WAPD
Idiot’s Guide to Diabetes
By
Anne Forbes
United Kingdom
Introduction
This booklet was originally written for colleagues
at my workplace, a residential facility for adults with learning disabilities,
so that they would have a better understanding of the needs of our one diabetic
resident.
It is intended to give the reader a comprehensive layman’s knowledge of diabetes.
It will explain what diabetes is, how you can recognise if someone has it,
how it is treated and what to do to help if someone with diabetes is having
problems.
OK, so who is Anne Forbes and what qualifies
her to write such a booklet?
Well first of all I’m a self confessed idiot
– those who know me I am sure will agree. Secondly 17 years ago I knew
very little …….. almost nothing in fact ……. about diabetes. I was vaguely
aware that someone with diabetes had to take insulin and eat special things
and I had this weird idea that it had something to do with feet. But
that was about it. As you will learn there is some truth in all the
above, although my ideas were vague ……. and confused.
Then I started dating this guy …….. perfectly normal chap …… we did all the
usual dating stuff …… then one night he dropped a bombshell. “I have
to go now.” He said – we’d been out to the pub – “I have to eat soon …… you
see I’m diabetic.” Anyway I asked him about it. He explained.
He stayed and I fed him and a couple of months later he proposed to me flat
on his back on a trolley in the A&E Department of Worthing General Hospital.
He’d had a hypo in the wee small hours of the morning. I had awoken
to find him unconscious beside me. That w! as my first real experience
of the drama (and trauma) of living with diabetes. I resolved to learn
everything I could about the condition and how best to go about living a
normal life with my future husband under its spectre.
His proposal? “Anne, I was going to ask you to marry me hanging upside
down from a tree with a rose between my teeth. Well I feel like I’m
upside down and I’ve swallowed the ****** rose so ….. will you?”
How could I refuse? And the rest, as they say, is history.
So here I am with no medical qualifications but many years of practical experience
of living with diabetes. I hope that sharing my experiences and the
knowledge I have gained over the years will help you to understand diabetes
better.
Anne Forbes
WHAT IS DIABETES?
The term diabetes actually covers a number of
related medical conditions all of which cause problems with the control of
blood sugar levels in the body.
All of us need sugar (in the form of glucose) in our blood stream in order
for our bodies to function. In order for our circulatory system, muscles
and organs to work efficiently the level of glucose in the blood needs to
be within a certain range. In the UK this is measured in millimoles
per litre (mmol/l). The range of blood sugar in a normal person will
vary between 4 and 8 mmol/l depending on their level of exercise, how much
and what they have eaten etc. Any deviation much above or below this
range will cause problems (more about that later). In order for the
body to use sugar for the energy it needs it produces insulin. Insulin
is secreted in an organ called the pancreas – in fact in specific cells within
the pancreas called “The Islets of Langerhans” (I always thought it sounded
like a fairly promising holiday destination!) It is problems with the
levels of insulin production in the body that give rise to the various types
of diabetes.
For our purposes we will cover the 2 most common forms of diabetes:
Type 1 Diabetes (T1) – also known Juvenile Onset Diabetes
Type 2 Diabetes (T2) – also known as Late
Onset Diabetes
These will be explained in some detail.
However there are a couple of others worth a brief mention. There is
a type of diabetes that causes over production of insulin and therefore frequent
dips in the body’s blood sugar level, no to potentially fatal levels but
enough for the sufferer to feel faint and woozy (as we all do if we do not
eat for a very long time) sometimes several times a day. People who
have this type of diabetes will need to take frequent snacks in order to
keep blood sugars within normal range. There is also a type of diabetes
that occurs only in pregnant women (Gestational Onset Diabetes) which can
vary in severity. Pressures on the pancreas, both physical and physiological,
cause it to be sluggish in insulin production. Some women can control
it solely by an alteration in diet, others need oral medication and some
may need insulin injections. This type of diabetes almost always magically
disappears once the baby is born.
WHY IS DIABETES DANGEROUS?
Diabetes is dangerous because deviations in blood
sugar above or below normal levels can cause life-threatening problems, both
chronic and acute.
HOW IS DIABETES TREATED?
The way in which diabetes is treated (or managed)
depends on which type of diabetes it is. The object of management is,
by some means, to keep the blood sugar levels within the normal range as
much as possible. Good control of blood sugar is extremely important.
This can be achieved by a combination of diet, oral medication or insulin
replacement depending on the type of diabetes.
SO WHY IS GOOD BLOOD SUGAR CONTROL SO
IMPORTANT?
As already mentioned the body needs blood sugar
levels to be within a certain range in order to function properly.
Good control of blood sugar is essential unless you want to end up in and
extreme case prematurely DEAD ( which most of us want to avoid) or blind,
legless and hooked up to a dialysis machine!
Extremely high blood sugars can cause a condition
called Ketosis, which can lead to coma and death. However it is rare
for this to happen since the symptoms are quite obvious and usually spotted
well before the death stage.
However even moderately high blood sugar levels
over a long period of time can cause serious and life-threatening complications.
These include:
1) Diabetic
Retinopathy – this causes damage to the blood vessels within the eye
and can lead to blindness.
2) Diabetic
Neuropathy - this causes damage to the nerves in the peripheries (typically
feet and legs but sometimes also hands and arms) causing loss of sensation.
This can cause and increased risk of accidental injury as well as obvious
discomfort and distress.
3) Peripheral
Vascular Disease (PVD) – this causes damage to blood vessels in the peripheries
which can lead to increase risk of thrombosis and a slowness for wounds to
heal. This can lead to chronic ulcers and obvious problems if combined
with Diabetic Neuropathy. The possibility of the onset of gangrene
is a real threat and amputation can result.
4) Kidney failure
– due to damage to blood vessels around the kidneys. A common urban
legend is people who say they got diabetes BECAUSE they had kidney problems
….. when in fact they had undiagnosed diabetes for years which CAUSED the
kidney problems.
5) A highly
increased risk of heart disease or stroke
HOW IS GOOD BLOOD SUGAR CONTROL ACHIEVED?
Again this depends on which type of diabetes
it is. There are however 3 key factors in the control of blood sugar
levels which are common to all types of diabetes:
1) A HEALTHY DIET
2) EXERCISE
3) FREQUENT MONITORING OF BLOOD SUGAR LEVELS
1) A HEALTHY
DIET
ALL of us – not just those with diabetes – should
be eating a healthy diet. This should be low in sugar, low in fat, low in
salt, controlled (according to needs – metabolism, exercise etc) carbohydrate,
high fibre and necessary protein. Such a diet should also provide all
necessary vitamisn and minerals.
2) EXERCISE
ALL of us – not just diabetics – should be taking
regular exercise. It is essential for us to keep our bodies healthy and to
maximise the efficiency of the way our bodies both process and use the food
we eat.
3) FREQUENT
MONITORING OF BLOOD SUGARS
For someone with diabetes the frequent monitoring
of blood sugars is essential so that food intake and drug/insulin therapy
can be adjusted to achieve optimal levels. Knowing how your body reacts
to given situations e.g. exercise or stress or to certain foods is vital
to achieving tight blood sugar control. This is not to say that a diabetic
should become a slave to blood sugar monitoring but rather that it should
be used as a tool to help them understand their bodies and effectively control
their diabetes. In these days of enhanced technology blood sugar monitoring
is simple and quick and can be done unobtrusively in a very few moments.
WHAT IS TYPE 1 DIABETES?
Type 1 Diabetes (T1) – also known Juvenile
Onset Diabetes
As the name implies this type of diabetes is
most often diagnosed in childhood or early adulthood (although it CAN be
diagnosed at any age)
Type 1 Diabetes is characterised by the sudden failure of the pancreas to
produce insulin.
How do you know if someone might have Type
1 Diabetes?
Symptoms include a raging thirst, frequent urination,
lethargy, weight loss (despite high food intake), and eventually coma which
may result in death. Usually, and fortunately, it is diagnosed well
before the death stage.
Is there a cure for Type 1 Diabetes?
The short answer to that at this moment in history
is realistically “no”. Once the body stops producing insulin there
is no way known to kick-start it into production again. Sounds bad?
Well we would all, of course, love to see a cure but Type 1 Diabetes can
be effectively managed and those with it can live perfectly normal lives.
So ………. It could be worse!!!!
Is there ever likely to be a cure for Type
1 Diabetes?
Research is going on all the time to develop
a cure for T1 Diabetes.
There have been some limited successes with pancreatic
transplants and research has also been done on the transplant of the specific
insulin producing cells ( those exotic sounding Islets of Langerhans).
As with any transplant procedure, however, the patient is then committed
to a life time of anti rejection medication so on balance there is little
advantage over ongoing insulin therapy in terms of quality of life.
Some very promising animal studies have been done with cloned embryo stem
cells to regenerate insulin production. This offers a very real chance
of a “cure” but it is an ethical minefield. If this does show promise
it will be a long time coming. Ethics aside no one has yet succeeded
in cloning a human embryo beyond the 8 cell stage. In order for there
to be a therapeutic benefit it needs to be at least 32 cells. Whilst
in terms of cell development that is only 2 more divisions it could take
years before this is achieved. And that is if embryonic stem cell research
is allowed to! continue. More recently there have been some promising
developments with the cloning of adult stem cells, which obviate the ethical
issues to a degree, but these are still many years away from being therapeutically
useful.
How is Type 1 Diabetes Treated?
At present the only way to treat (or manage)
Type 1 Diabetes is to replace the insulin, which the body is no longer producing
with insulin from another source (i.e. from animal or synthetic production).
Insulin itself has a very delicate structure and, for this reason, it cannot
be taken orally since it would be broken down in the digestive process.
It needs therefore to reach the blood stream by a less destructive route.
There are several ways to achieve this.
Subcutaneous injection – this is by far the most common method.
The insulin is injected with a needle into the fatty layer under the skin
from where it is absorbed into the bloodstream. Injection sites tend
to be tops of arms, thighs, belly and buttocks. (Though most self-injectors
tend to avoid buttocks – ever tried stabbing yourself in the bum??
Not easy!!!) The dosage and type of insulin will vary from individual
to individual. Typically injections will be from 2 to 4 times per day.
The number of injections does NOT bear any relation to the seriousness of
the individua! l’s condition. Basically the more injections per day
the more flexible the patient can be with their regime, which leads to better
control. Most people now who lead busy lifestyles and require a level
of flexibility will be on 4 injections per day (a night time injection providing
a 24 hour slow release basal level of insulin plus injections prior to each
meal – breakfast, lunch and dinner – which can be adjusted to cater for what
one is about to eat.)
Insulin pump – this delivers insulin by basically the same route as injections
(i.e. subcutaneously) but avoids the necessity to stick needles in oneself
up to 4 times daily since the delivery point is implanted under the skin.
The pump delivers insulin automatically. This can be particularly useful
to those with needle phobias or those who are prone to forget to take their
medication.
Needle-less injections – this delivers insulin by the same basic route as
above (so again subcutaneous but shoots the insulin through the skin with
a super-fast jet of air. Trials have been carried out with this method
but as yet it is not widely available.
Inhalation – research and trials are currently being done on the absorption
of insulin via mucous membranes.
In addition to replacing the insulin it is also important for T1 diabetics
to pay attention to:
Diet
Exercise
Frequent monitoring of blood sugar levels.
Given that all the above are paid due attention
there is no reason at all why anyone with T1 Diabetes cannot live a perfectly
normal and long life.
Can Type 1 Diabetes be prevented?
Since the exact cause of Type 1 diabetes is unknown
prevention is problematical. It is known that the potential for developing
T1 Diabetes is genetic. Children of a T1 Diabetic have roughly a 4
in 1 chance of inheriting the potential to develop it. But not everyone
who inherits the potential develops the condition, which suggests that environmental
factors play an important role. Certainly eating a healthy diet and
taking regular exercise and, in particular, avoiding obesity can only help
in the prevention of the development of T1 Diabetes.
WHAT IS TYPE 2 DIABETES?
Type 2 Diabetes (T2) – also known as Late
Onset Diabetes
As the name implies this type of diabetes is most often diagnosed in late
adulthood and has, in the past, been considered (rather unflatteringly) an
old person’s disease. However in recent years, very worryingly, more
and more children, some of them very young, are being diagnosed with T2 Diabetes.
The factors that seem to directly relate to this are dietary changes (our
love of “junk food”) and a massive increase in childhood obesity.
Type 2 Diabetes is characterised by a slowing down of insulin production
in the pancreas so that it is insufficient to meet the needs of the body.
How do you know if someone might have Type
2 Diabetes?
Symptoms are similar to those of T1 diabetes
but less acute in onset both in terms of time-scale and severity. They
may include and increased thirst, frequent urination, lethargy, weight loss
etc. Unfortunately if the symptoms are mild they may go unnoticed for
years while the patient is living unknowingly with constantly high blood
sugar levels. The first real indication of the presence of T2 diabetes
may be one of the complications, which has arisen because of it. For
instance sometimes people say they developed diabetes following kidney problems
when in reality the kidney problems were caused by undiagnosed T2 diabetes!
Although good control can then be achieved some damage has already been done.
T2 diabetes really does pose an unseen danger and is potentially a hidden
killer!
What causes Type 2 Diabetes to occur?
There are a variety of factors that can cause
Type 2 Diabetes. One of the main ones is obesity. Ageing can
also play a part, as the pancreas becomes less efficient. There is
also some suggestion of a genetic pre-disposition to T2 Diabetes.
Is there a cure for Type 2 Diabetes?
This is dependant to a large extent on the cause.
If the cause is obesity simply getting back to a healthy weight can bring
about a reversal in T2 diabetes and effect “a cure”, although the individual
will always be prone to develop the condition again if they become overweight
and should therefore continue to be monitored regularly.
How is Type 2 Diabetes treated?
The treatment for T2 Diabetes is dependent on
the cause and the severity of the condition. Some T2 diabetics can
successfully control their blood sugar within the normal range by the use
of diet alone. Others will need to take oral medication in addition
to dietary control and, in extreme cases, insulin therapy may also be necessary.
The most important factors for Type 2 Diabetics
to pay attention to are:
Diet
Exercise
Frequent
monitoring of blood sugar levels
Given that all the above are paid due attention
there is no reason at all why anyone with Type 2 Diabetes cannot live a perfectly
normal and long life.
OK. SO WHAT ELSE DO I NEED TO KNOW?
You should now have an understanding of the two
most common types of diabetes, their causes, their management and their prevention.
You should also now be aware that it is essential for people with diabetes
to keep good control over their blood sugar, keeping it as close to normal
levels as possible in order to prevent the long term complications associated
with high blood sugars.
The main thing you still need to know about is HYPOGLYCAEMIA.
The major downside of keeping very tight control of blood sugar levels to
keep them DOWN is that on occasion the levels may fall TOO LOW. This
generally only occurs with T1 Diabetes or more rarely with T2 and Gestational
Onset diabetes if these are being treated with insulin. As previously
mentioned mild hypoglycaemia can occur in some people who have an overactive
pancreas or in anyone at all who has not eaten for a long time or has undertaken
excessive exercise. However in such cases the blood sugar rarely falls
low enough to cause anything more serious than feeling unwell or perhaps
fainting. However in people who take insulin it is highly possible
for the blood sugar to drop to dangerously low levels. And make no
mistake … this can prove FATAL … and
can do so frighteningly quickly if not treated.
Usually when someone is first diagnosed with
T1 Diabetes (or other types of diabetes requiring insulin therapy) they will
be admitted into hospital while their blood sugar levels are stabilised and
their insulin dosage adjusted. During this period the doctors will
often stimulate a hypoglycaemic attack (commonly known as a hypo) by giving
the patient an over dose of insulin so that the patient will then know what
it feels like to have a hypo and thus hopefully be able to do something about
it. Doctors can be sadistic people can’t they? But the point is that
if the patient REALISES their blood sugar is dropping they can reverse this
and offset a full blown hypo simply by eating something.
And hypos CAN be FATAL
or cause permanent brain damage so really
do need to be treated with the utmost respect.
How do I know if someone is having a
hypo?
1) The person may complain
of feeling unwell, dizzy, “funny” etc.
2) The patient may become pale
and sweaty (typically cold and clammy to the touch). They may have
increased pulse and respiration rates.
3) The person may become confused,
appear drunk or start acting oddly. (And sometimes this “odd” behaviour can
be truly bizarre and completely out of character! One night my husband
and I were reading in bed before going to sleep when he suddenly sat bolt
upright, grabbed my arm, bit it hard and said “Oh yuk! A cat!” – even
though we didn’t own a cat at the time!!!! For a less understanding
spouse this may have been a prelude to a hasty divorce but I fed him a Mars
Bar and kept well out of biting range until he had returned to his more usual
mild mannered self!) On recovery the patient rarely remembers any of
the weird and wonderful things they have done! Lucky them! I
have often thought that if a T1 Diabetic wanted to get away with murder they
probably could!
4) The patient may smell peculiar.
It’s a hard smell to describe but I am sure it is this which wakes me when
hubby has a hypo at 3 am. Once smelt, never forgotten.
5) The patient may be unconscious.
6) The patient may be having seizures.
……….. and if no one notices any of the above …………..
7) The patient may be as dead
as the famed Monty Python parrot.
What should you do if you suspect someone
may be having a hypo?
If someone is known to be diabetic it is HIGHLY
UNLIKELY that they will exhibit any of the above symptoms from having HIGH
blood sugar. High blood sugar is a long term, not short term, threat
to well being. So if a person that you know to be diabetic shows any
of the above symptoms it is pretty much certain that they have LOW blood
sugar (HYPOGLYCAEMIA). So what they
need – and QUICKLY – is ……. Yes! You guessed it ……. SUGAR.
How to give them the sugar depends rather on
what state they are in when you find them,
1) If the patient is conscious
and coherent and they have available blood test equipment you could get them
to check their blood sugar level. Normal blood sugar ranges from 4-8
mmol/l. Individuals vary greatly in their body’s response to low blood
sugar. Typically my husband will start to act oddly at about 2.5. If
he drops below 2 he will be slipping into unconsciousness. By 1.5 he
will be in a full-blown hypoglycaemic coma and by ! 1.2 he will be having
seizures. However I have worked with someone who can still be walking
around apparently fully coherent with a blood sugar reading of 1.2!!!
Basically I would be inclined to feed anyone with a blood sugar reading of
below 3.5, especially if it is someone you do not know. You are not
going to do them any harm by raising their blood sugar a few points and you
could, quite literally, save their life. OK so they don’t have blood
test equipment to hand? ….. FEED THEM! Anything sugary
will do. The body absorbs glucose most quickly since this is a simple
sugar and it is therefore ideal. But in the absence of glucose any
….ose will do!
2) If the person is behaving oddly
or appearing drunk but is still conscious and capable of swallowing then
FEED THEM! You may not find this easy however. Some
diabetics seem to have a subconscious aversion to anything sugary so if you
try to feed them a Mars Bar you may end up wearing it! (This has happened
to me on occasion). Hopefully they will co-operate. If not dial
999 (911) and keep trying. But if you fail and they fall unconscious
at least help will already be on the way. Whilst trying to feed them
stay out of biting range!!! (Just kidding!) but do expect the unexpected!
3) If the person is unconscious
DIAL 999 (911) (unless you are equipped as a family member or
carer with a glucagons kit in which case you will have been trained in its
use and know exactly what to do). Put the patient in the recovery position.
If you have glucose or glucose gel available you can try smearing this on
the patients gums. They may absorb enough to bring them back to consciousness
and eat something. However anyone who has been unconscious should be
checked out by medical staff.
4) If the
patient is unconscious and having seizures DIAL 999 (911) and follow
the first aid protocol for seizures i.e. remove anything on which the patient
could injure themselves, put in the recovery position once the seizure is
over etc. You can still try the gum-smearing thing once the seizure
is over but anyone who has had a seizure should in any case go to the hospital
to be fully checked out by a doctor.
5) If the
patient is dead resign yourself to endless paperwork and ……….. you’re allowed
to PANIC!!!!!!!!!!!!!!
Hopefully now you know how to recognise a HYPO
and what to do if someone is having one.
The only other thing I can add is ………… GOOD
LUCK!!! And its always handy to have a pack of glucose tablets
in your pocket just in case you come across a diabetic in distress.
You never know ……….. it might be my husband!!!
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