Neuropathy is a complication that is bothersome and not very often addressed or treated properly. This complication gradually develops over a period of time and is not always due to diabetes mellitus. This can be due to smoking or excessive alcohol intake as well. However, longer the duration of diabetes, chances of developing a neuropathy are higher. Neuropathy can be aggravated by insulin and some medicines. Rapid control of sugar is known to cause neuropathy for some people. Classically the neuropathy first affects the feet and toes and may gradually ascend.
There are four major types of neuropathy
- Peripheral neuropathy- this is the commonest form which affects the feet and hands. This can present in many forms. There may be numbness of the digits and reduced ability to feel changes in temperature or pain. Patients may complain of tingling or burning, feeling of insects crawling on the body, sharp pains at night, and some may experience extreme sensitivity to even the lightest of touches. Some may experience difficulty in walking or can have ulcers or deformity of the feet.
- Autonomic neuropathy: This part of the nervous system controls the functioning of the eyes, heart, lungs, stomach,intestines and sex organs. Thus, a dysfunction of this part of the nervous system may cause either of the following: urinary bladder problems ( too much urine or lack of control in holding the urine), constipation or diarrhoea, slow emptying of the stomach leading to fullness, difficulty swallowing, dryness of vagina, erectile dysfunction in males, reduced sweating, problems regulating body temperature, difficulty in eyes adjusting to a dark room when coming from a bright room. Some people have variations in blood pressure while getting up from lying down posture leading to imbalance.
- Radiculoplexus neuropathy- affects bigger nerves and hence the numbness can affect the thighs, buttocks, hip and legs. Characterestically patients complain of difficulty getting from sitting position. Some may complain of abdominal swelling and weak muscles.
- Mononeuropathy- this is the type of neuropathy affecting one single nerve. This may disappear over a period of time. No long term complications associated with this type. There maybe difficulty in focusing of the eyes, paralysis of one side of the face with deviation of angle of mouth, carpal tunnel syndrome where there is numbness of one part of the palm with weakness of muscles or loss of sensation. This can be corrected by a small surgery.
For details on how to test for neuropathy, please refer to the blog on feet.
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.
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.
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.
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:
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.
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.
You 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:
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.
- 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
• 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.
Though close to 85% use the internet even if from the low socioeconomic population, digital technology and web based application usage has been very slow to catch on when compared to the boom experienced in the retail shopping and banking sectors worldwide. The vast majority of online communities, mobile applications ( Apps, as they are commonly known) and web sites have been very sluggish in integrating with the mainstream health care stream.
Social networking sites such as Facebook, Twitter, Instagram, WhatsApp and many others I am unsure of, have helped transform social life in a big way to a point where people avoid face to face contact. But these sites have also helped create a platform to support sharing of knowledge, communication and understanding, lever positive behavioral changes and also help in using the audiovisual mode of communication which lingers longer in memory.
More frequent consultations will be costly and not affordable to many even this day. This way of e- health will help tide over this if used well. This will help in increasing treatment adherence, health related behaviors as well as give a feeling of being looked and cared for.
But, there are some barriers to accepting the digital technology such as :
- in those with physical or visual impairment
- those who are illiterate
- those who do not read or speak english
- those residing in geographically remote areas
- those with social phobias
- those concerned about their privacy
Telephones have become more than just a gadget to either receive or make a call. With the new generation smartphones, one can record conversations, take excellent photographs, transfer them instantly through internet, chat with friends on the social media, create presentations for meetings, store data in excel format, fax documents, scan documents, use the phone as an organizer, store songs and movies which can be played when alone or bored. Now – a days, these smartphones have also taken the role of a health assistant which can track the progress in exercise schedule, diet, weight loss, and store personal data such as sugar readings over the past 3 months with a graphical representation included. These can be uploaded where you are on this planet and can be linked to the doctors phone for an instant viewing. The list is endless. Maybe there is an app which can remind one to take the medicines on time in case one has forgotten.
There were days when people used log books to record their sugar readings and might even forget to get them when coming for the consultation. Now – a – days with advancements in technology, there have been significant developments in the way a person with diabetes can record their progress or even hide their frustrations by making excuses such as worn out batteries and even having forgotten them at home.
Things have become so technological these days with the data being uploaded to a remote system or a good mobile devise or even the doctors chambers. This comes particularly handy among the young children who sometimes tell lies to escape the wrath of their parents. The data is instantly shared with the parents phone devise helping them keep a track of the events.
There are numerous applications ( Apps) which can be downloaded either for free or for a price which can help in various functions and even take over as a personal health secretary. The list is so vast and all have not been mentioned here. Some are free to download , some have to be paid for.
Some apps for nutrition include : Fooducate, Carbs and Cals, Carbmaster free, calorie counter, calorie tracker, daily burn, lose it, Go meals, weight watchers mobile
Some apps for exercise include: my fitness pal, run tracker,workout trainer
Some for glucose monitoring include: Bant, dLife, Glucose buddy, GluCoMo, Wave sense, Glooko, DBees.com, Glucatrend diabetes, VRee, On track, Handylogs sugar
Ihealth wireless smart glucomonitoring system and TelCare wireless glucose meter can help synchronize ( or sync ) the data with an App, website or even an i cloud.
This is a devise connected to a glucometer which can transfer data to a remote system or website.
This is a cable connecting a phone to a glucometer. This can be uploaded to the cloud .
Some of the Apps can even show long term trends and graphically represent them making the visualization much better ( if all is going well) . The only problem is one will have to enter the data and allow the App to take care of the rest. This data can be shared with the health care provider almost immediately which helps taking health care to another level.
Diabetes Pal- this helps even recording and advising on level of physical activity and can record the glucose readings as well.
This app lets you record blood glucose levels and note the time of day—such as “before breakfast” or “during activity.” You can view trend graphs, interact in the Glucose Buddy forums, and record insulin injections, exercise, and food eaten. You can also sync your phone to an online account to manage your data on Glucose Buddy’s website. Devices: iPhone, iPod Touch, iPad
Manufacturer AgaMatrix’s app lets you log blood glucose levels and type in personal notes. You can record the amount of insulin injected and the number of carbohydrates eaten, and view one-, three-, seven-, 14-, 30-, and 90-day trends in graph or chart form. High, in-range, and low readings are color coded in the logbook. And you can e-mail your stats to family or your doctor. The app comes loaded with about 50 diabetes-related videos. Devices: iPhone, iPod Touch, iPad
With this app one can log and store the blood glucose level as well as food intake, blood pressure, weight, exercise, pulse, A1C results, body fat percentage, and medications taken. For each entry, personal notes can be added. Results can be exported via e-mail to your medical team. Devices: Android phones
Track weight loss, daily food intake, and exercise with this comprehensive app. Meals taken can be added instantly (from a list of common foods, brand-name foods, and restaurant meals, or own recipes) and watch the sliding scale climb toward the recommended daily calorie limit. One can record exercise (choose from a long list of activities), graph the weight loss, get reminders, and share the progress on Facebook and Twitter. Devices: iPhone, iPod Touch, iPad
Calorie Counter by MyNetDiary
With this app, eon can record meals (choose from an expansive food library that includes restaurant picks), exercise, water intake, medications, weight and measurements. Food selections include nutrition facts
This app gives an idea of food and how it affects the sugar, recipes and even short videos. The diabetes website dLife makes a diabetes application that you can use to log glucose levels, find recipes and nutrition information, watch dLife videos, and connect with the dLife community and experts to get answers to your diabetes-related questions. Aside from logging the sugar levels, you can graph daily, weekly, or monthly levels and track trends—all of which can be e-mailed to yourself or your health care provider. Devices: iPhone, iPod Touch, iPad
This app could be your shopping companion on the next trip to the grocery store. You can scan barcodes, search for products, and browse categories to find foods you’re shopping for. By selecting a food, you’ll get a list of health pros (100 percent whole grain!) and cons (loaded with high-fructose corn syrup!) and can compare it to similar products. Keep track of products you eat regularly by “liking” a food. Then, next time you hit the store, you can pull up a “my likes” list of foods you might want to buy again. Devices: iPhone, iPod Touch, iPad
7 MINUTE WORKOUT
This is an app which can fit into any routine, has 12 simple exercises which are scientifically formulated.
This has exercises for strength training, yoga, cardio and stretching. All one has to do is to select a workout category, and how long the exercise plan should be for. Accompanying videos will help show how to perform the exercises properly with minimum injury and maximum effect.
This is an app which is ideal for those interested in cycling, running, swimming and biking. This has an in built Goal Coach which sets a realistic goal to follow.
ManageBGL is an app that offers a simulated insulin pump. This is of use among those who are having Type 1 diabetes or those having type 2 diabetes with multiple doses of insulin.This needs some input such as current and previous blood sugar levels, carbohydrate intake, insulin dose and this will predict the future glucose readings and aid in auto calculation of bolus insulin dose.
To help those who are handicapped with poor eyesight, some glucometers have come with a voice readout.
Sharing the data through social media such as WhatsApp, TalkRay , Viber, Instagram and Facebook have made the modes of sending across data almost instantaneously. If you ever noticed, a once upon a time luxury called email, has now almost become mandatory. There have been instances when patients have even used the above to send me snaps of the medicines they wish to have refilled or even to send me snaps of some ulcers on their foot to help monitor the progress and even to help with their appointments. Scanning and sending their test results from the far corners of the world can be sent across through one of these portals.
Smoking has been the passion of many though the prevalence has come down from a lofty 40% in 1965 to 20.9% in 2006. 90 % of the smokers were below 20 years of age. 18.1% of the adult females and 23.9% of the adult males smoked in a survey conducted across some continents in 2008. It sure must be higher now.
Peer pressure, stress at work, status symbol, a recreation, a pastime, copying their role models all are causes of initiating smoking.
All are aware that smoking is associated with reduced life span, higher risk of different types of cancers, digestive problems, staining of the teeth, leg problems and also problems during pregnancy.
Those who remain in the company of smokers are equally at risk for developing complications– called environmental tobacco smoke. Children whose parent/s smoke had a higher chance of being an asthmatic , having recurrent respiratory infections or even ear infections.
Diabetes and smoking
Among those with diabetes who smoked , the risks were greater than those who did not smoke and had diabetes.
Metabolic control was poor among the diabetic patients who smoked. The following were noted among the diabetic patients who smoked:
• Increased fluctuations in sugar levels and HbA1c, the 3 month average of sugar
• Increased blood pressure and retinal blood flow
• Increased bad cholesterol- LDL and triglyceride
• Associated increase in adrenaline, growth hormone or cortisol which could increase glucose levels.
• There could be associated alcohol intake with an increased high fat diet consumption.
• Less likelihood of exercising.
• There may be a progression of complications such as retinopathy, neuropathy and nephropathy.
Cessation of smoking is an important step in the management of diabetes management. This is associated with less chances of developing a heart related disorder, stroke, cancer or leg vascular disease and improving life expectancy. Those who benefit most are those who quit at a younger age, those who have lesser tobacco pack years. Smoking cessation has health benefits for all ages even after the age of 65 years or even after smoking related complications develop. Mortality rates of those smokers who have abstained for more than 15 years closely approach that of those non smokers.
Withdrawal symptoms -craving, depression, anger, frustration, irritability and sleep disorders.
The treatment of withdrawal includes psychological treatment, positive reinforcement and medicines which help to replace nicotine such as nicotine patches kept on the skin ,nicotine containing chewing gums, lozenges, nasal sprays or even inhalers.
Menthol cigarettes or low tar cigarettes do not reduce the risk for hazards to smoking.
Electronic cigarettes have not yet been approved for withdrawal, though many claim to find them beneficial.
Benefits of cessation of smoking
Half of the excess cardiovascular risk is eliminated in first year of quitting. There is 30- 50% excess risk for lung cancer even after quitting for almost 10 years.
The highest risk for the development of type 2 diabetes occurred in the first 3 years after quitting but this risk gradually declined to 0 at 12 years.
In lighter vein…….
- 46% admitted to not eating sweets when smoking and 38% admitted smoking calmed them down…..
- But, those who stopped smoking were found to gain 3.8 to 4 kg per year in men and among women a 2.8-3 kg increase per year. But, this increase can be prevented by good lifestyle management.
- I even had patients tell me they felt smoking was able to control their diabetes better due to the absence of weight gain as well as by not eating sweets. But, the hazards of smoking outweigh these small “benefits”.
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
The 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
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.
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.
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
** low in calories and highly nutritious
* empty calories
Did you know that every ten seconds a person dies from diabetes related complications?
Diabetes is the fourth leading cause of global death by any disease.
Remember that heart problem is the number one cause of death among those with diabetes. It is said that a person does not die of diabetes, but instead of the heart ailment. The presentation can be just as a spasm of the blood vessels supplying the heart muscles or a frank attack where the blood vessel supplying the heart muscle is blocked completely or the heart may be enlarged.
The pain normally associated with heart attack is absent for those with diabetes. Hence, any “simple” chest discomfort may warrant a heart check up rather than treat it as simple gastritis or “gas”. Sometimes the discomfort may travel down the left arm, neck, back or to the shoulder. If the discomfort is associated sweating and faintness, consult with your doctor immediately. There are many tests that the cardiologist( doctor who specializes in heart diseases) will order for.
Control of the blood pressure and lipids are more important to prevent a heart attack. Sugar control is not all that important to prevent an attack, though. There are medicines which may have to be started by the health care professional to prevent such a calamity.
An ECG ( electrocardiogram) is done with patient in resting state and can tell if an ongoing chest pain is related to the heart or not or if a previous episode of chest discomfort was from the heart. It also tells about the rate.
An ECHO cardiogram is also done either in resting or under some form of exercise. This shows the size of the chambers of the heart, the dimensions of the valves, the blood flow and other parameters.
A Treadmill test will show how the heart copes with exercise. Patients with problems in their back bones or knees cannot do this test unless under supervision. Changes in the heart rate, rhythm , blood pressure may be noted which can point towards a block in the coronary vessels.
A coronary angiogram is a test done to map the coronary vessels. This is done by either introducing a tube through a vessel in the thigh or through a normal cannula in the arm. A dye is injected and films are shot. Blocks can be seen which are interpreted by either the radiologist or cardiologist. The blocks can be stented or ballooned or operated depending on the site and number of blocks.
The doctor will check the kidney function periodically to check if there is the beginning of kidney disease. Reduction of urine output and swelling of the face, body and feet with losing consciousness is a late feature. The presence of microalbumin in urine is an early feature which needs treatment. However, having menstrual periods, a mild urinary infection, having exercised just prior to giving the sample or having fever, the levels of microalbumin can be high. The health care provider will determine if another test is to be repeated. With proper control of sugar, blood pressure the levels improve. Some need medications to help reduce the levels.
Sometimes , dialysis or transplantation is needed when the kidneys reach a terminal stage. Consult with your doctor regarding the diet to be followed if there is such an event. You may have to consult a nephrologist( specialist in kidney diseases).
This is probably the most important of all the organs as far as we all are concerned. What is the use in living, if your eyes are not working or you are blind? Diabetes is the commonest cause of preventable blindness. One would never enjoy the beauty around us and the marvels of the Almighty if it were not for the eyes. Strangely even with good eyesight, we sometimes do “not see” the marvels of God.
Most of the people decide to meet the eye doctor when their eye sight is quite bad…. Till then most meet with the optician who checks the power of the glasses and they are happy.
Good control of sugar can prevent the onset of eye disorders. High blood pressure can also damage the eyes. Being a smoker too can affect the eye sight. It is generally believed that eye sight will become poor with advancing age due to onset of cataract (clouding up of the lens) , Being a diabetic can even make a young patient susceptible to development of cataracts.
The ophthalmologist( the doctor who specializes in eye diseases) will check the pressure in the eyes, look for cataract and also for the retina after instilling drops in the eyes. The eyes will be out of focus for close to an hour or two after the test. Remember checking the power of the eyes is not the test for diabetes check up. Close to 70% of the retina will be damaged before problems arise in vision. It is important to prevent these complications from arising by having an annual checkup with your eye doctor.
Changes in sugar levels can affect the clear fluid in which the lens is bathed in the eye. Thus there is a blurred vision which many people compare to a curtain kept in front of their eyes. The clear fluid becomes turbid when high sugar levels occur and then clears up when the sugar level normalizes. It is, therefore, important to mention to the eye specialist you are diabetic and whether under good control or not. It is wise to have new reading glasses when the sugar levels are normal.
When to meet the eye doctor?
• Blurred vision
• Trouble reading
• Seeing double
• Injury to eye
• Spots or floaters in the eyes
• Eyes get red and itchy
• You cannot see things on the outside of your eye vision field.
Know your eyes
The eyes are your mirror to the outside world. The eyes are covered by eye lids protecting it from external trauma or injury. This also prevents the eyes from drying out. Light enters through the cornea and travels through the center of the iris, which is the colored part of the eye. Light then falls on the retina situated at the back of the eye which then converts these signals to signals which can be read by the brain and is transmitted through nerves to the brain for us to understand what we are seeing. All this happens in fractions of seconds …
Know some terms
Glaucoma: This is term used when the pressure in the eyes increase. This can happen in those with a longer duration of diabetes. The vision of the eye is gradually lost. The eye doctor will perform tests which will determine how severe it is and will prescribe either eye drops or surgery.
Cataract: This is term used when the lens becomes cloudy. Normally elderly people get cataracts even without being a diabetic. Cataract may occur in younger adults if they are diabetic. The eye doctor will advise what to do after checking for cataract. For some people the retinopathy will become worse if treated for cataract and for some glaucoma may develop.
Retinopathy- this is term used to mean damage to the retina, the nerve layer of the eye. About 70 percent of the retina has to be damaged for one to show changes in eye sight. By this time, it will be so severe, complex treatment plans will have to be made with outcomes resulting in compromised vision. The small blood vessels in the back of the eye balloon out and may form pouches. They may start leaking. This may cause swelling of the nearby parts of the eye and even cause a lifting up of this layer, called retinal detachment. The eye doctor will advise how to get treated depending on the stage the eyes are.
Often, this is the most neglected of all the body parts. It has been studied that women care more for their feet than men. It has also been shown in studies that the foot problems are less among the muslim population due to the washing of their feet for prayer 5 times a day. One should pamper the feet at night daily.
The feet may swell up ( due to high blood pressure, kidney disease, the effects of the medicines you are given, or heart disease). You may notice the skin becomes dry (which can cause itchiness), the nails can get deformed, you may notice white rashes between the toes, decreased sensation to hot and cold and small wounds go unnoticed unless pointed out by somebody.
You have to inspect your feet daily with a mirror, apply moisturizing cream to the top and bottom of the feet ( avoid the areas between the toes), trim the toe nails straight ( taking care not to cut the corners), use one size extra shows or footwear, avoid narrow footwear, use loose cotton stockings, check the inside of the shoes daily and wash your feet daily, but dry them properly. Never cut calluses( thickened skin) yourself as it will risk injury.
The doctor will usually check the pulsations of the feet blood vessels, check for temperature sensation, check for fine sensation with a thread and the reflex at the ankle. You may need to have custom made footwear in some cases.
Remember to show the doctor for any wounds or cracks or ulcers that may develop. Remember that any infection can spread rapidly in diabetic patients which may sometimes need an operation resulting in loss of limb. Coupled with smoking, diabetes is dangerous combination.
Sometimes the legs may ache while walking or may have cramps at night. This can be the starting feature of a nerve problem. Consult your doctor if this happens.
Get educated. One key to preventing diabetic skin problems is to understand what causes them. Talk to your doctor. Learn about diabetic skin complications, what your particular risks are, and how you can lower them.
Control your diabetes. Controlling the blood glucose within normal range can go far toward preventing common diabetic skin complications.
To get a handle on your diabetes, strive for a healthy weight, eat right, cut back on salt, maintain a healthy blood pressure, and exercise. That’s a tall order, but talk to your health care team for support.
Be aware. If you suffer from diabetic nerve damage (neuropathy), you can have an infected cut, scratch, or skin puncture and not know it. Don’t let a small problem turn into a big one .Check your feet, ankles, in between your toes and legs regularly for wounds that aren’t healing.
Do something about wounds and sores. Don’t neglect wound care. If you find a nick, a scratch, a small cut, anything that isn’t healing or that worries you, talk to your doctor immediately.
Cover up. This simple first line of defense can help you avoid the cuts and scratches that can lead to infection. Whether you’re gardening or walking the dog, cover your legs with long pants and your feet with flat, good-fitting shoes.
Practice good skin care. Keeping skin clean and dry, but not too dry, is key to good diabetic skin care.
Keep skin comfortably dry, especially at armpits, toes, and groin. Talcum powder can help.
But avoid drying skin out. Skin that’s too dry can crack, itch, and get infected, so prevent that by taking short, lukewarm showers or baths and using mild soaps and shampoos when you wash. Avoid deodorant or scented cleansers, which can be harsh on sensitive skin.
Moisturize if your skin is dry . The best time to moisturize is right after a shower or bath, when skin is still moist.
Dry well by patting gently — don’t rub — focusing on underarms, between legs, under breasts, and between toes.
Diabetes and teeth
This is probably the most neglected of the various aspects of ones body. Many are unaware that care of the mouth is as important as looking after the eyes, feet or heart when one has diabetes.
Some presentations will be :
• Slow healing time after dental procedures
• Fungal infections coming very frequently( white patches)
• Dry mouth
• Cavities in the teeth
What can be done to minimize the risk
• Brush your teeth after every meal and floss the space between the teeth at least once daily.
• Use oral antibacterial rinses to wash away the germs
• Meet the dentist at least yearly once.
The gums ( pink tissue on which the teeth are embedded) can become soft, spongy and start bleeding. Later on the gums may detach themselves from the teeth causing them to have pockets. These pockets can harbor organisms which can erode into the underlying bone and can cause the tooth to be loose. The infection may spread at an alarming rate that you may have to be hospitalized and the infection can even spread to as far as the brain through the rich network of blood vessels on the face.
High Blood Pressure ( Hypertension)
Blood pressure has 2 values- a systolic ( the reading at top) and a diastolic ( reading at the bottom). This is checked at every visit to the doctor by a machine called sphygmomanometer. The most accurate one is the one using mercury( which are rare these days). Often, digital and air driven machines are used and freely available for use at home or office. Normally the blood pressure can be high when consulting with the doctor( due to anxiety). If found high, recheck either at home first thing in the morning and before going to bed for a week. Show the readings to the doctor for making a decision. Alternatively, a machine can be left attached to the body which will record the pressure for a week during the days for varying periods up to a week. The average of those readings will determine of you are having high blood pressure or not. This can help detect blood pressure fluctuations while asleep. Most of the serious side effects of high blood pressure ( heart attacks and strokes) are in the early hours of the morning after midnight.
If found to have high blood pressure, the doctor will advise you to cut down on salt intake. (Pickles, sauces, tinned vegetables, ketchup, salted butter, sausages and hams all contain salt in excess) Besides this, you will be asked to reduce the consumption of red meat, fried food, smoking and alcohol. You will also be advised to increase intake of fruits and vegetables. The doctor will advise you to
Try out relaxation methods. This may vary from person to person- such as dancing, listening to music, playing golf, walking, reading, gardening, painting, yoga classes, swimming and so forth. ALCOHOL and SMOKING DO NOT FORM HEALTHY RELAXATION TECHNIQUES!.
The normal blood pressure is < 130/80 mm Hg. Even reducing the pressure by 20/10 mm Hg has significant benefits on the various organs such as heart, eyes, kidneys and brain. Very often, more than one medicine may be needed to control the blood pressure. Sometimes the doctor has to prescribe blood pressure medicines to control the leak of protein in the urine though the blood pressure reading will be normal. Most of these medicines help to protect the kidneys and heart as well. The blood pressure will never reach zero as the body will take measures to correct itself. Only 18% of the diabetic patients reach the target goal of blood pressure.
This is a state of disillusion, frustration and a meek submission to diabetes which results in complete disregard to blood sugar level management. This is regarded as “freedom” from this confusing , frustrating and ever demanding condition. This is often seen many years after commencement of treatment.
This burnout is usually accompanied by varying levels of stress, anxiety, depression and labile emotions.
- Scared of living with diabetes
- uncomfortable social situations- cannot swim, cannot party, cannot be out for late night meetings, cannot do this or that…
- overwhelmed and angry with diabetes
- feeling “alone”
- Feeling diabetes is taking too much of mental and physical energy
- Food deprivation
- concerns about the future- “Can I marry?”, “Will I be able to conceive or have a normal sexual life”, “How long can I live?”
The commonest modes of presenting can be:
- Self destructive behavior
- Eating or drinking whatever one wants knowing fully well it is not good for those with diabetes.
- Improper insulin shots or lying about medicine intake
- Improper maintenance of log books
- Fabricating glucometer readings
- Complications of diabetes can set in which in turn makes things worse to a point of suicidal behavior.
How to overcome a burnout?
- Stay focused and motivated. Do not attempt to be perfect- forgive those occasional high sugar levels if other readings are fine.
- Identify barriers to care of diabetes and resolve them.
- Edit negative thoughts
- Enroll into support groups
- Speak with a friend or health care professional
- Rethink exercise schedule
- take a break
- Laugh it off
A check list:
Ask yourself whether you have done the following:
• Enough medicines are there with you.
• Have you had the blood tests for cholesterol, liver, kidney, hemoglobin , urine for protein, sugar and 3 month average of sugar at least once in the past 6 months.
• Have you had a foot check , an eye check by eye doctor and a heart check such as having an ECHO cardiogram and Treadmill test in the past one year. There are instances when the treadmill could not be done due either being overweight or having knee or back problems.
• If an elderly male, have you had a PSA test done in the past one year ( this is a blood test for the prostate) Alternatively, you could meet with a Urologist, the specialist for these problems.
• If an elderly male or female, have you had the calcium, vitamin D levels checked in the past year and a bone mineral density which is a scan for the bones showing if they are prone for fractures. Vitamin D levels, if very low, will need a correction with medicines and a recheck done depending on the doctors advice.
• Women after the age of menopause or those with a strong family history of cancer of the breast should have a mammogram ( special X ray of the breast) done once yearly.
• Thyroid levels can be checked yearly once , unless on treatment.
• Distended abdomen, “gaseous feeling” and belching with a mild upper chest discomfort can sometimes be a marker for something sinister. Have a gastroscopy done to make sure there are no ulcers.
• All bleeding from below is not from ‘piles”. It may also be worthwhile to have a colonoscopy done.
• Have you been monitoring your progress and if you can see no improvement in either the sugar levels or weight, you must seriously reconsider your options. Please do not always find fault with the doctor or the medicines, the reason could be elsewhere.
• Have you got the glucometer serviced or checked out especially if more than an year old
• Have you shown the Insulin delivery devise to the doctor once a year if the refilled pens are being used. Faulty devices can lead to errors in dosing.
• All said and done, there is no point in doing an annual whole body scan to make sure all is well. There are so many things which may go unnoticed and also will be risk of too much of radiation.
• Please check the footwear daily for wearing out or foreign bodies. They can prevent serious mishaps later.
• Have you had an annual Flu vaccine? This will reduce the flu which occurs while traveling a lot
• For those above 65 years of age a pneumococcal vaccine is useful. This is to be taken just once in a lifetime.
Once we are born, we all have to die someday. During the course of our life, we learn a lot from our experiences, sometimes we do not. We all wish to live longer and age gracefully. You may recollect that our grandparents lived longer and healthier. This is largely due to reduced stress levels, natural unprocessed food, more of physical activity and less dependent on automated gadgets or electronic gadgets.
Ironically, people of today look for shortcuts to everything for example weight reduction surgery, face lift surgeries various plastic surgical techniques to help beat natural aging and also gadgets which can remotely control everything in life from opening the gates, switching on the lights, locking the house and what not. Who knows, maybe in the near future we may even have drive in hospitals where you drive into the OPD room, speak out your symptoms into a machine , get a token, have blood drawn for tests and have the doctor give the medicines at another counter.( like as in Mc Donalds drive through)
Life has indeed become so fast, we hardly have the time to stop and think of ourselves. There are so many age defying cosmetics flooding the market these days.
Many people with diabetes live to a ripe age by leading a healthy lifestyle and regular check. However, some are lucky not to have diabetes until their middle years, but become diabetic after 65 years or more. In a study around 7% of the older adults were diagnosed as having diabetes by noting high fasting sugar, whereas 6% were diagnosed based on their post meal sugar levels.
Common changes with advancing age
Glucose intolerance increases and slowing of the glucose absorption occurs with advancing age. There is a decline in lean body mass, there may be an increase in body fat due to increasing insulin resistance. There may be a decline in level of physical activity.
The medicines that were once doing well in controlling sugar levels may not work as effective as age advances.
Older adults may not perceive hunger and may not feel thirsty as well. Digestion becomes delayed. Bowel habits may not be regular as before. Skin may become dry. The response to low sugar levels are much slower as age advances. Low sugar levels may manifest as confusion and dizziness. Tremors and sweating are not common.
- Reduced vision, reduced mobility and memory loss is also common. Mistakes while dosing the medicines are also common.
- Complication of the eye, nerve and kidney is directly linked to the level of sugar control. Maintaining good levels can delay the onset or progression of the above complications.
- However, heart diseases stroke, and blood vessel problems are directly linked to the control of blood pressure and cholesterol panel. This is one reason why doctors prescribe medicines for cholesterol even when the levels are normal.
- With advancing age, any of the above complications are possible. The recovery from the complications will not be as smooth as when coming at a younger age.
- Some need assistance while walking such as a physical support or a walking stick. The floor in most of the places has a smooth surface and planting the feet is quite a hazard.
- Most of the time, older adults feel embarrassed to address their fears to their dependents. They may feel better to mention those to their healthcare providers. This is quite normal
There are not many studies involving older adults. However, based on some of the studies, the following are applicable:
- Sugar levels between 7 to 8.5 mmol/L is acceptable
- Blood pressure ≤ 140/80 mm Hg
- Total cholesterol ≤ 5.2 mmol/L
- HbA1C ( the three month average of sugar ) is not reliable in older adults as red cell span may be reduced with advancing age. Diseases of the kidney and liver may affect the value.
However, the levels of blood sugar and 3 month average are not to be as stringent as for that of a younger person.
Increase in urine output may be due to urinary bladder irritation or dysfunction, medications for reducing blood pressure or due to prostate enlargement in males and not always due to high blood sugar levels.
Low sugar levels can mimic having a fit or stroke.
- The check up for the older adults must be more regular and frequent. The annual eye, heart check and foot check may have to be done more frequently if there are minor problems.
- Assessment of the kidney function is made by blood tests which may show changes. This can be tackled if checked for.
- Care of the feet may need heel protection, extra cushioning of wheel chair of bedding and prevention of dry skin is important.
- Driving at this age may be troublesome due to the reduced vision, reduced judgment and reflexes.
- Have the calcium, vitamin D levels checked as well as the bone mineral density. Older men have to be assessed for prostate as well.
- Make sure the older patient above 65 years must have taken a vaccination against pneumonia once and a vaccine against flu yearly.
- Many of the older adults may be having medicine such as diuretics ( which increase urination), hormones such for post menopause or steroids , and anti depressants which may worsen sugar control.
- Maintain good oral hygiene, check the feet, the skin folds for fungal rashes and boils which may go unnoticed by the patients.
- Make sure the bowels move once a day as constipation is very common.
The consultation with the health care professional:
- It will be useful if a small handbook can be used for mentioning their concerns as they may forget during the consultation.
- Maintaining a log book of the sugar readings and a diary of food intake will help to make inferences and plan management.
- The consultation can take more time than normal making the patient understand what is expected.
- The waiting period can be a problem as well. It will be worthwhile to have the blood and urine samples drawn early and they can have a light snack while waiting for their turn.
- Most of these adults are on many medicines and so may have gastritis.
- It is worthwhile to have a check by Gastroscopy ( a tube inserted through mouth to see if any ulcers in the stomach) or colonoscopy( tube inserted through anus to look for any problems down below)
- It sure pays to empathize with the elderly. They need the love and attention.
- Exercises in this age group are to be carefully planned.
- For those with eye problems or after laser treatment, it is advised to avoid intense exercises which may further increase the pressure.
- For those with neuropathy, it is advisable to perform exercises such as walking or cycling. Be careful of weight lifting.
- Jogging and swimming can be done if they have been doing the same routine over the years.
- However, get the doctors advice and clearance before planning a regime.
- Any exercise in water is useful and safe for the joints. It helps to burn calories as well.
- Walking together in groups or even performing aerobics, Yoga or Tai Chi also help in a better way as combining enjoyment with exercises make this pleasurable and motivated to continue with this. Yoga, meditation also help in relaxation.
The aims of management:
- The management of older adults involves avoiding low sugar levels, avoiding weight gain or loss in excess and to maintain well being.
- Metformin, gliclazide, Vildagliptin and Sitagliptin are safe to use among the oral medicines.
- Insulin is safe if used sensibly. The advent of pen devices has helped the patient care. It allows accurate dosing and gives audible clicks while dialing the dose. Using the bottle of insulin and syringe may be clumsy at times and can give erroneous dosing which can be quite a headache.
- It is better to have simple treatment plans rather than complex regimes difficult to remember.
- The patient care given, the patient care giver, the patient care process and the patient care outcome are very important in the management of this elder population.
In todays world,one needs to relax in between to recharge ones mental and physical faculties. Just being a diabetic should not ruin your chances for a pleasurable trip.
See Your Doctor Before You Go
Before a long trip, have a medical exam to make sure your diabetes is in good control. Schedule the exam with enough time to work on your control before you depart. Get immunization shots — if you need them — at least one month before you leave. If the shots make you sick, you’ll have time to recover before your trip. Some countries do insist on some vaccinations which are mandatory. Most of the vaccines are available at the Tertiary care centers here in the Sultanate. They will issue a vaccination card as well which you may have to produce at the port of entry.
You might be needing a letter stating you are carrying the insulin shots, the glucometer kits, syringes and the pump in your carry bag. The site www.OneBag.com will help. The site diabetesaliciousness.blogspot.com also helps in knowing rules at airports around the world.
Before any trip, get two papers from your doctor: a letter and a prescription. The letter should explain what you need to do for your diabetes, such as take diabetes pills or insulin shots. It should list insulin, syringes, and any other medications or devices you use. The letter should also list any allergies you have or any foods or medications to which you are sensitive.
The prescription should be for insulin or diabetes pills. You should have more than enough insulin and syringes or pills to last through the trip. But the prescription may help in case of emergency. It may be useful to have a prescription in the language of the country you are visiting as English is not widely spoken or understood in some parts of the world. The sites https://translate.google.com as well as packitup.com give an idea how to do this translation.
It is safer to have enough stock of the medicines with you. It will be cumbersome to hunt for a doctor and schedule an appointment in the middle of enjoyment. This can even ruin your vacation. Carry enough stock of batteries for the glucometer or pump.
Prepare for an Emergency Abroad
No matter where you go, wear a medical ID bracelet or necklace that shows you have diabetes. If you’re leaving the country, also learn how to say “I have diabetes” and “sugar or orange juice, please” in the language or languages of the countries you’ll visit.
Insure yourself if need be. InsureMy Trip.com can help.
Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times.
In the event of a severe hypoglycemic episode, a car accident, or other emergency, the medical ID can provide critical information about the person’s health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can’t speak for themselves.
The second rule of travel for a person with diabetes: pack at least twice as much medication and blood-testing supplies as you think you need. Pack all of them in your carry-on bag so that your medication is always with you (checked luggage can get lost). Keep a photograph of the medicines you are on in your smartphone. This will help in case the prescription is lost.
Whether you travel by car, plane, boat, bike, or foot, you’ll want to keep this “carry-on” bag with you at all times. Pack this bag with:
• all the insulin and syringes you will need for the trip
• blood testing supplies (include extra batteries for your glucose meter)
• all oral medications (an extra supply is a good idea)
• other medications or medical supplies, such as glucagon, antidiarrhoeal medication, antibiotic ointment, drugs for motion sickness.
• your ID and diabetes identity card
• a well-wrapped, air-tight snack pack of crackers or cheese, peanut butter, fruit, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.
Eating in the Air
When you fly, you can request a special meal low in sugar, fat, or cholesterol. Make your request at least two days before the flight.
If you take insulin, wait until you see your food coming down the aisle before you take your shot. Otherwise, a delay in the meal could lead to low blood glucose. To be safe, always carry some food with you. If your meal is delayed or an order is mixed up, you won’t be stuck with an empty stomach.
I am on insulin
- When you travel with insulin, give some thought to where you’ll be storing your supplies. Insulin does not need to be refrigerated, but insulin stored in very hot or very cold temperatures may lose strength.
- Do not store your insulin in the glove compartment or trunk of your car. Backpacks and cycle bags can get quite hot in the direct sunlight. If you plan to travel by car or bike or to be out in the elements, take steps to protect your insulin. Many travel packs are available to keep your insulin cool.
- In general, you should stick with the exact brand and formulation of insulin that you have been prescribed by your doctor.
- However, if you run out while you are on the road, and your regular brand is unavailable, you may substitute another brand’s equivalent formulation (for example, NovoLog for Humalog, Humulin R for Novolin R). Changes in formulation (for example, from rapid-acting Humalog to to short-acting Humulin R) require medical supervision.
Insulin can come as U-40, U-80 U-100 and U-500. This means one ml of that insulin could have either 40 units or 80 units or 100 units or 500 units.
If you need to use these insulin preparations, you must buy new syringes to match the new insulin to avoid a mistake in your insulin dose. If you use U-100 syringes for U-40 or U-80 insulin, you will take much less insulin than your correct dose. If you use U-100 insulin in a U-40 or U-80 syringe, you will take too much insulin. However, the pen devices do not have these problems.
Crossing Time Zones
If you take insulin shots and will be crossing time zones, talk to your doctor or diabetes educator before your trip. Bring your flight schedule and information on time zone changes. Your doctor or educator can help you plan the timing of your injections while you travel.
Remember: eastward travel means a shorter day. If you inject insulin, less may be needed. Westward travel means a longer day, so more insulin may be needed.Visit www.voyagemd.com for insulin dose calculation while going on long hours. One may also need to adjust the insulin dosages when going on trekking or climbing mountains when abroad.
- To keep track of shots and meals through changing time zones, keep a watch on the home time zone until the morning after arrival.
- Keep the home time in the watch for half a day after arriving so that you take the shots of insulin at the normal time as back home. The time can be set after 8 hours.
- If on an insulin pump, change the time to new country before take off and program the pumpaccor
- If one injects insulin while in flight, those traveling frequently suggest you be careful not to inject air into the insulin bottle. In the pressurized cabin, pressure differences can cause the plunger to “fight you.” This can make it hard to measure insulin accurately.
- Checking the blood glucose while traveling is as important as when at home. Also, check the blood glucose level as soon as possible after landing.
- Jet lag can make it hard to tell if one have very low or very high blood glucose.
Welcome to a new place
After a long flight, take it easy for a few days. Check your blood glucose often. If you take insulin, plan your activities so you can work in your insulin and meals.
- If you are more active than usual, your blood glucose could go too low. Take along snacks when hiking or sightseeing. Don’t assume you will be able to find food wherever you are.
- No matter what kind of diabetes you have, it’s smart to watch what you eat and drink when traveling. Avoid tap water overseas. This includes ice cubes made from tap water.
- Ask for a list of ingredients for unfamiliar foods. Some foods may upset your stomach and hurt your diabetes control. But you will also find foods that give you a healthy taste of culture.
- Wear comfortable shoes and never go barefoot. Check your feet every day. You should look for blisters, cuts, redness, swelling, and scratches. Get medical care at the first sign of infection or inflammation.
- Go wherever your heart leads you. Just remember that you take your diabetes with you. Take your self-care along, too.
- It is always refreshing to have soda, slushies or coffee when traveling. Remember that these can have a lot of calories and carbohydrates.Try to have plain coffee with low fat milk rather than the fancy Cuppa Mocha, Starbucks or Latte which can pack quite a lot of calories. You must enjoy the vacation and so even if you wish to have all these, go for a stroll after the meals or these beverages.
- Those planning on visiting a beach, must remember to carry some cool fluids and keep the medicines cool. Those who wish to have their blood sugar checked by pricking must remember to wash their hands well before doing so. Some have alcohol while in the pool or on a beach.
- The effects of alcohol can be blunted while in water and so many may consume more to get the “kick”. Alcohol can increase the sugar levels. Cocktails can be pretty dangerous in terms of calories and sugar levels.
- Please do not walk barefoot however beautiful the beach may be.
- For those on an insulin pump, have the pump disconnected while taking off or landing as the pressure changes can sometimes deliver more insulin than needed. During the reconnection, remember that small air bubbles must be removed or else less insulin will be delivered. The extreme heat can sometimes damage the insulin in the infusion tubing which can work less effectively.
Carry the following with you to avoid problems at the airport
• Some document from the doctor mentioning you are diabetic
• A document to explain why carrying an insulin pump, glucometer, lancets for pricking blood, test strips, insulin pens and the needles, insulin storage cans or packs.
• Carry enough stock of insulin
• Quick acting carbohydrates such as glucose powder.( remember that chocolates, juices may get damaged with travel and the glucose tablet may harden)
• Slow acting carbohydrates such as biscuits or cereal bars.
• Let the flight attendant know of your diabetes as low sugar can mimic drunken behavior!
• Inform the flight attendant or airlines of your diabetes status, so they know what to do if traveling long distances. They may give you extra leg room seats.
• You can also request for a special menu which comes with some of the leading airlines.
• While flying, never aim for perfect glucose control ( keep the levels between 8 – 13 mmol/L or 144 – 203 mg/dL)
• Check the sugar levels in between if long haul flights( more than 4 hours)