55 Raisins 64                          Spaghetti, durum wheat 55           Macaroni cheese 64        Popcorn 55                                             Beetroot 64 Muesli 56                          Mars bar 64                                          Mangoes 56                         Black bean soup, tinned 64         Potato, boiled 56

Cake , tart 65                  Mini Wheats (wholemeal) 57           Potato, steamed 65 *       Table sugar (sucrose) 65       Apricots 57

Barley, flakes 66             Potato, new 57              Pineapple 66         Digestives 58              Rice, white 58     Croissant 67         Pizza, cheese 60               Ryvita 67                          Hamburger bun 61      *Ice-cream 61 Whole meal bread 69     Shredded Wheat 69          Muffin (unsweetened) 62                Potato, mashed 70
High GI food with their GI levels
White bread 71                    Broad beans 79                     Golden Grahams 71                 Jelly beans 80                                               Millet 71             Pretzels 81 **                         Watermelon 72                     Rice Krispies 82                     White rolls 73                          Potato, micro waved 82    Puffed wheat 7                   Cornflakes 83                             Corn chips 74                      Potato, instant 83                                       Chips75

**Potato, baked 85             Rice pasta, brown 92             Doughnut 76                      Wafer biscuits 77 **                 Rice cakes 77

Dates 103
** low in calories and highly nutritious
* empty calories

 

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Insulin in diabetes

Insulin in diabetes

download                            insulin pen device parts Indications for insulin usage:

  • When oral medicines fail to control the sugar in maximum doses
  • when there are complications to the eyes, kidney or heart,
  • when the sugars are very high,
  • when there is pregnancy associated with diabetes,
  • when intolerant to oral medicines ,
  • when diagnosed with latent auto immune diabetes of adults
  • when being planned for surgery.
  • If diagnosed with type 1 diabetes.

Insulin preparation: There are 3 main types of insulin based on duration of action- short acting, intermediate acting and long acting. • Short acting insulin acts for a short time and peaks fast. This is why this has to be administered with the main meals at least three times a day. • Intermediate acting insulin acts for close to 10 hours and so needs twice daily dosing • The long acting insulin can last for 16-24 hours and thus, needs one or two shots a day • There are premix insulin which comprise short and intermediate acting insulin in one. • Ultra short acting and ultra long acting insulin preparations are now available. • Non injection forms of insulin are now becoming available- studies are on. Nasal, inhaled forms, patches, pills, oral sprays are all forms being researched into to avoid the needle prick. The doses of insulin are usually tailored by the doctor or nurse initially and then adjusted by the patient depending on the sugar reading. Insulin delivery devices are now- a days by pen devices or by continuous subcutaneous devices. The old method of using a vial and syringe is still present. Insulin can be safely administered if used sensibly. Store the insulin in fridges ( not in the freezer) or in a cool room, lightly shake the pen before use if pre mix insulin and roll the insulin pen between the palms of the hand to prevent injecting cold insulin and inject at different sites each time. The needles are to ideally thrown after each injection( though some can use up to 3 injections with a needle) .   Sites for injecting: where_to_inject • The thighs on inner side, the outer side and front side are the most preferred sites. • The abdomen wall can be used- but remember not to inject just around the belly button ( umbilicus) inject any place on the flanks more than two finger breaths on either side of the umbilicus. • The arms are not commonly used in adults. • The buttocks and back are used for small children insulin injection How to inject: • Have the needles changed before injecting • Roll the insulin between the palms of the hands if insulin is cold. • Select the site for injection. It is not mandatory to wipe the area with a spirit wipe. However, if you do, make sure the alcohol or spirit dries out before injecting. • Feel for any thickening or induration. If present, avoid injecting into that site. • If skin is dark at that site avoid injecting there. • Do not inject into dilated veins on the thigh, if present. • Dial the required dose. • There are people who pinch a fold of skin before injecting. It is not necessary to. • Plunge the needle vertically into the site ( perpendicular to skin and not at an angle). Needles are fine and almost painless • Depress the plunger down. The meter will return to zero. • Count to five slowly and remove the pen. • It is common to see a drop of blood after removing the needle. • There is no need for a vigorous massage as is done after deep intramuscular injections. • Do not inject soon before or after an exercise regime. • Rapid acting ( short acting) insulin can be injected in the abdominal wall. The absorption from the thighs is ideal for intermediate and long acting insulin as the absorption is not so fast. The absorption of insulin is slowest if injected in the buttocks. The arm is not ideal for self injection. • The pen device has a spring device which can get worn out over a period of time, maybe after an year or two. Change the delivery system when this happens. The needles after use are to be discarded in a proper manner after putting them in a sharps container. There are places around the world where the used needles are sold again in a fresh pack thus helping spread of disease such as AIDS, Hepatitis B and Hepatitis C. Side effects of insulin: • Hypoglycemia- low sugar • Allergy to the preservative or type of insulin( this is quite rare these days with the advent of purified and human varieties of insulin) • Weight gainThickening of the subcutaneous tissue at injection site • Neuropathy- sometimes insulin can cause nerve pain which can be very depressing. Being started on insulin does not mean the end of the road. It is used by the doctor when the sugar levels are very high to bring I down, or when you are undergoing an operation or when you are pregnant or when you have complications affecting the eyes, kidney or heart. It does not mean that insulin once started remains so for the rest of your life. There are needless insulin delivery systems which are present elsewhere. There are other insulin routes available which had been researched, but fell out of favor due to the less efficiency. . While traveling long distances, use a temperature controlled pouch or ice box for keeping the insulin at a cool temperature. If you party, take a small dose before the party, have a snack before you leave, and have the rapid acting insulin after the dinner .Meet your doctor for advice on the dose. Alcohol intake can cause a delayed hypoglycemia(low sugar) The three main insulin delivery options are a pen, syringe, or pump. There are also a few newer insulin delivery systems, including the jet injector. Here are the pros and cons of each insulin delivery method to help you get started. Most of the insurance companies do not approve of these delivery systems which are new and innovative. The pen delivery system is, of course, approved and effective. Pen, Pump, or Syringe? Here’s a rundown of the three different insulin delivery systems, how they work, and their pros and cons. Insulin Syringe You use an insulin syringe to inject insulin into your body with a very fine needle. Pros: • Flexibility. You can choose from many different brands and types of syringes, and you can use them with just about any kind of insulin. • Cost savings. These work more economical than the latest medicines which could be very costly. • People with very regular schedules and consistent meal patterns can do well using this method. Cons: • Time. You have to be meticulous in loading the syringe, remember to warm the insulin if cold , by rolling the cartridge in the palm three or four times. Before injecting you need to check there is no air bubble, attach the needle, and draw the correct dose of insulin into the syringe. • Dosing mistakes. Sometimes error while loading the dose can lead to problems. Insulin Pen An insulin pen works much like a syringe, but it looks like the type of pen you use to write. Insulin pens come in disposable and reusable versions. • Disposable pens come pre-filled with insulin. • Reusable pens use a cartridge filled with insulin. Pros: • Ease and convenience. Pens are convenient to carry about unlike the insulin which ( and still is) comes in bottles.. To use an insulin pen, you just dial up the insulin dose on the pen. Then you press a plunger at one end to inject the insulin through a needle at the other end. • Memory storage. Insulin pens have a handy memory feature that will remind you how much insulin you took, and when you took it. Cons: • Expense. The disposable pens are costly and the ones which could be reused are more economical. However, the reusable ones may have to be changed once in a year or two as the dose dialer spring may become faulty. • Lack of options. Some types of insulin are not available in pen form. Insulin Pump An insulin pump is a device that’s about the same size as a pager. You wear it on your belt or in a pocket, and it delivers a steady stream of rapid acting  insulin to your body 24 hours a day through a needle attached to a flexible plastic tube. Whenever you eat, you press a button on the pump to give yourself an extra boost of insulin, called a bolus. The pump is an option for people with type 1 diabetes who have not reached their target blood sugar level using other delivery methods. It’s also a good option for people with diabetes that have very active lifestyles. It’s not clear whether people with type 2 diabetes benefit from using a pump. However among those with type 2 diabetes, who have failed to achieve good sugar control with maximum doses and have to take multiple doses of insulin instead, this is a convenient option. Pros: • Steady insulin release. The pump releases insulin as if mimicking the pancreas. The dose of insulin used will be quite less as it will be delivering tiny doses at pre fixed times. Only short acting insulin is used in this. Pumps are so efficient that you can use less insulin than you would with a syringe or pen. • Ease of use. You’ll no longer have to give yourself injections of insulin throughout the day–the pump will do it for you automatically. You can also eat whenever you choose. • Better blood sugar control. Because it delivers insulin steadily like your pancreas, the pump helps prevent blood sugar swings. • Ease of monitoring. Your pump can communicate with your glucose monitoring system so you can track your blood sugar over time and make changes to your routine as needed. Cons: • Constant wear. You’re going to be attached to this pump nearly all of the time — even when you sleep. • Risks. You need to be very careful about changing the needle every couple of days because there is a slight risk for infection. You also have to monitor your blood sugar levels, because you may be more likely to have a drop in blood sugar (hypoglycemia) with the pump than with a syringe or pen. If the catheter slips out or the pump fails, you might not get the insulin you need and over time your sugars can increase and you could develop a dangerous complication called diabetic ketoacidosis. • Cost. Pumps are costly and so also are the infusion tubing and reservoir. Some of the new ones come with inbuilt sensors as well which are costly. Insurance companies do not approve of this usually. • The infusion tubing and reservoir have to changed once every three days • Sometimes the tubing gets kinked without delivering the insulin which could cause problems • One has to feed in the carbohydrate consumption at the start to prime the pump. • The insulin will not be delivered if there is air in the tubing or if the insulin remaining in the cartridge is very low.   Jet Injector Jet injectors don’t have a needle. Instead, they use very high pressure to push a fine spray of insulin through the pores in your skin. Pros: • Needle-free. If you hate needles, a jet injector is an alternative to the insulin syringe or pen. Cons: • Pain. Though needle less, they can cause more pain in some of those with sensitive skin as the insulin is driven inside the body by sheer force. You have a high concentration of nerves close to the surface of your skin. Trying to push insulin through the skin can hurt more than injecting — especially considering how thin needles are. • Uneven insulin delivery. Because they send insulin into the body through the pores, jet injectors may not always deliver an accurate dose. Other options include an insulin patch. Work closely with your doctor to choose the option that best fits your budget, health needs, and lifestyle. Not all the above are available here in Oman. Afreeza is a powder form of insulin which is an ultra rapid acting insulin. The powder is used by an inhaler called the Dreamboat inhaler. Peak levels are reported in 12-14 minutes of inhalation. This is especially beneficial for those with type 1 diabetes who are dependent on insulin for life and also for those with type 2 who become insulin dependent with failure of the pancreas. Close to 5300 patients have been studied in trails across the world and the results so far are promising, but needs further time to be found effective. This has been found to reduce the post meal sugar levels, fasting levels, have less incidence of hypoglycemia( term used for low sugar levels) , reduced weight gain as when compared to rapid acting insulin. However, this may need to be combined with long acting insulin or with oral medicines as the case may be for a better effect. The side effect so far noted has been a non productive cough ( dry cough) Degludec insulin is a new ultra long acting insulin which is still on research programs to test its efficacy. Though it is being marketed for injection once in 3 days or once a week ( which sounds like sweet music) , the effects of the insulin wear off after a day or two. Which means it is still better to have the shots of insulin daily for better control. The sugar control and episodes of low sugar have not shown any improvement over the insulin preparations available in the market today.   Continuous glucose monitoring CGM                                              CGM 2 Continuous Glucose monitoring (CGM) devices are in the market for quite some time. These are small gadgets the size of a pager which help to monitor the sugar levels throughout the day and night. On an average a child between the ages 5 and 14 may have to poke the finger for sugar checking at least 50000 times and about 15000 injections of insulin during that time. This is quite phenomenal and frightening. For people on intensive insulin therapy as among those with type 1 diabetes or among those with frequent dips or spikes in their sugar levels which could be related to either food, alcohol or exercise. These machines detect the glucose level just under skin with the help of sensors. These levels are transmitted to a receiver. Pros: • This will give a constant reading and you can adjust the doses accordingly with the help of the health care provider. If the blood glucose reading is 7 mmol/L or 126 mg/dL, it could mean the sugar is going up or down and that is the reading at that time. The machine gives an arrow mark which will give the trend based on the readings just before.. • The tracings can be downloaded and interpreted • The tracings are given for every day in different color lines for easy interpretation • It also gives the average and how many lows one had experienced in the interim. • Alarms are there which could be programmed into the machine which could go on either when sugar swings too low or too high. Cons: • The cost is quite high • Normally the insurance companies do not approve of this unless in certain cases. • The sensors will have to be changed once in 3-7 days. This is costly • This is to be worn at all times. • May not be feasible for children below the age of 12. • One will have to calibrate the machine from time to time so that the readings are accurate. Needle less devices Frequent puncturing of the delicate skin at finger tips and also the insulin shots which are so frequent especially among those with type 1 diabetes are a cause of frustration. Now-a-days needle free CGM devices are coming out. Some are awaiting patents. There will be sensors, a transmitter and receiver. The signals can be sent to smart phones, computers or even laptops. This can be useful for working mothers who have children at home and can remotely access the sugar levels and send information to make corrective steps. The sensors are to be changed once in 3 days which helps prevent skin irritation. The skin top layer which comprises dead cells is painlessly removed and leaves a small abrasion not visible to the naked eye. The Symphony is one brand making such needle free CGM. Dexcom G4 Platinum is awaiting patents rights. This is sleek and hardly noticeable

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