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Pancreas transplantation

Pancreas transplantation

transplant

 

This is a novel step in the management of diabetes. Many people, even today, fail to understand the indications for transplantation. Many assume this can be done for almost anybody with diabetes.  Incidentally, as early as 1890 in England, the first transplant involving fragments of sheep pancreas was first tried on a young boy with uncontrolled diabetes. Improved surgical techniques, better immunosuppressive medicines and healthier recipients have helped improve the outcomes.

What is pancreas transplantation?

This is a surgical procedure involving transfer of a healthy pancreas from a deceased donor to a person whose pancreas no longer functions at all.

Indications:

This is reserved only for those with type 1 diabetes , but does not form part of standard treatment.

  • When standard insulin treatment cannot control diabetes type 1
  • Poor sugar levels
  • Kidney damage in those with diabetes type 1
  • Frequent insulin reactions

Types:

  • Pancreas only transplant
  • Simultaneous pancreas- kidney transplant
  • Pancreas transplant after kidney transplant

Normally the endocrinologist or the diabetologist refers the patient to the nephrologist, the specialist in kidney diseases, who will run some tests to assess extent of kidney function. Once the possibility of transplant is considered, the transplant team is consulted. The team comprises a medical transplant doctor, a transplant surgeon, diabetes educator, a social worker, a psychologist and a financial advisor.

Pre requisites:

It will be assessed if you are a healthy candidate to tolerate the procedure, if there is anything in your records to hinder the success of the procedure or if you are compliant with the advice given by the team. It is an emotional, mental, physical and financial burden on the family and the patient.

Not to be forgotten are the legal issues associated with the transplantation ( still considered a taboo in many parts of the world), availability of donor, blood group and the severity of the kidney damage. Most of the centers have a waiting period which varies. The donor must be aged between 4 and 55 years and free from diabetes and must not be obese. There are areas in the world where organ donation is a business and various trade rackets have been busted.

Do your homework well….

Find out about the transplant center- the number and type of transplants done there, survival rates, the support given, the recovery phase stay and travel arrangements. The cost of the procedure is also of importance and how much the insurance will cover.

After the transplant you can expect the following:

The surgery can last for 4 to 6hours generally.

Stay in the intensive unit for the first few days- this is for frequent monitoring and to cut back on visitors during the crucial first few days. There will be frequent blood checks. The attendants will be asked to wear a face mask and those with common cold, fever or cough should be refrained from attending on the patient. Frequent hand washing with a hand sanitizer is needed.

 

Insulin is no longer needed as the new pancreas starts functioning. That will be the striking change the patient notices. However, one should also bear in mind the possibility of a rejection, possibility of a bacterial, viral or fungal infection as immunity is compromised by the medicines taken to prevent the rejection.

Failure of the pancreas to function can also occur for some unfortunate people.

immunosuppressive drugs

 

The side effects of the medicines to prevent rejection include:

 

  • Weak and thin bones
  • High blood pressure
  • High cholesterol levels
  • Puffiness of the face
  • Diarrhea or constipation
  • Gums can be swollen, mouth ulcers can occur
  • Acne on the face

Survival rates:

These depend on a lot of factors. Based on data from around the world, 72% of the simultaneous pancreas- kidney transplant survive after 5 years, 59% of the pancreas after kidney transplant survive after 5 years and 52% of pancreas only transplants survive after 5 years.

 

 

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A dazzling smile

A dazzling smile

smile 2smile

 

If eyes are the window to the soul, then the smile offers a look into the health of the pancreas. Diabetes can affect the kidneys, feet, heart and eyes just as much as it could affect the oral health. Oral hygiene has often been the most neglected even among those without diabetes.
A smile is fat free, sugar free, reduces blood pressure, can relieve pain and depression, requires no battery and is free of cost.
There are about 500 micro organisms in the mouth which make a human bite quite dangerous ( more dangerous than an animal bite). Some of the micro organisms are helpful and some are harmful. There have some studies which tried studying the organisms in the mouth and predicting the heart health as these organisms could travel by blood stream and get deposited in the coronary vessels.
The oral cavity contains teeth, the gums which hold the teeth together, the bones on which the teeth rests, the tongue, saliva which bathes the mouth and the pink mucosa lining the mouth inside.
Those with diabetes are more prone for developing gum disease and it progresses twice faster than those without diabetes. Serious gum disease could worsen the sugar control and will need an intensification of treatment. The ability to fight the bacteria is affected in those with diabetes. Further , the diabetes is also a good medium for the organisms to thrive.

 

A look into your mouth:
Gums:  teeth 6

 

 

Gingivitis is a mild form of gum disease, periodontitis is a more serious form of the same. Pockets form between the gums and the teeth which get filled with organisms, pus and then deepen. This can lead to destruction of bone around the teeth, leading to loosening of the teeth and subsequent falling off. The habit of using tobacco rolls or tobacco containing sweetened “paans” can cause a small burn on the insides of the pink mucosa which can later lead on to cancer.
Dry mouth can be due to snoring, poor sugar control, use of too much of alcohol based mouthwashes, some medicines, and also due to kidney diseases. Low salivary production can be a sign of diabetic neuropathy ( autonomic neuropathy) . Saliva helps in digestion of the food while chewing, protects the gums and teeth against the plaques and acid deposition which can damage the teeth and cause decay.
Thrush is a type of fungal infection common among those with diabetes.

 

Teeth
• Soda, energy drinks, carbonated sweetened beverages and lemon water can damage the enamel which is the protective outer coating of the teeth. For people who have recurrent episodes of low sugar, they consume a lot of sweets which could damage the teeth. Speak with the health care provider on ways to prevent low sugar spells and thereby reduce the intake of sweets, thus protecting the oral hygiene.

 

Brushing

Technique of brushing teeth

• Brushing the teeth effectively is to dislodge the plaques which build up at the gum line.
• The tooth brush must meet at the outer and inner surfaces of the teeth at an angle of 45 degrees.
• Move the toothbrush in short strokes, vibrating it back and forth across gum line, gums and tooth surfaces. This involves up and down movements, movements across and also movements to clean the inner sides of the teeth. For brushing the chewing surface, hold the brush horizontally and brush. For cleaning the inner side of the teeth, hold the brush vertically and move it up and down.
• Stiff brushes will not help remove plaques
• Brushing too hard can do more harm and even damage the protective enamel.
• Use a brush size that fits inside your mouth comfortably. A soft bristle brush is good for the gums and also to brush for at least 2 minutes.
• Those with arthritis or braces of the teeth can use an electric brush instead. The electric brush is effective and some of them have a 3000 rpm.
Tooth pastestoothpaste
• There are so many tooth pastes which have flooded the market. Generally the fluoride containing tooth pastes are better.
• Sensitive teeth are due to the damage of the enamel. There are so many toothpastes available for that as well.
• The junk food culture and consumption of processed food items have damaged the teeth enamel more than the yesteryears.
• Use of turmeric is good for those with gingivitis ( diseases of the gums). Use of clove in those with dental aches is another well known home remedy. These have also been incorporated in some of the tooth pastes.
Flossing:

  flossing 1
Dental floss is a string which helps dislodge food between the teeth. Measure an arms length of floss, roll around the index finger of one hand and roll the other free end around the index finger of the other hand. Slide the floss gently between the teeth, keeping the floss taut across the thumbs and floss up and down in a shoe shine manner following the curve of the teeth. Sometimes blood may come while flossing. Do not floss too hard.
Tongue:
Clean the tongue using the under surface of the toothbrush head. The use of metallic cleaners and too vigorous cleaning is to be discouraged to avoid damage to the taste buds on the tongue surface.
Mouth wash:mouthwash

Water is a good mouth wash after any meal. However, there are breath fresheners which make the mouth feel, smell and taste fresh after any meal. There are treatment rinses containing fluoride which help prevent plaque deposition and decay of teeth.
Avoid alcohol containing rinses to avoid dry mouth.
Ask the dentist whether these are needed.

Meet with the dentist at least twice a year to make sure all is well. It is safer and lighter on the purse to have the problem sorted out earlier.
Change your tooth brush at least once in 3 months are if bristles have splayed earlier to that.

 

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Let us walk to good health

Let us walk to good health

From time immemorial, man has been walking for traveling to reach one place, to hunt and gather food for self and family and also in search of a better place to live. Those were the days when there was no transport. God gave humans the legs so they could walk upright which is a feature not common among the animals by nature, though some animals can walk upright with training. Unfortunately, with the advent of modern transportation facilities as well as time pressures and deadlines to be met, people have literally forgotten to use their legs for the use they were meant to be used.

 

Benefits of walking
This is probably the safest form of exercise which can be done by anybody provided the eyesight is good and there is no neuropathy ( affection of the nerves which can cause lack of sensation on the feet making the person unaware of where the feet are planted on the ground).
The farther, faster and more frequently one walks can definitely improve the benefits by many folds. Walking also improves the balance and strengthens bones and muscles besides improving circulation.
Walking is proven to prevent the onset of diabetes, depression, cancer, joint problems, osteoporosis ( fragile bones) and heart ailments. This also helps the worsening of the above. The swinging action of the arms, the strides taken while walking, the fresh air , the sights to enjoy ( one does not get these benefits while walking the treadmill in the confines of either the gymnasium or home) and change in pace while walking navigating the turns all help in improving the muscle power and co-ordination.
Walking in groups with either your colleagues or with friends and family all could be entertaining as well you could even do long distances without being aware of the distance covered at all.

Walking at a speed of 6 km/hour , which amounts to a brisk walk, can burn up to 600 Kcals. But, may be not all can walk as fast. Some may be having either knee or back problems which needs a slower pace. But walking at any given speeds whether unaided or with the help of a walking stick is much better than not walking at all. Parking the car away from where you wish to go and just walking to your destination helps. You may still park close to your destination ( especially during the summer time when the heat maybe quite strong) and take a longer route rather than choosing the shortest route or just walking along the aisles in the malls are good options.
Walking with small children and pets is also a good option.

Ensure the following before walking:
• Check the blood sugar before walking.
• Ask your health care provider if it is safe to embark on a regime.
• Go at a pace comfortable. Walking should not leave one gasping for breath.
• It is okay to rest in between.
• It is okay to take sips of water in between the walk and before the walk.
• If you experience feeling of nausea, chest discomfort, pain in the arms, jaw or back while walking, please seek medical help immediately.

Stretching before any exercise program:
Proper stretching before any exercise or even walking can help tone up the body and prevent joint problems.
Some of the commonly done stretches:

 

Calf stretches- calf stretch

 

Stand at an arms length distance from the wall. Keep one leg forward with knees slightly bent. The other leg with knee straight and heel down. Keeping back straight, move hips towards the wall and feel the stretch. Hold for 30 seconds, relax and repeat with other leg.

 

Quadriceps stretch- quadriceps stretch

 

While supporting a fixed structure, grasp the ankle with one hand and pull the heel up and down till one feels the stretch in the front of the thighs. Hold for 30 seconds, relax and then repeat with other side.

 

Hamstrings stretch-

hamstrings

 

Sit on one chair, and keep the other leg on another chair in front. Keeping the back straight, bend the pelvis forward till a stretch is felt in the back of the thighs.

 

Low back stretch- lying on the back with the feet kept flat and knees bent, bend the knees ( both together or separately) towards the chest using both hands. If one has knee problems, one can hold hands behind the thighs instead.

 

Chest stretches- chest stretches

Clasp hands behind the head. Pull elbows gently by pinching the shoulder blades together.

How to walk?

The ideal way of walking involves walking upright, head held up eyes looking forward, chest pulled out, shoulders thrown back, landing the feet on the heel and taking the stride on their toes. Swing the arms freely slightly bent at the elbows. Walking with small weights held in the hands further enhance the calories burned.
The neck, shoulder and back must be relaxed and not stiff. While walking the treadmill one usually does not maintain these as people have to be holding onto the side railings and the back is usually arched back and stiff to prevent slipping.
Please make sure the footwear is of a good quality and have the insoles and heels checked for wear and tear. View the shoes from behind. If the shoe is tilted to one side, it is time to change the shoes. Change the shoes after it has done 400-600 km.

walking to good health 17
One should dress appropriately in attire that suits the climate, a comfortable and well padded pair of shoes, a scarf or hat as the case may be and some music if needed to be played and listened with an ear phone if needed. Generally the pavements are safe, but it still pays to look ahead and down as well.
150 minutes of any exercise a week is recommended. You can do 30 minutes 5 days a week or split that every day in some form like three sessions of ten minutes each or two sessions of fifteen minutes each.
The long term goal is to make 10000 steps a day. This is ideal for maintaining good health.
One needs to walk at least 30 minutes a day to maintain his or her weight and at least 45 minutes a day to have some weight reduction.
A pedometer is a small device which can be clipped on to the belt or kept in your pocket close to your body. This will count the steps one takes during the course of your daily chores such as walking, climbing stairs, jogging and even adventure sports. But, pedometers vary in their function.

clipped on pedometer

pedometer

 

Get to know your pedometer

 

Ease of use: Some of the pedometers just have to be clipped and it starts. These will be needed to be reset to zero the next day so you could count the number of steps taken.

All pedometers have a battery which needs to be replaced depending on the life.
Some pedometers need to have the data fed in such as date and time, the weight of the person, the length on ones stride which will be calculated and input fed in.
The extra benefits: Some just give the number of steps taken during the day till one resets it back to zero. Other pedometers count the calories burned during the activity, the distance walked and some even upload the data to a remote computer which will maintain a log book of the progress.
Accuracy: generally all pedometers are accurate. However change of strides such as a sudden increase in pace ( or decrease) , jogging in between or even climbing stairs in between the walk may not be counted by the machine( after all it is a machine) and so the calories counted may not be very accurate in that way.
Get a pedometer that has good back lighting so it could be easy to use both indoors and outdoors and also during either the day or night.
Some pedometers are small, others are big. Go for a size that suits you.
The pedometer must have a sturdy clip to help attach on the waistband or have a strap.
Price is also of major concern.
The recent smartphones have an app which could be downloaded for performing the same function as that of a pedometer.
Before you use the pedometer regularly the following are to be noted:

 

  • Please attach the pedometer on yourself for three days in succession whenever you are awake. The total number of steps covered in 3 days divided by three will give the average steps in a day. This is called the baseline steps. ( This will also give you an idea how many steps you had taken in a day which might be embarrassing)
  • Once you know the baseline steps, set up short term goals such as adding a thousand steps a day, for example, to your baseline number which you do target for a week.
  • Once you have achieved this short term goal, you could set yourself another goal. You could reward yourself and make this interesting.

 

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Love your feet !!

Love your feet !!

Feet are, strangely, the most neglected of all the body parts. There are many who pamper their feet, more ladies than men. The feet are an important part to be checked for while being a diabetic. Generally the problems with the feet can occur whether one has either type 1 or 2 diabetes, whether young or old and in any part of the feet though generally the under surface are affected more than any other part of the feet.
Feet are the parts of the body that keep one mobile, that maintain the balance and stance of a person, help drive us around, help us to swim, pedal a cycle, go on hikes or trekking, the list is endless.
Causes of foot problems while having diabetes mellitus:

foot ulcers

 

Trauma to the foot due to poor or ill fitting footwear, not wearing a footwear,
Foot deformities such as an in growing toe nail caused by improper nail clipping, having flat foot when the arches of foot collapse, having claw toes, having over ridden toes.
Poor blood flow to the feet due to small blocks in the blood vessels
Neuropathy due to diabetes which leads to poor sensation- impaired sensation to temperature changes or pain or touch.
Lack of proper access to proper education.
Living alone.
Poor socioeconomic conditions
Poor control over blood sugar, blood pressure and cholesterol.
Smoking
Previous amputation or ulcer foot
Poor eye sight

 

What can be done to prevent foot problems?

foot ulcer

DFU- Diabetic foot ulcer

 
Maintain good blood sugar and blood pressure control
Maintain normal lipid levels
Stop smoking
• Regular exercise
Check the feet regularly- check for cracks or fissures on the heels. Check between the toes for any fungal infection.
• While clipping the nails make sure it is cut straight taking care not to take the corners. The corners can be filed.
Do not cut callosities which are thickened pads of skin. Have either a trained podiatrist( who specializes in foot care and pedicure) manage it. You also use a pumice stone after bathing to rub down the thickened skin.
Apply moisturizing creams on the feet and under surface before retiring at night. Take care not to apply moisturizing creams between the toes as they will retain moisture and favor fungal infection. Use the ones containing Aloe Vera or vitamin E.
Use a hand held mirror to check the under surface of the feet.
Use cotton based socks without tight bands. Some socks now come with silicone impregnated gel pads as well.
Use shoes that are one size bigger. Buy the shoes towards the end of the day when the feet will be swollen slightly. There should be enough room for the toes to wriggle comfortably. Wear and also the sole of the footwear for any nails or sharp objects. Pointed shoes are not advisable.
Check the inside of the footwear with the hands for any irregularity or wearing off.
Have the feet checked at least once by a health care provider.

ingrowing toe nail 1

Ingrowing toe nail due to improper cutting of nails

ingrown-toenail 2

 

 

Look at the difference in the left foot

Charcots foot

 

This is a foot disorder that can happen to almost anybody with diabetes. The loss of deep sensation leads to destruction, degeneration and disorganization of the bones and joints of the foot. The foot can be swollen, warm to touch and be red. But, the pulses of the feet will be normal on examination. Once suspected of this, you will be referred to either a foot care team or the orthopedic doctor. Normally, the foot will be immobilized in a cast. This will be removed after a period of time as suggested by the team and protective custom made footwear will be given.

For those who are used to wearing high heel footwear, the pressure while walking is shifted to the forefoot and there will be strain on the Achilles tendon at the back of the foot ( the thickened cord felt behind the ankle)

Regular check up of the feet:
The feet will be checked for color, any cracks, any infection between the toes, any deformities, any callosities, and non healing wounds, any color changes, the skin of the feet, the hair growth and the nails.
Blisters are water filled collections ,corns are thickened skin due to repeated friction, calluses occur usually on the bottom of the feet which are due to thickened pads of skin, and bunions are those out projections seen from the joint of the big toe which is a structural deformity.

Clawing of toes

bunion 2
The feet will be checked for local warmth, the sensation will be checked with a monofilament, the sensation to appreciate hot and cold sensations, vibration sense will be checked. The pulse will be checked for on the feet. The ankle brachial index ( comparing the pressure of the ankle and arm BP are compared to assess blood flow) are checked in high risk feet.

A podoscan can be used to measure the pressure while walking or stepping.

Customized foot wear is often required when there is a problem to the feet which have to be designed by cobblers specialized for this.

There are tests to measure the amount of blood flow to the legs such as an ultrasound Doppler test ( which is non invasive) or an angiogram which is invasive. If blood flow is compromised ,depending on the severity, either medicines or stents or surgery are advised.
Ulcers ( breach of the skin) may heal with medicines or may remain active or in some people may progress rapidly to cause infection. In some cases, an amputation is performed to save the limb or even life. There are many comfortable prostheses available in the market to get over the handicap.

 

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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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Know more about Uric Acid

Know more about Uric Acid

PRinc_photo_of_inflamed_gout_toe

Gout is an inflammatory disease affecting the joints , commonly the big toe of the foot, the mid foot or the ankle. This is caused by an increased level of uric acid in the blood. Purines break down inside the body to form uric acid. When there is too much of purine intake or when there is less of excretion of uric acid by the kidneys, it leads to an increase in the body.

A lot of people are affected by this and often are mistaken for having fractures and land up having X-rays taken. The pain is excruciating and can make life miserable to a point where common chores such as walking, standing, driving are so much limited.

Hyperuricemia ( high levels of uric acid) are associated with the following:
kidney stones

 

 

 

• Abdominal obesity
• Associated with diabetes mellitus type 2
• Associated with metabolic syndrome
• Joint destruction with recurrent attacks
• Stones in the urinary system- these cannot be seen in normal X-Rays as it does not block the X -rays. Uric acid stones are smooth rounded and so may not cause blood in urine.

• Generally males are affected more. Women after menopause can be affected.

Stages in Gout

gout3

 

• Hyperuricemia- high uric acid levels in blood.
• Precipitation of uric acid crystals in the joints ( commonly the base of the big toe, mid foot joints or ankle)
• Acute pain and swelling of the foot or joints. The skin may be reddened which is why it is often mistaken for an abscess.
• Chronic inflammation leading on to joint destruction and change in bone shape. This can lead to Tophi ( pronounced as TOE-fi)

 

What precipitates high uric acid levels? :
kidney stones 3kidney stones 2

 

 

 

 

 

 

• Being exposed to very cold climate
• Binge drinking of alcohol
• Red wine in excess of 2 units/day
• Tea in excess of 4 cups a day ( whether green or black)
• Coffee in excess of 4 cups a day.
• Dark chocolate in excess
• Food such as mushrooms, asparagus, anchovies, moong beans, lentils, soya beans, white beans and raisins.
• Sea food such as mussels, lobster, shrimps or prawns, scallops, salmon and tuna.
• Rabbit meat, duck meat, turkey, chicken, Pork, salmon, beef and mutton.
• Some medicines for blood pressure, medicines taken for preventing rejection after organ transplant, those on cancer chemotherapy and low dose aspirin.
• Drastic weight loss measures.
• Dehydration
• To vigorous an exercise regime
• Too much of sugar sweetened carbonated beverages

What are the gout friendly food items ?:
• Fruits such as apples, figs, bananas, pineapples, grapes, cherries, water melon, grape fruits, papaya, peaches, pears, guavas, lemon, orange, strawberries.
• Vegetables such as celery, egg plant, onion, lettuce, cabbage, cucumber, ginger
• Tofu, eggs, low fat dairy, sesame seeds, cereals, vitamin C, nut butter.
Beware the sugar content of some of the food items listed above.
Interestingly, the high blood sugar levels can help in excretion of uric acid by the kidney. Thus, when the sugar levels improve, the uric acid levels can increase leading onto a flare.
How to prevent gout:
• Adequate water or fluid intake
• Avoid the precipitating factors
• Consume the gout friendly food
• Maintain a healthy lifestyle and prevent being overweight or obese.
• Avoid sugar sweetened beverages

How to treat:
• Meet the doctor.
Ice cubes to be used for fomentation of the affected areas.
• Pain killers such as Indomethacin or Naproxen or Sulindac are preferred. However noted pain killers such as Ibuprofen ( Cataflam®) or diclofenac ( voltaren®) will not always be effective.
Colchicine to be used within the first 24 hours of an attack helps.
Oral Steroids ( prednisolone) in high doses can be used to reduce the inflammation. Some need an injection of steroids into the joints to relieve the pain.
• After the acute attack is subsided, allopurinol can be used to prevent the flares. Taking this during an acute attack may cause worsening of the attack.
• Sometimes Probenecid is advised by the doctor along with the other medicines to help in excretion of uric acid.

 

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Vitamin D

Vitamin D

sunshine

Vitamin D is a fat soluble vitamin which is not excreted through kidneys unlike the water soluble vitamin . Over the past 6 years, Vitamin D has caught the attention of both patients and health care providers alike.
Causes of deficiency:
• Animal based products are richer in Vitamin D in comparison to vegetarian diet.
• Those who spend more time indoors.
• Those using a lot of sun block lotions.
• Those with dark skin absorb less.
• Obese people absorb less.
• Elderly people are more prone as they spend less time outdoors, kidneys do not work well, the skin will not absorb sunshine effectively.
• Some people have digestive tract problems which will not help in absorption. Those with Crohns` disease, cystic fibrosis and Celiac disease are known to have associated Vitamin D deficiency.

In the Muslim population wearing of the ” Abhaya” by the women which covers the whole body as well as the men who wear long robes can prevent sunshine falling on the body. This robe is helpful against the harsh sunlight in the middle east.

Vitamin D deficiency is quite common among the middle East population as they prefer spending more times indoors. Vitamin D deficiency is quite common in the USA or UK because of lack of effective sunlight.
A study was conducted in Hawaii among 93 people who spent an average of 29 hours a week in the sunshine without sun block. Interestingly, slightly more than half of them had low levels of vitamin D !!!.

Sunshine is a good but unreliable source of vitamin D. The vitamin D inactive form absorbed from the intestine and skin are converted to the active form in the kidney.

Dietary Sources of vitamin D
• Fish and fish oils
• Egg yolks
• Fortified dairy products including milk, cheese, yoghurt, buttermilk. Most of the calcium containing food and beverages can be fortified with vitamin D.
• Grain products
One tablespoon cod liver oil contains 1360 IU of vitamin D
3 oz salmon contains 800 IU vitamin D
8 oz fortified milk contains 100 IU vitamin D
8 oz fortified orange juice contains 100 IU vitamin D
Check the nutrition labels for the vitamin D levels which will be entered into the DV ( Dietary value) section.

good food

Assessment of vitamin D levels
VitD-13-grph3

Laboratory assays for vitamin D measurement are highly variable from laboratory to laboratory. Different standardizations are there in different labs.
Ordering the test is to be done after careful deliberation by the health care team.

Interpretation of the results 

< 10 ng/mL                         Deficient
10-30 ng/mL                      Insufficient
30-100 ng/mL                   Sufficient
>100ng/mL                         intoxication

How is Vitamin D produced in the body?

Vit-D-Sources-and-Cycle

 

 

Effects of low vitamin D levels
• In children, the bones become soft- called Rickets
• In adults, the bones become fragile and altered in shape which is prone for fractures- called osteomalacia.
Low levels are found linked to cancer of breast and prostate, high blood pressure, diabetes mellitus type 1 or 2, asthma, depression, unexplained weakness and muscle fatigue, multiple sclerosis, rheumatoid arthritis.
Treatment of low levels:

  • Maintenance -Vitamin D is available in tablet forms combined with calcium (available as an over-the-counter form). This is given in those who have near normal levels.
  • Intensive- Vitamin D is available as capsules or sachets or even injection forms. This is used for treatment of those with low levels.

Like calcium, this vitamin is a threshold nutrient which means, once levels are normal, any excess ingestion will not be of any benefit. All of the vitamin D cannot be absorbed from the intestines. But, there is no easy test to measure the rate of absorption.

International governing bodies from around the world have recommended the following needs of vitamin:
• Infants up to 6 months of age need 400 Units a day and safe limit not more than 1000 IU a day
• Infants aged between 6 and 12 months need 400 units daily and safe limit not more than 1500 IU a day
• Children between 1-3 years- 600 units a day and not more than 2500 IU a day.
• Children between 4 and 8 years 600 Units daily and safe limit not more than 3000 IU daily
• Those between 9 and 70 years, 600 units a day and safe limit not more than 4000 IU daily
• Those above 70 years 800 units daily and not more than 4000 IU daily.
• Pregnant and breast feeding ladies need 600 IU daily.

Magnesium has a huge role in absorption of vitamin D from the intestines. Soya beans, black beans, sesame seeds, green leafy vegetables and dark chocolate are good sources.

Spending quality time outdoors in sunshine such as playing at the beach, getting a whiff of fresh air or going for a swim will definitely make one more energetic rather than remaining indoors. But, too much of sunshine can also predispose to cancer of the skin .

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Tips for Dining Out With Diabetes

Tips for Dining Out With Diabetes

Tips for Dining Out With Diabetes

Eating less salt can substantially reduce the risk of health problems associated with high blood pressure, which is a risk factor for heart disease and stroke — a cause of death for more than 2 out of every 3 people with diabetes

Appetizers

fruits

  •        Select fresh fruit or vegetables.
  •        Avoid creamy soups .
  •        Stay away from bread and rolls with salty, buttery crusts.
  •        Stay away from fried food or breaded snacks.
  •        Muffins, croissants and garlic toast are rich.

Salads

  •        Select fresh fruits and vegetables.
  •        Avoid pickles, canned or marinated vegetables, cured meats, cheeses, salted seeds.
  •        Order salad dressings on the side and use small amounts of them.
  •        Be careful of mayonnaise based salads.

Main courses

  •        Select plain foods including broiled, grilled, or roasted meat, poultry, fish, or shellfish.
  •        Select plain vegetables, potatoes, and noodles.
  •        Ask about low salt menu items
  •        Request food to be cooked without salt or mono sodium glutamate (MSG).
  •        Avoid restaurants that do not allow for special food preparation (such as buffet-style restaurants or diners).
  •         Avoid casseroles, mixed dishes, gravies, and sauces.
  •         At fast food restaurants, skip the special sauces, condiments, and cheese.
  •         Avoid salted condiments and garnishes such as olives and pickles.

Desserts

cakes 3

  • Select fresh fruits, ices, sherbet, gelatin, and plain cakes.

Controlling Portion Size at Restaurants

Servings at many restaurants are often big enough to provide lunch for two days.

  •   Ask for half or smaller portions.
  •   Eyeball your appropriate portion, set the rest aside, and ask for a take home pack.
  •   If you have dessert, share.

Beware of the urge to order more and the urge to eat all that is on the plate…

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