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BDA (BRITISH DIABETIC ASSOCIATION) / OB (OUTWARD BOUND) MOUNTAIN COURSE: CANOE TRIPS
Canoe trips
Canoe trips need careful planning because the party will be away from roads and therefore emergency help for much of the time. There is not much space in a canoe and everything unprotected gets wet. All the participants carry their own snacks in plastic bags (at least twice the amount they would normally need) and the staff carry extra food in waterproof containers, and some drinking water. We also carry resuscitation equipment, spare woolen clothing, glucose and glucagon and a first aid kit, all in waterproof containers tied into the bottom of staff canoes: On meandering rivers it is especially important that the group stays together, to prevent the danger of someone having a hypoglycemic attack around a corner out of sight. The staff is dispersed throughout the group, with the doctor at the back.
White-water canoeing requires a shore back-up and the groups have to be much smaller so that attention can be given to each person going over rough stretches.
You can get very cold on canoeing trips and warm clothes and windbreakers are essential. (Wool stays warm even when wet.) Wet suits should be worn in winter. Warm, dry clothes should be available at the destination to stop further chilling while you are packing up and loading the vehicle to return to base. Extra food should also be available in the vehicle.
Hypoglycemia
A capsize may be the first sign of a hypoglycemic attack. Some people behave recklessly when going hypoglycemic and capsize because of it. Others just drift farther and farther towards the back of the group as they get more and more tired. It is virtually impossible to decide if someone who has just found himself head first in the cold water is hypoglycemic or not and so our rule is to give glucose after every capsize.
*98/102/5*

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DIABETES AND GROWING UP: FOOD, EVENING OUT
Food
Breakfast will usually be at home and should give you a good start to the day. One way of ensuring that you get the right type of lunch is to take a packed meal with you. There are several books that give a dietary breakdown of take-away foods. If this is the kind of meal you and your friends have, learn which of the items on the menu fit into your diet. A little dietary homework can reduce anxiety. Many sandwich shops now serve whole-wheat bread and a wide variety of fillings and you can often buy baked potatoes with fillings. It will help if you carry an apple and some high fibre bars with you to fill in gaps and to use as snacks.
An evening out
If you go out with your friends after school or work, eat a snack and find a quiet moment to check your blood glucose level. You can keep yourself going on snacks until everyone decides to have a meal. It is not a disaster if your evening meal is one or two hours late provided you stoke up with snacks and keep an eye on your blood glucose level. When the time comes for the main evening meal, take your insulin, remembering to adjust the dose according to your blood glucose level and what you plan to do afterwards. If you are going to a disco or ice skating rink or any other activity which will be energetic, take less short-acting insulin than you would usually have.
It is better to take your insulin somewhere clean than in a dirty lavatory. If you have told your friends that you have diabetes, there is no harm in taking it in front of them. They may be startled at first, but will almost certainly be interested in the insulin and diabetes. After a while, it will simply be a usual part of an outing and no one will bother if you just take out your insulin and syringe and give yourself the injection. If you treat the practical aspects of diabetes as ordinary and matter-of-fact, so will your friends. The abdomen is a useful place if you are taking your insulin in public because you can just undo your blouse or shirt and give yourself the injection. If you are sitting at a table very few people will notice what you are doing.
As the evening runs on you may need extra snacks to keep going, and you will certainly need something extra to eat if you are out at a time when you would usually be in bed.
*49/102/5*

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TAKING COMMAND OF DIABETES: ALCOHOL AND SMOKING
Alcohol
Can people with diabetes drink alcohol? Yes, providing they stick to the rules. Alcohol blocks the release of glucose from the liver and can produce hypoglycemia in people with and without diabetes. It takes smaller amounts of alcohol to produce this effect if you have diabetes requiring insulin than if you do not. Therefore, you must not have too much to drink at any one time. How much is too much? More than two pints of beer, or three US beers, or two short drinks. Always eat something if you have an alcoholic drink, such as some peanuts or nuts and raisins (these are available in most bars) or potato chips if there is nothing else, although they are too greasy to form a regular part of your diet.
Remember that alcohol is a calorie source and must be counted as part of your diet. You must not count it as a carbohydrate exchange but just as part of the total calories. Remember too that low-carbohydrate beers and lagers have a higher alcohol content than ordinary beers. Do not be tempted to binge. Intersperse your alcoholic drinks with low-calorie soft drinks if you want to keep up with your friends. Getting drunk may seem like fun at the time but you may make yourself crushingly hypoglycemic and no one will notice, least of all you!
Smoking
People with diabetes do not smoke. All the reasons for not smoking that apply to non-diabetics are equally valid for diabetics. Some are more so. People with diabetes are at greater risk of developing arteriosclerosis or hardening of the arteries than non-diabetics and smoking is a very good way of furring up your arteries. In practical terms this can mean having a heart attack or getting such bad gangrene in your legs that they have to be amputated.
Yes, but that is a long-term problem. I’m interested in now! Fine. Smoking can make you ill now. Just smoking one cigarette can halve the rate at which insulin is absorbed. This is because the nicotine from the cigarette constricts blood vessels throughout your body. A diabetic smoker may have very irregular insulin absorption and very poor blood glucose control. Smokers need more insulin than non-smokers to control their diabetes.
*50/102/5*

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INSULIN INJECTIONS FOR CHILDREN WITH DIABETES
On most occasions you will be able to take your morning insulin injection at home. There is no reason for you to come home to take your evening insulin. Draw it up in the morning and put the syringe in a small case or bag. Nowadays there are several devices such as BD Lilly pen or Novopen that can easily be carried in a pocket. Even an ordinary plastic syringe with needle, filled with insulin is reasonably portable, especially if you find a carrying case which prevents the plunger being pushed in by mistake. An empty syringe with needle and bottles of insulin with a foil-wrapped swab can also be carried in a pocket or case. You can then make a quick blood glucose check and give the appropriate insulin injection wherever you are.
Wendy has had diabetes for 14 of her 20 years. “She was always so good about her injections” said her mother, “and she always ate her diet and did her tests perfectly. Now I just can’t do a thing with her. Out all hours, won’t eat what I give her, eats junk food, not a single blood test this month. What are we to do with her, doctor?” Wendy sat m her bed looking at the wall. She had just recovered from an episode ?f diabetic ketoacidosis. “What do you think about your diabetes, Wendy?” I asked. “I’m fed up with it,” she replied sullenly. “What makes you most fed up?” “Having to come home for my insulin.”
During our discussion Wendy said that she felt her diabetes was stopping her from doing everything she wanted – getting a job, going 0ut with her friends, eating nice food. Life was just not worth living. Wendy and her mother seemed to be fighting over the diabetes, yet Wendy was 20 years old. From what Wendy said, all anyone ever did about her diabetes was tell her off. When I told Wendy about insulin pens which would allow her freedom to go out, her mother developed a disapproving silence. But Wendy relaxed for the first time, and smiled a little, “Could I really have one of those?” she asked. “Of course,” I said. She agreed to come to the Young Adult diabetic clinic.
*48/102/5*

Micronase (Glyburide-Glibenclamide)

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CHILDREN? DIABETES: HANDING OVER RESPONSIBILITY. ENJOYING LIFE

Handing over responsibility
Parental concern is natural and it is very difficult and worrying to give up running your child’s diabetes. There is the constant fear of hypoglycemia and the unspoken dread of your child being found unconscious or ill in the street. The teenage years with their rebellions and new activities must seem to many parents the worst possible time to hand over the care of the diabetes to the teenager. But most doctors believe that the diabetic child should start learning to look after his or her own diabetes as soon as possible. Very small children can give their own insulin injections and by the time they have reached their teens all diabetics should be injecting themselves. Similarly, all diabetic children should learn to measure their own blood glucose level as soon as possible and should gradually start to make their own decisions about adjusting their insulin dose according to the results. If the handover process from parent to child is gradual it is easier on both sides; you should not forget that your child may be as frightened of taking over responsibility as you are of relinquishing it. During this time your child must learn the rules.
Steve became diabetic when he was eleven years old and was allowed to eat what he wanted as long as he ate enough to stop him from becoming hypoglycemic. When he started going to an adult diabetic clinic in another city he was appalled to discover that his blood glucose control was poor and that he had been eating the wrong foods for years. He deeply regrets not having been encouraged to eat a sensible diet from the time his diabetes was diagnosed as it is very hard to change now. He feels let down and angry.
Enjoying life
How can a diabetic teenage enjoy life without the diabetes getting in the way? Your ticket to trouble-free fun is a little common sense and forward planning. First, make sure you are so practiced at checking your blood glucose level that you can do it quickly and efficiently anywhere. Get all your blood testing kit into an easily portable form that will fit into a pocket or bag. If you can keep an eye on your blood glucose level you can allow yourself more flexibility over insulin injections and meal times.
*47/102/5*

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GROWING UP WITH DIABETES

For everyone, being a teenager is an exciting and confusing time. It is a time when you start moving away from your parents and exploring life on your own. You want to do your own thing, and at the same time fit in with your friends – wear the right kind of clothes, eat the same, and stay out late at night. It can be very embarrassing being the odd one out. As a teenager, your parents always seem to be nagging you – clean your room, don’t come home late, have you done your homework? So you rebel and then feel guilty because you love them really. The older generation just does not seem to understand you. You want to burst out into the world and do great things and suddenly it all seems very large and frightening and you feel rather lost
Nowadays, the world can seem very unkind if you leave school ready to work, then find you cannot get a job. You start off applying for the exciting jobs, then the possible ones, then any jobs. Being turned down by prospective employers is no fun for anyone. Being unemployed is depressing and boring. If you have been lucky enough to get a job or go on to further education, this too has its good and bad moments. You want to do well and create a good impression and there is a lot to take in all at once. Your safe circle of school-friends has moved on and you have to start making new friends.
*45/102/5*

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DIABETES IN CHILDREN: PARENTAL WORRIES
What I have just said can apply to any teenager. It may seem much harder if you are a diabetic teenager. For a start you have to be a little more organized than your friends. You have to take your insulin injections once or twice a day and you have to eat meals at about the same time each day which have the right food content. You cannot just go out to a disco and dance the night away on two beers and some potato chips. Everyone with diabetes gets fed up about their disorder at times. ‘Why me? Why have I been singled out in this way? It is not fair.’ ‘Why should I take my insulin anyway? I’m not going to take it today – so there!’ But the only person you are fighting in the long run is yourself, and it is no fun waging war on your own body. So you get frustrated instead and get depressed, or get angry with your parents or friends. No one expects you to be perfect; there is no such person as a Perfect diabetic. It is natural to resent being diabetic at times, so do not feel guilty about it.
The parents of someone with diabetes can be a little more worried about their teenage son or daughter than other people’s parents. Their concern may come across as extra nagging. Have you had your insulin? Have you checked your blood glucose? You must be home for supper. Why were you late home last night? We were worried; we thought you might have had a hypoglycemic attack. In the early teenage years, your mother or father may still be giving you your insulin injections and taking most of the responsibility for looking after your diabetes. Some parents find it very difficult to realize that you are now old enough to take over this responsibility for yourself.
Jane is now twenty years old and has been diabetic for ten years. When she was nineteen she went on the local diabetic association holiday and was thoroughly enjoying herself. She telephoned her mother to tell her all about the holiday. During the conversation her mother asked her about her diabetic control.
Later that night I had a telephone call from her mother, who said, among other things,? Jane?s blood glucose is 10 mmol/l(180mg/dl). I?m sure you are doing something about that!’
A single reading of 10 mmol/1 is hardly a disaster, but the whole telephone conversation showed how over-anxious and over-protective Jane’s mother was. Jane was a sensible and intelligent young woman and would have been mortified to learn that her mother had telephoned me. A year later, Jane succeeded in leaving home and now has a demanding and exciting job. She continues to look after her own diabetes efficiently.
*46/102/5*

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CHILDREN WITH DIABETES AT SCHOOL
Examinations and reviews
School reviews, whatever the pupil’s age, are always times of stress. Examinations may determine the future; higher education colleges and universities and many employers use examination grades as a criterion for choosing candidates for interview. It is therefore vitally important that the diabetic pupil:
1. Does not miss classes because of his diabetes
2. Is able to concentrate during class
3. Devotes the necessary time to homework and studying for exams
4. Performs at his best during the review.
Do not miss classes
Careful monitoring of the diabetes and rapidly sorting out any problems, particularly the blood glucose level during coughs and colds, should minimize the time spent away from school. You should be able to concentrate well if your blood glucose level is normal, whereas very high or low blood glucose levels may cause muddled thinking.
Studying for exams
This inevitably involves a lot of sitting and reading with little energy output. Coupled with increasing stress as the examination approaches, this tends to raise the blood glucose level. This may become worse if you ‘worry eat’ while working- many small nibbles soon add up. Your normal diet may need to be decreased and low calorie snacks added. Resist the temptation to allow your blood glucose level to run high ‘just until the exam is over’. Your brain may not be working as efficiently as it should if the blood glucose level is high. If you take up an academic career there will be many examinations to come, so you must get used to taking them in your stride.
Some people with diabetes find that their blood glucose levels fall when they are worrying about grades. It is therefore important to check the blood glucose to find out what is happening.
*43/102/5*

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SCHOOL?CHILDREN AND DIABETES: DAY OF THE REVIEW, TRIPS AND PLANNING
The day of the review
On the day of the review it is essential that there is no risk of hypoglycemia and also that your blood glucose is not very high. Make sure that the examiner is told in advance that you may need to check your blood glucose level before, during or after the review and that you must have food and drink available during the examination. It is sensible to run your blood glucose around 7 or 8 mmol/1 (126 or 144 mg/dl) rather than 4 mmol/1 (72 mg/dl). You should take your blood testing kit, cans or containers of fruit juice, biscuits or crackers, glucose tablets or candies and tissues into the assessment with you. Make sure that you check your blood glucose before you go into the examination, and eat something if it is low. If yu do, wipe your fingers – a sticky paper could lose you marks! Do not panic if your blood glucose level is higher than you would like – it is not a disaster and you will not fail because of it! Just think afterwards what you could have done to achieve better glucose control so that you can learn for the next time.
School trips
In the old days pupils with diabetes were sometimes left behind when the rest of the class went off on a school trip because the teachers were afraid that they would not be able to cope if something went wrong. This made the diabetic pupils feel very left out. Nowadays they should be able to share in all class activities. There is no problem if you can measure your blood glucose level and adjust your own insulin and food, and if the supervisors are all told how to recognize and treat a hypoglycemic episode.
For younger pupils or inexperienced diabetic teenagers, the teachers need to be given more information about coping with the diabetes. If parents are asked to help with the trip, your mother or father could come along. Supervisors may feel happier if they have a telephone number to call in an emergency, although few will have to use it.
Planning
The first thing to do on hearing of a school trip is to find out exactly what is planned and for how long you will be away. Then work out how much food you will need and add some extra snacks for extra energy and an extra meal in case of delays. Take your insulin and blood testing kit and some money. Of course, you will be carrying glucose tablets and some form of identity card, locket or bracelet.
*44/102/5*

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JOINTS AND DIABETES
Most people with diabetes do not realize that their joints may be affected. This condition is not often a nuisance, and most people do not even notice that they have it. What usually happens is that the tendons and ligaments of the hands get a bit tight and, for example, you cannot flatten all your fingers against the table with your hand palm down. This condition goes under the wonderful name of cheiroarthropathy. If your hands are getting a bit stiff, get into the habit of doing a few finger exercises every day, perhaps with your hands in warm water. Playing an imaginary piano, clenching and straightening your fist and stretching your fingers as straight as they will go are useful exercises.
Very rarely, people with bad neuropathy get a severe form of joint trouble called Charcot’s joints. This is usually in the feet or ankles and may develop after a minor injury. If you have bad neuropathy and have a sprained ankle or foot injury which does not improve, insist on repeated x-rays.
*38/102/5*

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DIABETES AFFECTING FEET
Because our feet are so far away from the rest of us, there is a tendency to forget about them. But if you have diabetes you must look after your feet as carefully as you do your face.
Mavis closed the front door and staggered into the sitting room with her shopping. She collapsed onto the sofa and pulled off her new shoes. “My feet are killing me,” she gasped as she put them up and reached for a cigarette.
Two weeks later, her feet were killing her. The blisters from her new shoes had become infected, the infection had spread up her legs and she had developed septicemia (blood poisoning). Fortunately, good control of her diabetes and large doses of antibiotics saved her life. An operation to bypass her blocked atherosclerotic leg arteries and restore her circulation saved her legs. Her husband threw away her cigarettes and her new shoes.
Diabetes causes circulatory problems and the arteries which supply the feet can become furred up (atherosclerotic). Diabetic nerve damage often affects the feet causing numbness. This means that you may not realize that you have injured or rubbed your foot, or that your shoes do not fit. If you have joint problems in the feet or other reasons for your foot to rub on your shoe or abnormal pressure areas to develop, ulcers can occur at the pressure sites. If your blood glucose is high your body cannot fight infection as well as it should. All these factors combine to cause ulcers, gangrene and infections. In the most severe cases the only solution may be amputation of the foot or leg.
Foot care is a part of basic diabetes self-care. Keep your feet clean and wear socks/tights which cannot rub inside shoes which fit comfortably from the start. Trim the nails straight across, smoothing the corners so that they cannot dig in. Check your feet every night and seek help immediately if you notice anything wrong. Most problems are minor and can be treated rapidly. Neglected minor problems are what cause major problems. Be especially vigilant on holiday.
*39/102/5*

Glucovance (Glyburide)

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TAKING COMMAND OF DIABETES: PREVENTIVE ACTION
There is no need to be. If you are aware of the risks, you can take preventive action before these conditions have a chance to develop. If you have regular check-ups, minor changes can be identified at a time when something can be done about them. This is one reason why it is important to keep your] appointments even if you feel well and your blood glucose levels are all right. Most people with diabetes are untroubled by complications, and even if you develop them, a great deal can be done to treat them.
? Have regular health check-ups.
? Tell your doctor at once if you have any trouble with your vision; notice any change in sensation in your limbs; have pain or burning on passing urine or need to urinate very often; have soreness or irritation between the legs; pain in your calves when you walk; pain in your chest; or any problems with your feet.
? Do not smoke.
? Watch your weight.
? Eat a high fibre diet, without added salt, with reduced fat content, low in saturated and high in polyunsaturated fats.
? Keep your blood glucose levels normal.
? Take any pills prescribed by your doctor.
*40/102/5*

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DIABETES AND SCHOOL
Most people with insulin-treated diabetes first learn that they have diabetes while they are school-children. Most people with maturity onset diabetes discover their diabetes when they are working or after they have retired. Whether you are sixteen or sixty years old, the news that you have diabetes comes as a shock. It is important to get back to your usual daily routine as quickly as possible and thereafter not to allow your diabetes to get in your way. Being diabetic should not prevent you from achieving what you want from life, whether it is a senior management position, a holiday in the sun, a job as a sales assistant or a college education.
Life at school usually has a regular pattern and times of energy output (whether mental or physical) are predictable. This means that you can adjust your food and insulin pattern to suit your activities with a reasonable amount of accuracy.
It is probably easier to take a constant dose of insulin and alter your food intake according to what you will be doing next. However, if you have a very energetic morning or afternoon on the same day every week, it may be helpful to reduce your insulin on that day. For example, you could reduce short-acting for morning activity and intermediate-acting for the afternoon in addition to eating more.
Tom is fourteen years old and takes twelve units of Actrapid (short-acting insulin) and twenty units of Monotard (long-acting insulin) in the morning before breakfast and eight units of Actrapid before his main evening meal. On Tuesdays he has history and geography before break-time, woodwork until lunch-time and football all afternoon. He has had a couple of mild hypoglycemic episodes during football in the past, so he reduces his Monotard insulin to seventeen units on Tuesday mornings, but still takes twelve units of Actrapid. He has his normal breakfast but eats an extra apple at break-time if he is going to do a lot of sawing in woodwork. At lunch-time he has an extra helping of potato and a double portion of dessert. Half-way through football he has a chocolate bar and an apple. He also has a couple of biscuits or crackers before he changes after the lesson, because he will be riding his bicycle home. On some Tuesdays he checks his blood glucose level several times during the day to see if his dietary and insulin changes are being successful.
*41/102/5*

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DIABETES IN CHILDREN: ROLE OF TEACHING TEACHERS
Children spend nearly half their waking hours at school and school heads and teachers should be told that a pupil has diabetes. Teachers should be given:
1. Precise details of the pupil’s dietary and treatment needs.
2. Clear instructions as to what to do should problems arise.
The British Diabetic association provides information folders for parents to give to schools. Most diabetic clinics are also happy to help in this way. It is important that every teacher who comes into contact with your child is taught about diabetes. This may mean speaking to fifteen to twenty teachers – and repeating the discussion each year as your child moves up in the school. Informing the teachers can be organized more efficiently through the principal. It also helps if your child’s classmates know about his or her diabetes, so that they understand why the extra food and injections are needed.
Janine is fifteen years old and has been diabetic for three years. For about a year her diabetes was very difficult to control. At that time she would have severe hypoglycemic episodes of which she had no warning. It was not unusual for her suddenly to fall to the ground unconscious, a very rare problem for people with diabetes. Her best friend at school, Sue, knew nothing about diabetes until she met Janine. Now Sue has learned to recognize an impending hypoglycemic attack and gives her friend glucose immediately.
During the bad year, Sue also calmly dealt with the more severe episodes, awakening Janine from coma by rubbing glucose tablets inside her mouth. She came to think of coping with Janine’s attacks as part of her daily routine and neither she nor their other school-friends were unduly disturbed by them.
Fortunately these bad hypoglycemic attacks stopped and Janine’s diabetes is now better controlled.
*42/102/5*

Duetact (Glimepiride, Pioglitazone)

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PREVENTING DEVELOPMENT OF ATHEROSCLEROSIS IN PEOPLE WITH DIABETES
Smoking
Smoking is a definite cause of atherosclerosis. There is no argument about this in medical and scientific circles. Smoking is bad for everyone, but especially for people with diabetes. If you are a smoker, stop now. Smoking is so dangerous that you should stop even at the expense of a temporary gain in weight, although obviously it is better not to gain weight if possible. If you are a non-smoker, do not start smoking.
Blood fats
Although elevation of the blood glucose is the most obvious abnormality in your body chemistry, fat metabolism is also affected. This may have the effect of raising your blood fat levels and making the development of arteriosclerosis more likely. It is therefore particularly important that anyone with diabetes does not eat excessive amounts of fat. Most researchers also think that the fat that diabetics eat should be low in saturated fats and high in polyunsaturates, but a few feel that this point is still debatable. As well as reducing fat, keeping to a high fibre diet is helpful in preventing the development of atherosclerosis.
Hypertension
High blood pressure of hypertension is more common among diabetics than non-diabetics. Various effects of diabetes, including atherosclerosis, contribute to this. The important message is that you should have your blood pressure checked at least once a year. If it is high it should be treated, because high blood pressure can put a strain on the heart and also lead to kidney damage and strokes. It may also add to the effects of diabetic angiopathy.
If your doctor starts giving you treatment for hypertension, you must continue to take the pills for ever, or until the doctor tells you to stop. There are many different pills for the treatment of hypertension. If those you are taking do not agree with you, do not just stop taking them, but tell your doctor so that he or she can choose another drug that may suit you better.
Beta-blocking drugs (for example, propranolol, atenolol, metoprolol and other -olols) may reduce or suppress the warning signs of hypoglycemia. This effect is more frequent with so-called non-selective or more widely active beta-blockers. Thiazide drugs (for example, bendrofluazide) may increase the blood glucose level and sometimes make mild, previously undetected, diabetes obvious. Thiazides cause diuresis or urinary water loss. Other diuretic drugs may be used to treat hypertension and can also increase the blood glucose level (for example, frusemide or bumetanide). Diuretic drugs cause sodium and potassium loss in the urine. Chlorpropamide can also produce a low blood sodium level and this may occasionally cause symptoms.
Many doctors advise people with hypertension to avoid added salt in their diet. There is still some controversy over this but it seems sensible to avoid excess salt. The food we eat contains what we need before flavouring is added.
Obesity
Being fat makes high blood pressure worse and also places a strain on your heart. It makes your cells resistant to the action of insulin. The solution is obvious.
Exercise
Regular exercise is also good for the circulation and the heart and helps keep your body sensitive to the effects of insulin. If you have poor circulation in the legs, regular exercise of the leg muscles, such as walking, helps alternative circulation to develop and improves the blood supply.
Always bear these points in mind:
1. Hardening of the arteries or atherosclerosis is more common in diabetics than in non-diabetics.
2. Atherosclerosis can cause poor circulation in the legs, coronary artery disease (angina, heart attacks), high blood pressure and strokes.
3. Much can be done to prevent atherosclerosis.
4. If you smoke stop. If you do not smoke – do not start.
5. Reduce your intake of fats. It is probably better to eat polyunsaturated rather than saturated fats.
6. Eat a high fibre diet.
7. Avoid added salt.
8. Watch your blood pressure.
9. Do not get fat.
10. Exercise regularly.
*37/102/5*

Diamicron Mr (Gliclazide)

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HEART AND BLOOD VESSELS IN DIABETES
Large blood vessels can be damaged in diabetes and this is called macroangiopathy (macro – large, angiopathy – blood vessel abnormality). Macroangiopathy is atherosclerosis, or hardening of large arteries. It is more common in diabetics than non-diabetics. Hard deposits of fatty tissue in the lining of the blood vessel obstruct and eventually block blood flow, or encourage blood clots to form on their roughened surfaces.
Intermittent claudication and angina
Atherosclerosis may cause poor circulation in the legs, producing a cramp-like pain in the calves on walking, which is relieved by rest. This causes intermittent limping -the medical term is intermittent claudication. If you suffer from this, check your feet daily so that small rubs or injuries can be treated immediately: poor circulation leads to poor healing. Do not let your feet get cold in winter; even in a temperate climate it is possible to get frostbite in winter if you have poor circulation.
Atherosclerosis in the coronary arteries which supply the heart muscle may produce chest pain. This is because the muscle is not getting enough oxygen. This chest pain sometimes spreads down the left arm, and it is felt during exercise. It is called angina. If the blood supply to a particular area of heart muscle is completely blocked off, that muscle is damaged and a heart attack, or myocardial infarct, results.
*36/102/5*

Avandamet (Rosiglitazone, Metformin)

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NERVES IN DIABETICS. CHECK FOR NEUROPATHY

Many newly diagnosed diabetics notice tingling or pins and needles in their hands or feet. This is caused by an alteration of the function of the nerves supplying sensation to the hands or feet and tends to improve when the blood glucose is under control. Sometimes interference with nerve function lasts for longer, or develops several years after the diagnosis of diabetes. This is called neuropathy. Occasionally neuropathy may affect just one nerve or the working of the muscles instead of, or as well as, sensation. After many years of diabetes it is not unusual to have slight numbness of the feet. This is usually not unpleasant or very obvious but it means that you may not e aware of small rubs or cuts on your feet. If you do have numb feet you should get into the habit of looking at your feet every day so that you discover any small injuries and can protect them. Do not walk barefoot and ensure that your shoes cannot possibly rub.
Check for neuropathy
You can find out if your feet are numb by yourself, but your doctor can make more detailed checks. It is important that sensation is checked regularly so that small changes can be detected early. Vitamin deficiencies are another cause of neuropathy that can be put right easily. Your doctor will be able to look for these.
As with retinopathy, studies have shown that people with diabetes who have neuropathy have had higher blood glucose levels in the preceding years than those who have not developed this complication. Furthermore, the symptoms of neuropathy may be improved with the return of the blood glucose level to normal. Occasionally a change to insulin treatment, even if your blood glucose control is all right, may produce an improvement in troublesome neuropathic symptoms. We do not fully understand why this works. There are also drugs that can be used to treat tingling or unusual sensations if these become unpleasant.
*32/102/5*

Avandaryl (Glimepiride, Rosiglitazone)

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DIABETES AND NEUROPATHY
Autonomic neuropathy
This is a form of nerve damage that affects the nerves controlling such functions as blood pressure, erection of the penis, bowel action and bladder emptying. Autonomic neuropathy is not usually noticed by the person with diabetes; it causes no problems and is detected only by sophisticated testing. Just occasionally it does cause sufficient disturbance of these functions to be noticed:
? Postural hypotension: poor blood pressure control may cause postural hypotension, which is a fall in blood pressure on standing. This may make you feel dizzy when you get up from a chair or bed. Wearing supportive stockings to prevent pooling of blood in the legs may help. Drugs such as fludrocortisones may reduce the pressure drop.
? Diabetic bowel and bladder: autonomic neuropathy which involves the bowel may cause diarrhea, and this may be especially troublesome at night. It can settle by itself. If not, the diarrhea may improve with tetracycline (antibiotic) treatment.
Incomplete emptying of the bladder is another effect, and occasionally leads to urinary tract infection in the urine that is not lost. Playing special attention to bladder emptying may improve this problem.
? Impotence caused by autonomic failure of erection.
Loss of hypoglycemic warnings
One practical problem for insulin-treated diabetics thought to be due to autonomic neuropathy is the reduction or loss of the warning symptoms of hypoglycemia. This does not necessarily apply to everyone with autonomic neuropathy; on the other hand, over the years the warning of hypoglycemia may be harder to recognize in people with no other signs of autonomic neuropathy. Bear these points always in mind:
1. Transient tingling of the hands or feet is common before diabetes is diagnosed and usually settles with treatment.
2. Tingling or numbness in the feet may develop over the years.
3. If you have numb feet, examine them every night for minor injuries. Do not walk barefoot. Choose your shoes carefully.
4. Have regular check-ups for neuropathy.
5. Good glucose control may prevent the development of neuropathy, and improve it if symptoms have become apparent.
6. Symptomatic autonomic neuropathy is uncommon and many of its features are treatable.
*33/102/5*

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HOW DIABETES AFFECTS KIDNEYS AND URINARY TRACT: PROTEINURIA AND CYSTITIS
In the kidney, urine is formed from waste substances and water that are passed from millions of tiny blood vessels into the drainage tubes. With diabetes, the walls of these blood vessels sometimes thicken until the waste substances and water can no longer pass out of the blood vessels to start forming urine. The kidneys have an enormous reserve capacity and most of the blood vessels have to be damaged before there is any noticeable effect.
Proteinuria
The earliest sign of kidney damage is protein in the urine, called proteinuria. This can be discovered with urine tests and everyone with diabetes should have his or her urine checked for protein at regular intervals. Nowadays, many clinics are testing urine for microalbuminuria, tiny amounts of protein which may indicate the earliest stages of diabetic kidney damage in people with insulin-dependent diabetes. In those with non-insulin dependent diabetes microalbuminuria may indicate an increased risk of heart or other blood vessel problems. If it is found in several samples but without urinary tract infection other kidney tests can be carried out. Proteinuria does not necessarily mean you have other kidney function problems but it does indicate the need to check for them. If you have high blood pressure it must be very carefully controlled and frequent checks must be made for urinary tract infection.
Cystitis
The commonest cause of proteinuria among people with diabetes is urinary tract infection, such as cystitis or bladder infection, pyelonephritis or kidney infection. A midstream urine sample is easily taken and will be sent to the laboratory for analysis so that appropriate antibiotics can be given. Non-diabetic men rarely have urinary tract infection but diabetic men may do so and it is common in women. The symptoms are a burning sensation on passing urine which may have blood in it or smell bad, and a very frequent desire to pass urine, although there may be little there to pass. Urinary tract infection may upset your glucose balance and so your blood glucose levels should be checked frequently.
*34/102/5*

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DIABETES AND KIDNEYS AND URINARY TRACT: THRUSH
One of the commonest early symptoms of diabetes among women is itching and soreness between the legs. The vulva and vaginal area, and sometimes the skin around the anus, are extremely sore and red and so itchy that the sufferer has a desperate desire to scratch, which is embarrassing and makes everything more sore. There is frequently a creamy vaginal discharge and the skin may be covered with white flecks. This condition is caused by the fungus which also produces thrush in babies. It can be cured by an antifungal cream (it is important to insert the cream high into the vagina to destroy the fungus completely) or by pessaries or special tampons. It is also important to control your blood glucose level, because the fungus likes a sugary environment.
Men can get thrush too, and may develop soreness of the penis. Thrush can be passed on by sexual intercourse and so both partners should use the antifungal cream.
The thrush fungus and other organisms may also colonize skin folds of very overweight people in places such as the groin, under the breasts and sometimes the umbilicus or belly button. This is because sweat collects there and provides a moist environment for the fungus to grow. Again, antifungal creams usually cure this, but the ultimate solution is to lose weight and to control your blood glucose level.
*35/102/5*