Diabetes:

How much do you know?

By Dr. Indu WAIDYATILAKA

Continued from last week

How is diabetes treated?

Specific treatment for diabetes will be determined by your doctor based on your medical history, family history, your age, overall health, the type of diabetes you have, the complications if there are any, your tolerance for specific medications and your opinion or preference.

Treatment can be discussed under the following headings 1. Diet control 2. Exercise 3.Oral hypoglycaemic drugs 4. Insulin Diet The dietary advice for people with diabetes has changed considerably over the last few decades. Earlier people with diabetes were asked to starve themselves! Later people with diabetes were told to avoid all sugars and starches. Today, however, the principle is to eat healthily, in the same way that is recommended for the whole population, with few modifications.

A balanced diet based on starchy foods and lots of fruits and vegetables, and is low in fat, salt and sugar.

What is important to know is what to eat, when to eat and how much you should eat.

Effective management of diabetes cannot be achieved without appropriate dietary modifications.

All newly diagnosed patients with diabetes should receive advice on life style and dietary modification from their `Diabetic team`.

The aims of these dietary advices are to provide you with knowledge of healthy eating, encourage lifestyle modifications in order to reduce obesity and ensure optimal weight, to maintain blood sugar and cholesterol levels as near normal as possible. Good dietary advice and following them properly may reduce the risk of acute complications of diabetes like low blood sugar reaction (hypoglycaemia) and high levels of blood sugar (hyperglycaemia).

Your diet should provide 50% energy intake from complex carbohydrates, such as that found in whole grain food stuff, which absorbs slowly. This prevents rapid rise in blood glucose level. Avoid rapidly absorbed carbohydrates, like sugar, desserts etc.

You must reduce the consumption of food stuff like butter, cheese, sausages etc to limit the fat intake to less than 30% energy uptake.

Instead of having three “large” main meals, try to reduce the quantities of main meals and have sugar/fat free snacks in between. This helps you to maintain a stable blood sugar level throughout the day. (Having six small meals is better than having three large meals and no snacks)

Exercise and diabetes

Exercise plays a major role in the management of diabetes. Physical activity can help you control your blood glucose, weight, and blood pressure, as well as raise your “good” cholesterol and lower your “bad” cholesterol. It can also help prevent heart and blood flow problems, reducing your risk of heart disease. Exercise helps you relax and can also help you feel better about yourself and increase your overall health.

The journey of a thousand miles begins with a single step. Exercise works the same way. Taking that first step can be hard, especially if you’ve been diagnosed with diabetes. Remember — it’s never too late. You can always improve your level of fitness.

For most people, it is best to aim for a total of 30 minutes of exercise a day, at least 5 days a week. However one can divide one’s activity for the day into 2 sessions, 15 minutes each.

An often heard excuse is that the patient does not have the time to engage in exercise. This is not an acceptable excuse. The lack of time factor can be addressed in some simple, practical ways(, eg. By getting off the bus 3 or 4 stops before the destined regular stop and walking part of the way.)

If one has to do marketing on foot, by taking a circuitous route one could get the requisite exercise without a time constraint.

One could use one’s own ingenuity to get the quota of exercise without making it look like a burden.

Benefits of exercise

1. Exercise burns calories, which will help you lose weight and maintain a healthy weight.

2. Exercise can help your body respond to insulin better and may reduce the amount of insulin needed to maintain good blood glucose levels.

3. Exercise can improve your circulation, especially in your arms and legs, where people with diabetes can have problems.

4. Exercise helps reduce stress, which can raise your glucose level.

5. It can lower your risk of heart disease

6. It reduces your cholesterol levels

7. It helps you control your blood pressure.

8. In some people, exercise and a proper diet can control Type 2 Diabetes without the need for medications.

Now that you know the benefits of exercise, you are ready to start your exercise program.But if you have recently been diagnosed as having diabetes have been inactive and out of shape not had experience with diet or insulin adjustment,have had complications from diabetes have other health problems such as high blood pressure, heart diseases, joint diseases etc Meet your doctor before you begin an exercise program. Your doctor can tell you about the kinds of exercise that are good for you depending on how well your diabetes is controlled, any complications you may have had or other health related conditions.

What kind of exercise should you do? Most doctors recommend aerobic exercise, which makes you breathe more deeply and makes your heart work harder. Examples of aerobic exercise include brisk walking, jogging, swimming or bicycling. There is another type of exercise and this improves flexibility, coordination and muscle tone (eg: ankle rotation, arm circles and stretching muscles). Depending on your health status your doctor will recommend the type of exercise that suits you the most. For example if you have problems with the nerves in your feet or legs, your doctor may want you to do a type of exercise that won’t put stress on your feet. These exercises include swimming, bicycling, rowing or chair exercises.

No matter what kind of exercise you do, when you start an exercise program, go slowly. Gradually increase the intensity and length of your workouts as you get fitter .Remember you should warm up before you start and cool down when you are done.

To warm up, spend 5 to 10 minutes doing a low-intensity exercise such as walking. Then gently stretch for another 5 to 10 minutes. Repeat these steps after exercising to cool down.

Exercise and low blood sugar reaction (Hypoglycaemia) Your health care team will discuss with you about the possibility of low blood sugar reaction (hypoglycaemia) which is a potential risk for a person with diabetes. This usually occurs while exercising or immediately after activity. But you should keep in mind the possibility of having a reaction even few hours afterwards.

You should be alert to the symptoms of hypoglycaemia and should never ignore the warning signs. When your blood sugar level drops below a critical level you may feel a change in your heartbeat, sweat excessively, get a headache, feel dizzy, become anxious and shaky, and feel irritable.

Or you may get a tummy pain, nausea or feel very hungry. If you ignore the initial warning symptoms your sugar level will drop drastically and you may even lose consciousness.

At the first sign of above symptoms, you should stop exercising and follow your doctor’s advice about how to treat hypoglycaemia. Your doctor may suggest you keep some toffees, packet of glucose/sugar or juice at hand to treat hypoglycaemia. It is important to remember, if you do have an attack of hypoglycaemia and even if you are treated promptly, it could recur during the course of the day. Be under medical supervision till the episode is clearly behind you.

Some exercise tips

If you’re planning to walk or jog, be sure you wear comfortable well fitting shoes. When ever possible wear socks. Be on the look out for blisters.

Stretch for five minutes before and after your workout regardless of how intense you plan to exercise. Start slowly with a low-impact exercise such as walking, swimming, or biking.

Build up the time you spend exercising gradually. If you have to, start with five minutes and add a bit of time each day.

Drink plenty of fluids while you exercise, especially when it’s hot.

Dehydration can increase your blood sugar. If you exercise for more than an hour, drink carbohydrate-containing beverages rather than plain water.Monitor your blood glucose levels before, if possible during (at least initially), and after exercise to assess your requirements for extra food.

Discuss adjusting carbohydrate intake with your doctor/dietitian.

Adjust insulin and medication.

In Western countries diabetics always wear a diabetes identification tag indicating that they have diabetes to ensure proper treatment in case of an emergency.

Have some chocolate, toffees, fruit juice, sugar tablets or glucose handy in case of low sugar reaction. If you experience any warning signs, stop exercising. If you don’t feel better within 15 minutes, seek immediate medical help.

Oral hypoglycaemic drugs

Controlling your blood sugar is essential to feeling healthy and avoiding long-term complications of diabetes. Some people are able to control their blood sugar with diet and exercise alone. When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help of medication. There are different classes of oral medications available.

Oral medications may include: Sulfonylurea drugs (eg Glibenclamide, Gliclazide, Glipizide), which stimulate the production of insulin in the pancreas. Most common side effect is low blood sugar reaction (hypoglycaemia) especially during the initial period of therapy.

Biguanides (eg Metformin), which decrease the amount of sugar made and released from the liver, hence you need less insulin to transport blood sugar into the cells. Another added advantage is, this group of drugs produce less weight gain. Side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, and rarely diarrhoea. It is advisable to take this medication with food to avoid these side effects .A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness.

Alpha-glucosidase inhibitors (eg Acarbose), which slow down the absorption of starches. This helps prevent the rapid rise in blood sugar that usually occurs right after a meal. Commonly patients complain of abdominal bloating. Higher doses can cause liver damage as well.

Meglitinides (eg Repaglinide, Neteglinide), which stimulate the production of insulin in the pancreas just like sulfonylurea drugs. But hypoglycaemia is not as common.

Thiazolidinediones (eg Pioglitazone, Rosiglitazone), which makes the body more sensitive to insulin and keep the liver from overproducing sugar. Side effects include, weight gain and fatigue. There is a possibility of liver damage and if you are being prescribed this drug your doctor will advice you to check your liver functions every two months during the first year of treatment. You must contact your doctor immediately if you experience any of the signs and symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will need to investigate all possible causes.

Drug combinations

Sometimes your doctor may decide to combine two or three drugs from different classes for better blood sugar control. Each class of oral medication can be combined with drugs from any other class.

Insulin is a hormone that controls the level of blood sugar (also called glucose) in your body.

When we eat, our body breaks food down into organic compounds, one of which is glucose.

The cells of our body use glucose as a source of energy for movement, growth, repair, and other functions. But before the cells can use glucose, it must move from the bloodstream into the individual cells. This process requires insulin.

Insulin is produced by some small cells in the pancreas (beta cells). When glucose enters our blood stream, the pancreas should automatically produce the right amount of insulin to move glucose into our cells.

If the beta cells degenerate so that the body cannot make enough insulin on its own, Type I diabetes results. A person with this type of diabetes must inject exogenous insulin (insulin from sources outside the body).

In Type II diabetes, the beta cells produce insulin but this amount is either not enough or the cells throughout the body do not respond normally to it. Nevertheless, insulin also may be used in type II diabetes to help overcome the resistance of cells to insulin.

By reducing the concentration of glucose in the blood, insulin is thought to prevent or reduce the long-term complications of diabetes, including damage to the blood vessels, eyes, kidneys, and nerves.

Types of Insulin

There are more than 20 types of insulin products available in four basic forms, each with a different time of onset and duration of action. The decision as to which insulin to choose is based on an individual’s lifestyle, a physician’s preference and experience, and the person’s blood sugar levels. Among the criteria considered in choosing insulin are: how soon it starts working (onset) when it works the hardest (peak time) how long it lasts in the body (duration).

What are the types of Insulin Delivery Devices? All insulin delivery devices inject insulin through the skin and into the fatty tissue below.

Most people inject insulin with a syringe that delivers insulin just under the skin. Others use insulin pens, jet injectors, or insulin pumps.

Several new approaches for taking insulin are under development.

Syringes are hypodermic needles attached to hollow barrels that people with diabetes use to inject insulin. Insulin syringes are small with very sharp points. Most have a special coating to help the needles enter the skin as painlessly as possible. Insulin syringes come in several different sizes to match insulin strength and dosage.

Insulin pens look like pens with cartridges - but the cartridges are filled with insulin rather than ink. They can be used instead of needles for giving insulin injections. Some pens use replaceable cartridges of insulin; other models are totally disposable after the pre-filled cartridge is empty. A fine short needle, like the needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin.

Insulin jet injectors may be an option for people who do not want to use needles. These devices use high pressure air to send a fine spray of insulin through the skin. Jet injectors have no needles. In Sri Lanka jet injectors are hardly used.

Insulin Pumps

Insulin pumps are small pumping devices worn outside of your body. They connect by flexible tubing to a catheter that is located under the skin of your abdomen. You program the pump to dispense the necessary amount of insulin. Usually, you set the pump to give a steady small dose of insulin, but you can give an additional amount in a short time if needed, such as after a meal.

If adjusted properly, these pumps allow close control of your insulin levels without multiple injections. You should not use this type of pump during physical activities that may damage the pump or disrupt the pump’s connection to the body. You still need to monitor your blood glucose levels regularly if you use this type of device. Insulin pumps are not commonly used in Sri Lanka.

What information should my doctor have before starting insulin? Before using this preparation make sure your doctor or pharmacist knows: if you are pregnant, trying for a baby or breast-feeding if you suffer from kidney problems if you have ever had an allergic reaction to insulin or any other medicine if you are taking any other medicines, including those which could be bought without a prescription, herbal or complementary medicines What are the goals of insulin treatment?

The goal of insulin treatment is to keep blood glucose levels at normal or near-normal levels. Careful control of blood glucose levels can help prevent both the short-term effects of poorly controlled blood glucose and the long-term effects of poorly controlled blood glucose (diabetic complications of the eye, kidney, nerves and heart).

How to use insulin? Use your medication exactly as directed. Try to have your injection at the same time each day. Before you inject, if you have pre-drawn your insulin in the syringe, take it out from the refrigerator half an hour before injection Your doctor will show you how to inject yourself with insulin. It is usually injected into the upper arms, thigh, buttocks or abdomen.Always read the printed information leaflet, if possible before beginning treatment.Some types of insulin require mixing, check with your doctor if you are unsure. Mix insulin well by rolling the bottle slowly between the hands or by tipping the bottle upside down and gently rotating about 10 times.

Do not shake the insulin as frothing or bubbling can cause an incorrect dose.

Insulin doses are referred to in terms of units.

Clean the skin before, and after injecting.

Eat 20 - 30 minutes after your injection.

Never take more than the prescribed dose. If you suspect that you or someone else has taken an overdose of this preparation immediately take some sugar/glucose because hypoglycaemia can kill you. Then you contact your doctor or go to your local hospital at once. Always take the container with you, if possible, even if empty.

This medicine is for you. Never give it to others even if their condition appears to be the same as yours.

Carefully dispose of your used needles and syringes in a used bottle with a screw cap.

Where should I inject the Insulin? The usual places to inject insulin are the upper arm, the front and side of the thighs, and the abdomen (tummy area). Ask your doctor which place you should use. Insulin injected near the stomach works fastest, while insulin injected into the thigh works slowest. Insulin injected into the arm works at medium speed. Some prefer the abdomen as it is easy to inject than limbs and the rate of absorption is fairly constant.

It is important to rotate your injection sites because repeated injection at the same site causes fat to accumulate at that area. This results in poor absorption of the insulin when injected. It is also unsightly.

Shift each injection site by 1 finger space and do not inject bruised area.

If you take too much insulin it will lower your blood sugar level too much, and you may get hypoglycaemia (also called an insulin reaction). When you have hypoglycaemia, you may feel sweaty, more tired than usual, confused and shaky, and you may feel drowsy. In serious cases, you can pass out or have a seizure (a fit). Talk to your doctor about how to treat hypoglycaemia. Your doctor may suggest that you always carry a snack with you, such as candy, fruit juice or glucose, to treat hypoglycaemia.

Storage of Insulin Write the date on the bottle when you open it.

An opened bottle of insulin will expire 2 months after it is opened and must be discarded at this time Keep the opened bottle of insulin with syringes to be used again in a box Never freeze insulin; keep it in the middle compartment of refrigerator.

Penfill cartridges do not require refrigeration when they are in use.

Do not leave insulin in the sun or unattended in your car.

Getting the most from your treatment. As no two people are alike, treatment may consist of one or more types of insulin with the amounts you use carefully chosen to suit your requirements.Before taking any ‘over-the-counter’ medicines, check with your pharmacist which medicines are safe for you to take alongside this preparation.

Keep your regular appointments with your doctor. You must test for sugar in the blood or urine to make sure that you are taking the right dose of insulin for you. Your doctor will show you how to test your blood sugar and how to use the results of the test.

Do not drink alcohol on an empty stomach as this could cause severe hypoglycaemia (low blood sugar).

Check with your doctor before taking up any physical exercise as this will have an effect on your blood sugar levels, which can last for hours.

Check with your doctor if you develop an infection, you may need a change in dosage.

Check you have been given the correct insulin each time you collect your prescription.Change the injection site on your body regularly to help prevent skin problems and difficulties in injecting.

Keep at hand an extra supply of insulin and an injection device, a blood or urine testing strip and a source of sugar.

The writer is attached to the Colombo South Teaching Hospital,Kalubowila.