LIVING WITH DIABETES: BLOOD TESTS

The most useful information you can have in the day-to-day control of diabetes is to know how much glucose is present in the blood. This varies so much that it is essential to test frequently and on a regular basis at home. The tests are sometimes called Home Blood Glucose Monitoring.

The test is made on a drop of blood applied to a small test strip. You will need a fine needle or lancet to prick the skin, a small plastic device to ensure that the pricks are painless and easy, a supply of test strips, and for most people a meter to measure the glucose value.

The test is very reliable if it is done exactly correctly. It will give the wrong answer if it is done incorrectly.

Use the correct strip

There are several different types of test strip, and it is essential to use one that is right for the meter that you are using. Test strips must be stored properly. The container must be kept tightly closed at room temperature but not exposed to heat. Test strips should not be used after the expiry date shown on the container. The types of strips commonly used with blood glucose meters are: the AMES Test BG, BM Test BG, Glucostix, BM Test Glycemie 20/800 and Hypoguard GA. strips.

Obtain a large drop of blood

Use a fine lancet such as the Monolet either held in the hand or use an automatic pricking device such as the Autolet, Glucolet, Soft Touch or the Autoclix. You can use the lancet many times on one person, but if you do, you should keep it in spirit between uses and allow it to dry well before you use it.

The fingers are the easiest part to obtain blood. They need to be reasonably clean and must be dry. Do not use a spirit swab.

Warm fingers bleed more easily than cold.

You may do the test anywhere on the last joint of the finger to give a satisfactory drop of blood. It is often easiest to use the tip, but try not to use only the tip as eventually after many years this may lead to some loss of sensation. Try instead to use the edge of the fingers sometimes. Use a different finger each day to give them a rest.

You must get a large drop of blood; not just a smear. It should be applied to the strip by letting it almost fall on it. The strip should then have a drop of blood.

Time is vital

Blood must be on the strip for exactly the right time. The strip contains chemical reagents which react with the blood, and if the blood is on the strip for less than the proper time, the result will read too low. If the blood is on the strip too long, the result will read too high. If you are using a meter, it will have a timer and this will indicate exactly the right time to remove the blood. If you are not using a meter, you will need to time it exactly using a sweep second hand or a digital second timer on your watch or clock.

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DIABETES IN CHILDREN: THE BASIS OF NUTRITION

You should know something about the main food groups which form the basis of good nutrition. These are carbohydrates, fats, proteins, vitamins, minerals and water. Most foods are mixtures of some or all of these ingredients.

Carbohydrates

Carbohydrates supply energy for body heat and activity and for growth. The commonest carbohydrates are sugars and starches and it is this group of foods which is quickly absorbed and turned by the digestive process to glucose in the bloodstream. It is therefore especially important to control the quantity of carbohydrates eaten by people with diabetes.

There are numbers of different kinds of carbohydrate. We are particularly concerned with those that are natural and unrefined: cereals, fruits and vegetables. They supply glucose for energy but they also have other important nutrients — vitamins, minerals and fibre. They tend to have a high proportion of starch or complex sugars and these may be more slowly absorbed than the simple sugars.

Differences in the types of carbohydrate are important in choosing food for good nutrition. The diet in diabetes depends on plenty of foods which contain starches and complex sugars because they are more gradually absorbed into the blood stream. The rate of absorption of carbohydrates into the blood is also influenced by food preparation (e.g. cooking a vegetable will increase the rate of absorption, as will juice extraction from fruit). Cane sugar, taken as part of a meal, is absorbed more slowly than when eaten alone as a sweet or in a sweet drink.

Milk contains carbohydrate as lactose (sugar of milk) and so this is also considered as an important source of carbohydrate in childhood.

Fats

Foods containing fats and oils are very concentrated forms of energy for heat and body activities. They can be used as fuel by the body, so these too may be controlled. Examples of foods with a high proportion of fat are butter, cream, margarine, oils and eggs. It is considered by most physicians that excessive quantities of fat in the diet are undesirable.

Proteins

Protein-containing foods are especially important for growth and maintenance of body tissues, so it is especially important that children have ample protein in their diet. Protein may also, to some extent, be used to supply energy by being converted in the body to glucose. Examples of foods with a high content of protein are meat, eggs, fish, cheese and milk.

Vitamins

Vitamins are needed for growth and the efficient running of the body and the maintenance of good health. If a good, well balanced diet is given, adequate vitamins will be provided in the natural foods, and extra vitamins should not be necessary. For example, fresh fruit and vegetables provide vitamin Ñ Milk, eggs, meat and wholegrain cereals provide the  group of vitamins.

Minerals

Minerals such as calcium, iron and many others are also necessary for the efficient running of the body and for growth and maintenance of health. Most of the minerals needed are contained in eggs, milk, meat, fish and vegetables and fruit.

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DIABETES IN ADOLESCENCE: TEENAGERS DON’T ALWAYS OBEY ALL THE RULES

What is particularly worrying for some parents is the way teenagers with diabetes don’t seem to keep to the rules of proper care for diabetes. It is not easy for a teenager to keep to a strict medical regimen, and most fail to keep really good diabetic control in their early adolescent years. If it is a difficult time for them, it is often an anxious time for their parents.

In early teenage, almost all young people break their diet some of the time. Many don’t manage to keep to a food plan at all even though their mothers may provide a balanced meal with the correct exchanges. The teenager has strong drives to eat and drink at times other than usual mealtimes, and an overriding appetite may defeat even the best intentions. Eating and drinking are social activities, and it is hard to avoid having the wrong food and drinks when you are with friends. There have been a number of studies made on adolescent eating habits, and these confirm what most mothers of teenagers know very well. Many teenagers like to skip breakfast or lunch. Most teenagers have a high proportion of their food as snacks between meals particularly in late afternoon and in the evening. Teenagers often develop strong likes and dislikes and many take strong exception to the family meals which their parents provide. There is considerable reliance on take-away food which can be eaten quickly with friends. It would be unreasonable to expect teenagers with diabetes to be different in any of these ways from teenagers who do not have diabetes. It is not surprising then that a regulated meal plan prescribed for diabetes will be quite unacceptable for some teenagers and for others there will be times when social demands will override dietetic considerations.

Teenagers usually dislike blood tests, and some go through a period of not doing them. If they think this will distress their parents or their doctor, they even make up results. In a recent survey of teenagers attending our adolescent clinic for diabetes, half said that they sometimes made up their blood test results when they wrote them down.

Some teenagers resent parents supervising their diabetic care – even though it is only too obvious that some supervision is needed! Attempts by parents to advise or give gentle reminders about blood tests or meals on time may be met with accusations of nagging and interference. All this may make parents confused and upset and worried: how much can they sit back and watch their child neglect his health and risk complications of diabetes in later life?

Perhaps it is helpful to understand the reason for this contrary behaviour which is so common in adolescence.

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DIABETES IN CHILDREN: YOUR OWN FEELINGS ABOUT DIABETES

How do you feel yourself about diabetes?

As a parent, you may want to consider quite carefully what attitude you should adopt towards your child who has diabetes. Before you can do this, you may first want to consider your own feelings about diabetes. Probably you felt considerably distressed when you first learnt your child had this condition. This is natural and you should discuss diabetes fully with your doctor at this time. However with realization that diabetes can be treated successfully, and the sight of your child returning to normal health and activities, this anxiety will gradually give way to acceptance. Not only your child, but also you as a parent must come to terms with diabetes. If parents cannot do this, they will have difficulty in helping their child do so.

This is in fact an important task; for you as a parent to help your child accept his or her diabetes.

Avoid pity

A natural reaction of most parents is one of sympathy for their child when they contemplate the prospect of lifetime insulin injections and diet restriction.

Perhaps you have worried about your child having to face the possibility of illness and insulin reactions, of the stigma of a chronic disorder, and having to fit in with school and social life.

Your child needs you to express confidence about him

However you will realize the need to try to resolve these anxieties so that they do not upset your child. He will be helped best if you can express confidence; confidence in his health, in your own ability to cope with his treatment, and confidence in the future.

Naturally you will feel sympathetic, but you must face the fact that pity will not help your child. The child needs his parents to care about him, but not ever to pity him. He wants his parents to know what he has to put up with in the way of needles and restrictions, but not to feel sorry for him because of it.

Other relatives can help too

You may wonder how to talk to grandparents, who may also be upset or worried about diabetes.

Avoid special attentions and favours.

In your discussion with relatives, you may point out that special favours and fussing will be harmful in the long run – and not fair to the child’s brothers and sisters either. Relatives, who tend to reward children with sweets and cakes and special puddings when they visit, will want to think of other methods of giving treats – perhaps savory foods, outings and games may replace sugary foods – and be better for all the family.

That is not saying that children with diabetes must be denied all party foods and sweets. Low calorie soft drinks, ice-cream, chocolate, jellies, pies, cocktail sausages can all be taken at parties provided allowance is made where necessary. Discuss this with your dietitian.

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DIABETES IN CHILDREN: INSULIN HYPOGLYCEMIC REACTIONS

What is an insulin hypoglycemic reaction?

The term ‘insulin hypoglycemic reaction’ means the reaction of the body to an abnormally low level of glucose in the blood, due to the over effect of insulin. Abbreviations sometimes used are ‘hypo’ or ‘reaction’ or ‘insulin shock’. Literally, ‘hypo’ means below, or low, and glycaemic means sugar in the blood.

Because this may be experienced occasionally by any child with diabetes, you should know about the reasons for it developing, the signs of such a reaction, and its proper treatment.

The cause of a hypo reaction

What causes a hypo reaction?

If there is more insulin circulating in the body than is required at the time, the quantity of glucose in the blood will fall. This may occur if the insulin administered was greater than the needed dose or if less food than normal has been eaten, so that there is less glucose in the blood for the insulin to act on. A digestive upset may lead to the food not being absorbed fully. Or perhaps the child has had some unusual activity – a game of football for example – and used up more glucose than usual as extra energy expenditure.

There are also other things which can alter the body’s need for insulin, such as the state of general health, the presence of infections, rapid growth, emotional upsets and worry. Factors such as these may change and at times lead to a changing need for insulin. Thus there are many possible reasons why a child with diabetes may have an insulin reaction.

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CHOLESTEROL: POTENTIAL SIDE EFFECTS OF STATIN DRUGS

Raised liver enzymes: Statins can cause some inflammation and damage to your liver, thereby giving you raised liver enzymes. For this reason it is recommended that your doctor orders a blood test called a liver function test before you start taking a statin, and 12 weeks later. You are more likely to have raised liver enzymes if you take a statin along with another cholesterol lowering drug at the same time, such as Lopid (gemfibrozil) or niacin (vitamin B3) at high, prescription doses.

The irony is that many people who are put on statin drugs have a fatty liver and may already have raised liver enzymes. If you carry excess weight over your abdominal area, especially your upper abdomen, it is quite likely that you have a fatty liver. People with a fatty liver have an excessive amount of inflammation in their liver, and statin drugs will worsen this. Because the liver is the main site of cholesterol production, the reason your cholesterol is high is because your liver is dysfunctional. Taking a statin drug does nothing to improve your liver health, it does the opposite and worsens liver disease.

Therese in Western Australia has tried three different statins: Pravachol, Zocor and Lipitor. Therese recalled “All three drugs seem to raise my (liver) enzyme levels and now I have given up with feeling so lousy”. She experienced “constant pain in my legs from the knee down, and a constant feeling of weakness in my calf muscles. I also feel nausea not long after taking the tablet”.

Muscle soreness and weakness: Statins can cause muscle pain and tenderness, called statin myopathy. The pharmaceutical industry claims that only two to three percent of people experience muscle pain, but reality may be quite different. Dr Beatrice Golomb, MD, Ph D from the University of California, San Diego, USA is conducting a study funded by the National Institute of Health on the side effects of statins. She has found that 98 percent of patients taking Lipitor suffer with muscle problems.

You are more likely to experience this side effect if you regularly exercise, as Co Enzyme Q10, which is depleted by statin drugs is needed for muscles to contract. People who take statins usually take a lot longer to recover from exercise than people who don’t; they experience muscle pain for several days afterwards. Fibromyalgia is usually aggravated by statins also.

Statins are capable of causing a much more severe form of myopathy called rhabdomyolysis. This is where muscle cells break down and release a protein called myoglobulin into the bloodstream. Myoglobulin can impair kidney function and cause kidney failure, with eventual death. Certain medications increase the risk of developing rhabdomyolysis if taken with statins; these include:

•     Fibrates (another type of cholesterol lowering drug)

•     Erythromycin (an antibiotic)

•     Antifungal medications

•     Niacin at high, prescription doses

•     Cyclosporine (an anti-rejection drug for patients who have had an organ donation).

You can have a blood test to see if statins are causing muscle damage; a substance called creatine kinase (CK) will be elevated. However, many people experience muscle pain and tenderness even if their creatine kinase levels are normal. Patients who experience muscle pain and muscle damage from statins may never fully recover; in some cases the myopathy is not reversible.

June from Victoria could not tolerate statin drugs because of the myopathy they caused. According to June, “I stopped taking my cholesterol lowering medication (Lipex) because it made the muscles in the back of my legs so painful that I could not go for my morning walk.” Hal in the UK had a much worse experience. He was 32 years of age, with a diagnosed fatty liver and raised liver enzymes when his doctor put him on a low dose of Lipitor (l0 mg). It was after the first week of taking Lipitor that he started to experience “an unbelievable fatigue”. According to Hal, “Walking became almost impossible, and if I did decide to walk to the end of the garden I had to crawl. My sister remarked that I had become an old man within a week”. Hal immediately stopped taking Lipitor and decided to tackle his high cholesterol with diet and nutritional supplements. His liver enzymes are now normal, and his cholesterol is down to a healthy 5.3mmol/L.

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FEMALE METHODS OF CONTRACEPTION: LONGER-ACTING METHODS, INFRA-UTERINE DEVICES

Longer-acting methods (Depo Provera, Noristerat)

Depo Provera is synthetic progesterone which is given by injection, usually in the buttock muscle. It is slowly absorbed over the next three months and ovulation is stopped. Its use has been controversial but in 1984 in the UK it was granted a license for long-term use and is slowly becoming more available. Most family-planning experts don’t see this as a first-choice contraceptive.

Advantages

•     A four-times-a-year injection renders the woman contraceptively safe.

•     It is suitable for poorly-motivated women and those of low intelligence who would find other methods difficult to remember.

Disadvantages

•     There are several side-effects including irregular and frequent bleeding, weight gain and delays in return to fertility.

Noristerat is a similar type of hormone that lasts for two months. It is used after a man’s vasectomy to tide the woman over the vulnerable time while she needs contraceptive cover.

Infra-uterine devices (IUD, coil, loop)

An IUD works by preventing the newly-fertilized egg from implanting in the uterus. There are several types and your doctor or clinic will advise you which is best for you. Plastic types can be left in indefinitely but copper-containing ones should be changed every 2-3 years. IUDs used to be suitable only for women who had had children but today versions are available even for those that have not.

Advantages

•     Once in place it can be forgotten, except for feeling inside each month after a period to ensure that the tail or string coming out of the cervix is still there. If you can’t feel it, see your doctor at once and use another method of contraception in the meantime.

•     It doesn’t interfere with love-making and you don’t have to buy replacements.

• IUDs have no bad effects on hormones or on the body generally. They do, however, have local side-effects-see below.

•     It can, if inserted in the first few days after unprotected intercourse, act as an abortion-producing agent. It is used in this way as a post-coital contraceptive.

Disadvantages

•     Subclinical pelvic infections can cause infertility in a proportion of women.

•     During insertion there is a danger of the device being pushed through the uterine wall into the abdominal cavity.

•     It can be expelled without the woman knowing it.

•     The long-term effects of many years of irritation to the lining of the uterus are not known.

•     Tubal (ectopic) pregnancies are more common in IUD users. The IUD should be removed immediately a pregnancy is confirmed.

•     Heavy periods and ’spotting’ are not uncommon.

•     Some men complain of feeling the tail or string during intercourse.

•     It has to be put in by an expert in the first place and there can be quite a lot of pain for a few hours after its insertion.

•     You have to go back 2-4 weeks after insertion to see your doctor.

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DEFEATING DISEASE: FEEDING ON FAT

Exhibit number one: A high-fat meal at one of those ubiquitous burger stands. Before you can properly wash the grease off your hands-that is, within roughly two hours- much of the fat you’ve just gobbled down is already in your bloodstream, reducing the natural ability of your arteries to stay open, says Robert DiBianco, M.D., director of cardiology research, the Heart Failure Clinic, and the Risk Factor Reduction Center at Washington Adventist Hospital in Takoma Park, Maryland.

If you infrequently indulge in such a high-fat feast, your liver will eventually clear your blood of that extra fat (also called triglycerides), and all is well. But if this is your standard fare, you have several potential problems. For one thing, women aren’t impressed if you’re on a first-name basis with the guy at the drive-up window. And for another, you may be on your way to heart disease.

Here’s why. Even when we’re young, fat, cholesterol, and others bits of bloodstream debris-called plaque-slowly begin to build along the lining of our blood vessels. In most cases, the accumulation is as subtle and gradual as beach erosion.

But as the years, Ring Dings, and Buffalo wings go by, plaque from those fattening foods continues to build, especially in areas where your arteries branch, such as those that supply blood to your legs, kidneys, neck, brain, and heart. “The actual physical force of blood on the lining probably damages the lining and allows plaque to form,” says Thomas Pickering, M.D., professor of medicine at the Hypertension Center at New York Hospital in Manhattan and author of Good News about High Blood Pressure.

And the higher your blood pressure-literally the pressure exerted as blood flows through your vascular system-the greater the damage to its lining (known by the guys with the cold stethoscopes as your endothelium). Further damaging this lining are smoking and diabetes. “When healthy, your endothelium tends to deflect things like platelets and little small packages of fibrin or clot or scar tissue and cholesterol so that, in fact, you don’t develop plaque as easily,” says Dr. DiBianco. “But damaged endothelium allows these molecules to find their way into the vessel wall. And once they’re in the wall, they build up (in the form of plaque) or irritate the blood vessel wall and cause inflammation.”

Some guys living the high-fat life won’t have seemed to have any symptoms until their arteries narrow by about 50 percent. Then things really get ugly. “Clearly, if you have an obstruction to one of the arteries of your heart, anything that increases your need for oxygen-whether it’s exercise or emotional upset, intercourse or a meal-will cause angina or chest discomfort,” Dr. DiBianco says.

From there, all it takes is one soft plaque to dislodge and clog one of the narrowed arteries to bring on a heart attack. “Although these plaques would make up a minority of plaques in our blood vessels, they’re the ones most likely to cause these sudden events that require hospitalization or surgery or can cause death,” says Dr. DiBianco.

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WEIGHT PROBLEMS: THE MEDICAL DANGERS OF EATING DISORDERS

Your body needs food to function. Poor eating damages the body in a host of different ways and some of these medical complications can be fatal.

For example, gastric dilatation, in which the stomach expands and may rupture, can occur during a binge. Pancreatitis-inflammation of the pancreas-may also develop.

Starvation can lead to abnormal growth of fibrous tissue in the kidneys (interstitial fibrosis). Another risk is diabetes insipidus, which robs the body of its ability to conserve fluids.

Slowed heart rate (bradycardia) is a common effect of starvation. Potentially fatal heart arrhythmias may also develop, usually due to electrolyte imbalance, but sometimes occurring even when electrolytes are normal. Fatal cardiac failure can occur if weight is regained too rapidly.

Starving reduces the ability of bone marrow to produce blood cells. As a result, the white blood cell count may drop. (Surprisingly, this may not always lead to increased infections.) It also disturbs the blood’s ability to form clots, which can lead to bleeding problems.

As the starving body “turns down the thermostat” to conserve energy, the thyroid reduces its functions. Other endocrine abnormalities also develop. Another major problem is osteoporosis, a decrease in bone mass that can lead to fractures of the ribs or spinal vertebrae.

These potentially fatal medical consequences may frighten you. However, sometimes it takes a good scare to break through the wall of denial that accompanies these illnesses.

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END EMOTION-DRIVEN EATING: SHE SWAPPED STRUDEL FOR CEREAL AND LOST 86 POUNDS

When Teresa Pucsek and her family came to America from Hungary in 1951, Teresa brought that country’s tasty treats with her. She continued to make apple strudel, chicken paprika, goulash, and dumplings whenever she yearned for the satisfying cuisine of her homeland. It kept her from feeling homesick.

It also made her overweight. In 1975, at age 55, Teresa reached her top weight of 205 pounds. “I was at a point where I just didn’t like myself anymore,” she says. “Then I read about Weight Watchers in a magazine, and I decided to give it a try.”

The program taught Teresa how to make smart food choices and how to cook with low-calorie ingredients. “I was amazed at how quickly the pounds began to disappear,” she says. “I lost between 7 and 8 pounds in the very first week.”

But then, Teresa noticed that her weight loss was slowing down. She did an inventory of what she was eating and found one culprit showing up repeatedly—her favorite, apple strudel. She was indulging once or twice a week.

“You keep eating what you grew up with,” Teresa says. “It’s built into you. So I had to figure out a way to eat differently but still get that familiar, old-home feeling.”

Teresa decided to trade her strudel for cereal. She had a bowl every evening, before she went to bed. The sugar in the cereal satis fied her sweet tooth as the strudel once had. And the milk, which she drank while growing up in Hungary, reconnected her with her childhood. She was able to lose weight without feeling deprived.

Teresa, who’s now 80, shed a total of 86 pounds in about a year and has kept off the weight for 24 years. These days, she teaches baking at her local senior citizens’ center, where she occasionally whips up a batch of her apple strudel. She even allows herself a serving, as a treat. But she hasn’t forsaken her bedtime snack of cereal, creating her own concoction of one sugary brand and three nonsugary brands. “I constantly alter the proportions so that the mixture always tastes a little different,” she explains.

WINNING ACTION

Satisfy your sweet tooth with a new favorite. A bowl of cereal with skim milk can satisfy a craving for sweets without blowing a healthy diet. Like Teresa, I satisfy my nighttime cravings for sweets with cereal, but without milk. I just pour some into a bowl and sit down for sweet and crunchy handfuls of Golden Grahams.

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