| Acknowledgements
We are grateful to all the people who helped in the production of past editions of Diabetes at your fingertips: Anna Fox, Peter Swift, Clara Lowy, Suzanne Lucas and Judith North.
Peter Sönksen and Sue Judd had the original idea of a question and answer book for people with diabetes (The Diabetes Reference Book). This new edition is based on their text and the clear practical advice they gave.
We thank the following writers for their contributions to the new edition: Florence Brown for providing the nursing perspective in the chapters on insulin and monitoring; Helen Millar for answers to the questions on diet; Chris Moudiotis for advice about diabetes in children; Maria Mousley for the podiatry section and Liz Robinson for advice on the questions on alcohol.
We would like to thank the people who reviewed the book and provided helpful advice: Peter Sönksen and Sue Judd, Vasso Vydelingum for a cultural perspective, Peter Lapsley, Julia Harkess, Claire Mehmet and finally Rosie Walker for a detailed critique.
Our editors Caroline Sheldrick and Richenda Milton-Thompson have been both encouraging and endlessly patient. Jane Taylor drew the new cartoons. Richard Warner of Class Publishing has been the driving force.
|Appendix 1: Publications
At the time of writing, all the publications listed here were available. Check with your local bookshop or Diabetes UK for current prices.
About diabetes
Books
Type 1 Diabetes in Children, Adolescents and Young Adults, fourth edition by Ragnar Hanas. Class (2010)
Need to Know: Diabetes (Need to Know) by Jenny Bryan. Heinemann (2004)
Diabetes and Your Teenager by Bonnie Estridge and Jo Davies. Harper Collins (1996)
Magazines and booklets
These titles are all published by Diabetes UK.
Balance – Diabetes UK’s own magazine which appears every other month
Diabetes for Beginners: Type 1
Diabetes for Beginners: Type 2
What Diabetes Care to Expect
Living Healthily with Diabetes – a guide for Black African-Caribbean communities
Coping with diabetes when you are ill
Nutrition
Apart from the books listed here, you will also be able to find other titles in your local library or on Amazon.
Books
The Everyday Diabetic Cookbook by Stella Bowling. Grub Street Publishing (1995)
The Good Housekeeping Diabetic Cookbook by Azmina Govindji. Collins & Brown (2005)
Leaflets
These are available from Diabetes UK, some as downloads.
Food choices and diabetes
Eating well with diabetes
Alcohol and diabetes
Recipe books
These titles are all published by Diabetes UK.
The Diabetes Weight Loss Diet
Home Baking
Managing your weight – a balanced approach
Christmas and other celebrations
Quick cooking for diabetes
|Appendix 2: Useful addresses
AccuChek
Customer careline: Freephone Tel: 0800 701 000
Insulin pumps and blood glucose meters
A Menarini Diagnostics
Tel: 01189 444 100
Website: www.menarinidiag.co.uk
Blood glucose meters
Aventis Pharma
Tel: 01732 584000
Website: www.aventis.com
Bayer
Helpline: 01635 566366
Website: www.bayer.co.uk
Pharmaceutical company
Manufactures blood glucose meters and provides helpline
Becton, Dickinson & Co
Tel: 01865 748844
Website: www.bddiabetes.com
Manufactures insulin pens, syringes and needles and provides helpline
Bio-Diagnostics
Tel: 01684 592262
Website: www.bio-diagnostics.co.uk
Supplier of Glucogel
British Heart Foundation (BHF)
Helpline: 0300 330 3311
Website: www.bhf.org.uk
Funds research, promotes education and raises money to buy equipment to treat people with heart disease. For list of publications, posters and videos, send s.a.e. Their helpline, HeartstartUK, can arrange training in emergency life-saving techniques for lay people
British Hypertension Society
Tel: 020 8979 8300
Website: www.hamptonmedical.com
British Parachute Association
Tel: 01162 785271
Website: www.bpa.org.uk
Governing body of sport parachuting. Offers medical assessment on suitability for parachuting to people with medical disorders
British Sub-Aqua Club
Tel: 01513 506200
Website: www.bsac.com
Governing body for sub-aqua sport. Offers medical assessment for those with medical disorders wanting to take part in diving underwater
CDx Ltd
Helpline: 0191 564 2036
Website: www.cdx.uk.com
Maker of SensoCard Plus, a talking blood glucose meter
CP Pharmaceuticals
Now merged to form Wockhardt UK
Cygnus UK
Previously supplied Glucowatch, a continuous blood glucose monitor. There were a number of technical problems and Glucowatch has now been withdrawn
Department of Health (DoH)
Helpline: 0800 555777
Produces and distributes literature about public health. National Service Framework for Diabetes can be obtained from:
www.doh.gov.uk/nsf/diabetes.htm
Diabetes Research and Wellness Foundation
Tel: 02392 637 08
Website: www.diabeteswellnessnet.org.uk
A diabetes support organisation based in Washington DC, USA with a base in the UK. Funds medical research; its membership receive newsletters with personal stories and question and answer section
Diabetes UK
10 Parkway
London NW1 7AA
Helpline: 020 7424 1030/1000
Fax: 020 7424 1001
Textline: 020 7424 1888
Website: www.diabetes.org.uk
Provides advice and information on diabetes; has local support groups
DiagnoSys Medical
Helpline: 0800 08 588 08
Distributors of blood glucose monitors and a range of other products via mail order
Diesetronic Medical Systems
This pump manufacturer has been taken over by the American giant Roche, which now supplies insulin pumps under the name AccuChek
Disability Alliance
Helpline: 020 7247 8763
Website: www.disabilityalliance.org
Produces the Disability Rights Handbook. Updated three times a year, it addresses every aspect of social services benefits for people with disabilities. Offers advice on benefits and training for other organisations and is involved with policy issues
The Guide Dogs for the Blind Association
Tel: 0870 600 2323
Website: www.guidedogs@gdba.org.uk
Provides guide dogs, mobility and other rehabilitation services that enable blind and partially sighted people to lead the fullest and most independent lives possible
Health Development Agency
Formerly Health Education Authority and now taken over by NICE
Heart UK
7 North Road
Maidenhead SL6 1PE
Tel: 0845 450 5988
Fax: 01628 628698
Website: www.heartuk.org.uk
Will help anyone at high risk of heart attack, but specialises in inherited conditions causing high cholesterol (familial hypercholesterolaemia)
HeartstartUK
see under British Heart Foundation
The Impotence Association
see under The Sexual Dysfunction Association
Insulin Dependent Diabetes Trust
Tel: 01604 622837
Website: www.iddtinternational.org
Trust set up to help and advise people having problems with human insulin. Collects insulin for distribution in developing countries. Also runs Sponsor a child scheme for a clinic in India
Insulin-Pumpers UK
Website: www.insulin-pumpers.org.uk.
Offers information on the use of pumps and puts people in touch with each other. Advises on obtaining funding if pumps are not available via the NHS
John Bell & Croyden
50–54 Wigmore Street
London W1U 2AU
Tel: 020 7935 5555
Website: www.johnbellcroyden.co.uk
Dispensing pharmacy that can obtain medicines not manufactured in the UK, with appropriate named patient prescription and import licence
Juvenile Diabetes Research Foundation
Tel: 020 7713 2039
Website: www.jdrf.org.uk
Dedicated to funding research to find a cure for Type 1 diabetes. Provides information on the progress of research via leaflets, newsletters and open meetings
LifeScan
Helpline: 0800 121200
Website: www.lifescan.com Manufactures blood glucose monitoring systems and meters and offers advice
Eli Lilly Diabetes Care Division
Helpline: 0800 850777
Website: www.lilly.com
Pharmaceutical company. Offers helpline to people with diabetes
MedicAlarm
The Old Barn
Court Farm
Overstone
Northamptonshire NN6 0AP
Tel: 01604 646200
Email: sales@medicalarm.co.uk
Medic-Alert Foundation
Helpline: 0800 581420
Website: www.medicalert.org.uk
Offers a body-worn identification system for people with hidden medical conditions. Offers selection of jewellery with internationally recognised medical symbol. Has 24-hour emergency telephone number
MediSense Britain
Helpline: 0500 467466
Order line: 0845 607 3247
Website: www.abbottlaboratories.com
Manufactures blood glucose monitoring systems and meters, and provides information
Medtronic
Tel: 01923 212213
Website: www.medtronic.co.uk
NICE The National Institute for Health and Clinical Excellence
11 Strand
London WC2N 5HR
Website: www.nice.org.uk
National Kidney Federation
Helpline: 0845 601 0209
Website: www.kidney.org.uk
Provides information, campaigns for improvement in care and supports people through its network of local groups
Novo Nordisk Pharmaceuticals
Helpline: 0845 600 5055
Website: www.novonordisk.co.uk Manufactures injecting pens for diabetes, growth hormone and HRT injections
Nutech International Ltd
Tel: 01798 865882
Website: www.nutech-international.com
Supplier of the Lasette, a laser device for obtaining blood for testing
Owen Mumford
Helpline: 0800 731 6959
Website: www.owenmumford.com
Manufactures medical products for diabetics
Roche Diagnostics
Helpline: 0800 701000
Website: www.roche.com
Manufactures blood glucose monitoring systems and insulin pumps under the name AccuChek. Offers advice
The Royal National Institute of the Blind
105 Judd Street
London WC1H 9NE
Helpline: 0845 766 9999
Tel: 020 7388 1266
Fax: 020 7388 2034
Website: www.rnib.org.uk
Offers a range of information and advice on lifestyle changes and employment for people facing loss of sight. Also offers support and training in braille. Mail order catalogue of useful aids
Sanofi-Aventis
1 Onslow Street
Guildford
Surrey GU1 4YS
Tel: 01483 505515
Website: www.sanofi-aventis.co.uk
Servier Laboratories
Tel: 01753 662744
Manufactures diabetes meters, offers advice
Sexual Dysfunction Association
2–4 Windmill Lane
Southall
Middlesex UB2 4NJ
Tel: 0807743571
Website: www.sda.uk.net
Offers a listening ear and information on currently prescribed treatment and how sufferers should proceed to get best advice. Can advise on local specialists in erectile dysfunction
SOS Talisman
106–108 Vyse Street
Hockley
Birmingham
B18 6LP
Tel: 0121 233 7455
Website: www.allertag.com
Stroke Association
Helpline: 0845 303 3100
Website: www.stroke.org.uk
Funds research and provides information, specialising in stroke only
Sydney University’s Glycaemic Index Research Service (SUGiRS)
Human Nutrition Unit Department of Biochemistry
GO8 Sydney University
New South Wales, 2006, Australia
Tel: 0061 2 9351 3757
Fax: 0061 2 9351 6022
Website: www.glycemicindex.com
Commercial research and advisory service that measures GI values for foods, drinks and nutritional supplements. Provides advice to manufacturers to assist them in making low-GI products
Therasense
Customer Service line: 0800 138 5467
www.therasense.com
Manufactures blood glucose meters
Wockhardt UK
Tel: 01978 661261
Website: www.wockhardt.co.uk
Committed to the production of porcine and bovine insulin
© Peter Sönksen, Charles Fox, Sue Judd 1991, 1992, 1994, 1997, 1998, 1999, 2001, 2002, 2003
© Charles Fox, Anne Kilvert, 2008
All rights reserved
The authors assert their right as set out in Sections 77 and 78 of the Copyright Designs and Patents Act 1988 to be identified as the authors of this work wherever it is published commercially and whenever any adaptation of this work is published or produced including any sound recordings or films made of or based upon this work.
DISCLAIMER
The information presented in this work is accurate and current to the best of the author’s/editor’s knowledge. The author/editor and publisher, however, make no guarantee as to, and assume no responsibility for, the correctness or sufficiency of such information or recommendation. The author and publisher do not accept any legal responsibility or liability for any errors or omissions, or the use of the material contained herein and the decisions based on that use. Neither the author nor the publishers will be liable for direct, indirect, special, incidental or consequential damages arising out of the use, or inability to use, the contents of this book. The reader is advised to consult a doctor regarding all aspects of individual healthcare.
The authors and publishers welcome feedback from the users of this book. Please contact the publishers.
Class Publishing, Exchange House,
Express Park, Bristol Road, Bridgwater TA6 4RR UK
Tel 44 (0)1278 427800
Fax 44 (0)1278 421077
email: post@class.co.uk
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A CIP catalogue for this book is available from the British Library
Ebook ISBN: 9781859591772
Print ISBN: 9781859591758
Edited by Caroline Sheldrick
Cartoons by Jane Taylor
Line illustrations by David Woodroffe
Designed and typeset by Martin Bristow
Ebook conversion by JVR Creative, India
| Foreword
by Sir Steve Redgrave CBE
Vice-President, Diabetes UK
Diabetes: Answers at your fingertips has always – in its five editions, published over 20 years – shown a very constructive and positive approach to dealing with diabetes. Its layout encourages readers to develop a good understanding of their condition and to question their approach to the disease.
This new Sixth Edition maintains the same positive approach, and is now in two parallel versions: one specifically for people with Type 1 diabetes, the other written for people with Type 2 diabetes.
I have no hesitation in commending this book, which helps towards our understanding of diabetes as well as being very constructive in dealing with issues that surround the condition. I have always maintained that ‘I have diabetes but it doesn’t have me.’ As well as going out and leading a very active and normal life, not allowing diabetes to restrain you in any way, learning more about diabetes is also very positive. Happy reading.
| Foreword
Peter Sönksen and Sue Judd
Co-authors of previous editions
After 20 years with Diabetes at your fingertips, we were delighted to read this new book and to be invited to write a Foreword. Sensibly, the authors and publishers have decided that it would now be better to have two versions designed specifically for Type 1 and 2 diabetes.
This book will be of great value to people with Type 1 diabetes, as well as to any of their friends and family who wish to explore the condition and its treatment in more detail. It will also be invaluable to the professional medical and paramedical staff responsible for delivering care to people with diabetes, particularly those in the community.
Written in the now familiar ‘questions and answers’ format, it is designed for dipping into rather than cover-to-cover reading, but newly diagnosed patients might well like to read its contents in toto and will benefit from doing so.
The secret to successful self-care is knowledge, confidence and motivation; this new book will make a significant, positive contribution to this important area.
| Glossary
Terms in italics in these definitions refer to other terms in the glossary.
acetone One of the chemicals called ketones formed when the body uses up fat for energy. The presence of acetone in the urine usually means that more insulin is needed.
adrenaline A hormone produced by the adrenal glands, which prepares the body for action (the ‘flight or fight’ reaction) and also increases the level of blood glucose. Produced by the body in response to many stimuli including a low blood glucose.
albumin A protein present in most animal tissues. The presence of albumin in the urine may denote kidney damage or be simply due to a urinary infection.
alpha cell The cell that produces glucagon – found in the islets of Langerhans in the pancreas.
analogue insulin Insulin that has the molecular structure changed to alter its action.
angiography A special type of X-ray where dye is injected into an artery to detect narrowing.
angioplasty A technique which uses an inflatable balloon to widen narrowed arteries.
antigens Proteins which the body recognises as ‘foreign’ and which trigger an immune response.
arteriosclerosis or arterial sclerosis or arterial disease Hardening of the arteries: loss of elasticity in the walls of the arteries from thickening and calcification. Occurs with advancing years in those with or without diabetes. May affect the heart (causing thrombosis), the brain (a stroke) or the circulation to the legs and feet.
aspartame A low-calorie intense sweetener. Brand name NutraSweet®.
autonomic neuropathy Damage to the system of nerves regulating many automatic functions of the body such as stomach emptying, sexual function (potency) and blood pressure control.
bacteria A type of germ.
balanitis Inflammation of the end of the penis, usually caused by yeast infections as a result of sugar in the urine.
beta-blockers Drugs that block the effect of stress hormones on the cardiovascular system. Often used to treat angina and to lower blood pressure. May change the warning signs of hypoglycaemia.
beta cell The cell that produces insulin – found in the islets of Langerhans in the pancreas.
blood glucose monitoring System of measuring blood glucose levels at home using a portable meter and reagent sticks.
brittle diabetes Refers to diabetes that is very unstable with swings from very low to very high blood glucose levels and often involving frequent admissions to hospital.
calories Units in which energy or heat are measured. The energy value of food is measured in calories.
carbohydrates A class of food that comprises starches and sugars and is most readily available by the body for energy. Found mainly in plant foods. Examples are rice, bread, potatoes, pasta and beans.
cataract Opacity of the lens of the eye, which obscures vision. It may be removed surgically.
CEMACH Confidential Enquiry into Maternal and Child Health. An audit of pregnancy outcome in mothers with diabetes.
Charcot foot Swelling of the foot, sometimes leading to deformity, as a result of lack of sensation (neuropathy).
clear insulin The term used to refer to short-acting insulins. However, the two long-acting analogue insulins (Lantus® and Levemir®) are also clear so the term must be used with caution.
cloudy insulin Longer-acting insulin with fine particles of insulin bound to protamine or zinc.
coeliac disease A condition of allergy to gluten (the germ of wheat flour). Causes failure of the bowel to absorb food products normally and leads to fatty diarrhoea, weight loss and abdominal pain.
coma A form of unconsciousness from which people can be roused only with difficulty. If caused by diabetes, may be a diabetic coma or an insulin coma. See Chapter 12: Emergencies.
complications Long-term consequences of imperfectly controlled diabetes. For details see Chapter 9 .
control Usually refers to blood glucose control. The aim of good control is to achieve normal blood glucose levels (4–10 mmol/L) and HbA1c of 6.5–7.5%.
coronary heart disease Disease of the blood vessels supplying the heart.
cystitis Inflammation of the bladder, which usually causes frequent passing of urine, accompanied by a burning pain.
DAFNE Dose Adjustment For Normal Eating. An intensive education programme for people with Type 1 diabetes.
detemir A new insulin analogue designed to last for 24 hours and act as basal insulin. Also called Levemir®.
Dextro-Energy Glucose tablets.
diabetes insipidus A disorder of the pituitary gland accompanied by excessive urination and thirst. Nothing to do with diabetes mellitus.
diabetes mellitus A disorder of the pancreas characterised by a high blood glucose level. This book is about diabetes mellitus.
diabetic amyotrophy Rare condition causing pain and/or weakness of the legs from the damage to certain nerves.
diabetic coma Extreme form of hyperglycaemia, usually with ketoacidosis, causing unconsciousness.
diabetic diarrhoea A form of diabetic autonomic neuropathy leading to diarrhoea.
diabetic foods Food products targeted at people with diabetes, in which ordinary sugar (sucrose) is replaced with substitutes such as fructose or sorbitol. These foods are not recommended as part of your food plan.
diabetic nephropathy Kidney damage that may occur in diabetes.
diabetic neuropathy Nerve damage that may occur in diabetes.
diabetic retinopathy Eye disease that may occur in diabetes.
dietary fibre Part of plant material that resists digestion and gives bulk to the diet. Also called fibre or roughage.
diuretics Agents that increase the flow of urine, commonly known as water tablets.
epidural A type of anaesthetic commonly used in obstetrics. Anaesthetic solution is injected through the spinal canal to numb the lower part of the body.
erectile dysfunction Inability to achieve or maintain an erection (impotence).
fibre Another name for dietary fibre.
fructosamine Measurement of diabetes control that reflects the average blood glucose level over the previous 2–3 weeks. Similar to haemoglobin A1c which averages the blood glucose over the longer period of 2–3 months.
fructose Type of sugar found naturally in fruit and honey. Since it does not require insulin for its metabolism, it is often used as a sweetener in diabetic foods.
gangrene Death of part of the body due to a very poor blood supply. Usually occurs in the feet and may require amputation.
gastroparesis Delayed emptying of the stomach as a result of autonomic neuropathy. Can lead to erratic food absorption and vomiting.
gestational diabetes Diabetes which is diagnosed during pregnancy.
glargine A new insulin analogue designed to last for 24 hours to act as basal (background) insulin. Also called Lantus®.
glaucoma Disease of the eye causing increased pressure inside the eyeball.
glucagon A hormone produced by the alpha cells in the pancreas which causes a rise in blood glucose by freeing glycogen from the liver. Available in injection form for use in treating a severe hypo.
glucose Form of sugar made by digestion of carbohydrates. Absorbed into the bloodstream where it circulates and is used as a source of energy.
glucose tolerance test Test used in the diagnosis of diabetes mellitus. The glucose in the blood is measured at intervals before and after the person has drunk a large amount of glucose while fasting.
gluten sensitivity The underlying cause of coeliac disease. This is more common in people with Type 1 diabetes.
glycogen The form in which carbohydrate is stored in the liver and muscles. It is often known as animal starch.
glycaemic index (GI) A way of describing how a carbohydrate-containing food affects blood glucose levels.
glycosuria Presence of glucose in the urine.
glycosylated haemoglobin Another name for haemoglobin A1c.
haemoglobin A1c The part of the haemoglobin or pigment of the red blood cell which has glucose attached to it. A test of diabetes control. The amount of haemoglobin A1c in the blood depends on the average blood glucose level over the previous 2–3 months.
honeymoon period Time when the dose of insulin drops shortly after starting insulin treatment. It is the result of partial recovery of insulin secretion by the pancreas. Usually the honeymoon period only lasts for a few months.
hormone Substance generated in one gland or organ which is carried by the blood to another part of the body to control another organ. Insulin and glucagon are both hormones.
human insulin Insulin that has been manufactured to be identical to that produced in the human pancreas. Differs slightly from older insulins, which were extracted from cows or pigs.
hydramnios An excessive amount of amniotic fluid, which is the fluid surrounding the baby before birth.
hyperglycaemia High blood glucose (above 10 mmol/L).
hypo Abbreviation for hypoglycaemia.
hypoglycaemia (also known as a hypo or an insulin reaction) Low blood glucose (below 3.5 mmol/L).
impotence Failure of erection of the penis.
injector Device to aid injections.
Innolet A simple injector for insulin designed for people with poor vision or problems with their hands such as arthritis.
insulin A hormone produced by the beta cells of the pancreas and responsible for control of blood glucose. Insulin can only be given by injection because digestive juices destroy its action if taken by mouth.
insulin coma Extreme form of hypoglycaemia associated with unconsciousness and sometimes convulsions.
insulin dependent diabetes (abbreviation IDD) Former name for Type 1 diabetes.
insulin pen Device that resembles a large fountain pen that takes a cartridge of insulin. The injection of insulin is given after dialling the dose and pressing a button that releases the insulin.
insulin reaction Another name for hypoglycaemia or a hypo. In America it is called an insulin shock.
insulin resistance A condition where the normal amount of insulin is not able to keep the blood glucose level down to normal. Such people need large doses of insulin to control their diabetes.
intermediate-acting insulin Insulin preparations with action lasting 12–18 hours.
intradermal Meaning ‘into the skin’. Usually refers to an injection given into the most superficial layer of the skin. Insulin must not be given in this way as it is painful and will not be absorbed properly (see Figure 3.3).
intramuscular A deep injection into the muscle.
islets of Langerhans Specialised cells within the pancreas that produce insulin and glucagon.
isophane A form of intermediate-acting insulin that has protamine added to slow its absorption.
joule Unit of work or energy used in the metric system. A calorie is equivalent to about 4.18 joules. Some dietitians calculate food energy in joules.
juvenile-onset diabetes Outdated name for Type 1 diabetes, so-called because most people receiving insulin develop diabetes under the age of 40. The term is no longer used because Type 1 diabetes can occur at any age, although more commonly in young people.
ketoacidosis A serious condition caused by lack of insulin which results in body fat being used up to form ketones and acids. Characterised by high blood glucose levels, ketones in the urine, vomiting, drowsiness, heavy laboured breathing and a smell of acetone on the breath.
ketones Acid substances (including acetone) formed when body fat is used up to provide energy.
ketonuria The presence of acetone and other ketones in the urine. Detected by testing with a special testing stick (Ketostix®, Ketur Test®). Presence of ketones in the urine is due to lack of insulin or periods of starvation.
laser treatment Process in which laser beams are used to treat a damaged retina (back of the eye). Used in photocoagulation.
lente insulin A form of intermediate-acting insulin that has zinc added to slow its absorption. It is now obsolete and very few people use this insulin.
lipoatrophy Loss of fat from injection sites. It used to occur before the use of highly purified insulins.
lipohypertrophy Fatty swelling usually caused by repeated injections of insulin into the same site.
maturity-onset diabetes Another term for Type 2 diabetes most commonly occurring in people who are middle-aged and overweight.
metabolic rate Rate of oxygen consumption by the body; rate at which you ‘burn up’ the food you eat.
metabolism Process by which the body turns food into energy.
microalbuminuria Small amounts of protein in the urine, not detectable by dipstick for albumin (proteinuria). Raised levels indicate early kidney damage.
microaneurysms Small red dots on the retina at the back of the eye which are one of the earliest signs of diabetic retinopathy. They represent areas of weakness of the very small blood vessels in the eye. Microaneurysms do not affect the eyesight in any way.
micromole One-thousandth (1/1000) of a millimole.
millimole Unit for measuring the concentration of glucose and other substances in the blood. Blood glucose is measured in millimoles per litre (mmol/L). It has replaced milligrammes per decilitre (mg/dL or mg%) as a unit of measurement although this is still used in some other countries. 1 mmol/L = 18 mg/dL.
nephropathy Kidney damage. In the first instance this makes the kidney more leaky so that albumin appears in the urine. At a later stage it may affect the function of the kidney and in severe cases lead to kidney failure.
neuropathy Damage to the nerves, which may be peripheral neuropathy or autonomic neuropathy. It can occur with diabetes especially when poorly controlled, but also has other causes.
NICE National Institute for Health and Clinical Excellence. An independent organisation providing national guidance to promote good health. It provides guidelines for the use of new and existing drugs in the NHS.
non-insulin dependent diabetes (abbreviation NIDD) Former name for Type 2 diabetes.
orlistat A tablet that blocks the digestion of fat. Brand name Xenical®. Used to help people lose weight, which in turn may improve control of diabetes.
pancreas Gland lying behind the stomach, which as well as secreting a digestive fluid (pancreatic juice) also produces the hormones insulin and glucagon. Contains islets of Langerhans.
peripheral neuropathy Damage to the nerves supplying the muscles and skin. This can result in diminished sensation, particularly in the feet and legs, and in muscle weakness. May also cause pain in the feet or legs.
pernicious anaemia An autoimmune condition which causes failure of the body to absorb vitamin B12, which is a vital constituent of haemoglobin – the main component of red blood cells. In the absence of B12, red blood cells fail to develop normally and the patient becomes anaemic. Like many autoimmune conditions, it is more common in Type 1 diabetes.
phimosis Inflammation and narrowing of the foreskin of the penis.
photocoagulation Process of treating diabetic retinopathy with light beams, either laser beams or xenon arc. This technique focuses a beam of light on a very tiny area of the retina. This beam is so intense that it causes a very small burn, which may close off a leaking blood vessel or destroy weak blood vessels that are at risk of bleeding.
PKC inhibitors (protein kinase C inhibitors) Developed to try and reverse the changes in small blood vessels which cause diabetic eye disease (retinopathy). Though they seem to help in isolated cases, overall the results have been disappointing.
polydipsia Being excessively thirsty and drinking too much. It is a symptom of untreated diabetes.
polyuria The passing of large quantities of urine due to excess glucose from the bloodstream. It is a symptom of untreated diabetes.
pork insulin Insulin extracted from the pancreas of pigs.
pre-eclampsia A condition which occurs towards the end of pregnancy and leads to high blood pressure, protein in the urine and in severe cases, convulsions. Pre-eclampsia normally resolves soon after delivery.
protein One of the classes of food that is necessary for growth and repair of tissues. Found in fish, meat, eggs, milk and pulses. Can also refer to albumin when found in the urine.
proteinuria Protein or albumin in the urine.
pruritus vulvae Irritation of the vulva (the genital area in women). Caused by an infection that occurs because of an excess of sugar in the urine and is often an early sign of diabetes in the older person. It clears up when the blood glucose levels return to normal and the sugar disappears from the urine.
pyelonephritis Inflammation and infection of the kidney.
renal threshold The level of glucose in the blood above which it will begin to spill into the urine. The usual renal threshold for glucose in the blood is about 10 mmol/L, so when the blood glucose rises above 10 mmol/L, glucose appears in the urine.
retina Light-sensitive area at the back of the eye.
retinal screening Photograph of the retina to identify changes due to diabetes at a stage that they can be treated to prevent loss of vision. Usually carried out once a year.
retinopathy Damage to the retina.
rimonabant New drug designed to help obese people by reducing appetite. May also help people give up smoking, though it is not licensed for this. It is not yet available in the NHS and is being evaluated by NICE. Also named Acomplia®.
roughage Another name for dietary fibre.
saccharin A synthetic sweetener that is calorie free.
short-acting insulin Insulin preparations with action lasting 6–8 hours.
Snellen chart Chart showing rows of letters in decreasing sizes. Used for measuring visual acuity.
sorbitol A chemical related to sugar and alcohol that is used as a sweetening agent in foods as a substitute for ordinary sugar. It has no significant effect upon the blood glucose level but has the same number of calories as ordinary sugar so should not be used by those who need to lose weight. Poorly absorbed and may have a laxative effect.
steroids Hormones produced by the adrenal glands, testes and ovaries. Also available in synthetic form. Tend to increase the blood glucose level and make diabetes worse.
subcutaneous injection An injection beneath the skin into the layer of fat that lies between the skin and muscle. The normal way of giving insulin.
sucrose A sugar (containing glucose and fructose in combination) derived from sugar cane or sugar beet (i.e. ordinary table sugar). It is a pure carbohydrate.
thrombosis Clot forming in a blood vessel.
thyroid gland Situated in the neck, this gland controls the rate of metabolism. An overactive thyroid (thyrotoxicosis) causes a rapid heart rate, disturbed sleep, increased appetite and anxiety but also tiredness. An underactive thyroid leads to sluggishness and weight increase. Both conditions are more common in Type 1 diabetes.
tissue markers Proteins on the outside of cells in the body that are genetically determined.
toxaemia Poisoning of the blood by the absorption of toxins. Usually refers to the toxaemia of pregnancy, which is characterised by high blood pressure, proteinuria and ankle swelling.
Type 1 diabetes Name for insulin dependent diabetes which cannot be treated by diet and tablets alone. Outdated name is juvenile-onset diabetes. Age of onset is usually below the age of 40 years.
Type 2 diabetes Name for non-insulin dependent diabetes. Age of onset is usually above the age of 40 years, often in people who are overweight. These people do not always need insulin treatment and can usually be successfully treated with diet alone or diet and tablets. Formerly known as maturity-onset diabetes.
U40 insulin The old weaker strength of insulin, no longer available in the UK. It is still available in Eastern Europe and in some countries in the Far East, such as Vietnam and Indonesia.
U100 insulin The standard strength of insulin in the UK, USA, Canada, Australia, New Zealand, South Africa, the Middle East and the Far East.
urine testing The detection of abnormal amounts of glucose, ketones, protein or blood in the urine, usually by means of urine-testing sticks.
virus A very small organism capable of causing disease.
viscous fibre A type of dietary fibre found in pulses (peas, beans and lentils) and some fruit and vegetables.
visual acuity Acuteness of vision. Measured by reading letters on a sighttesting chart (a Snellen chart).
vitiligo A skin condition, more common in people with Type 1 diabetes and thyroid disease, in which areas of skin (mainly the back of hands, face and neck) lose pigment (melanin) and the surrounding skin often becomes over-pigmented. The patches of depigmentation enlarge slowly with time. There is no specific treatment but areas of vitiligo must be protected from sun damage with high factor UV products.
water tablets The common name for diuretics.
Xenical The brand name for orlistat.
| Introduction
You may be reading this because you, or someone close to you, have been found to have Type 1 diabetes. If you have just discovered that you have diabetes, you will probably feel shocked and anxious. There will be no time to adjust to the news before you have to make major alterations in lifestyle, with the need for insulin injections, blood tests and changes in what you eat. A lot of people, nurses, dietitians, doctors and podiatrists, will give you information and it may difficult to take it all in. Diabetes is a complicated condition and it will take time to learn everything you need to know – don’t feel pressured to learn it all at once.
Living with diabetes involves making day-to-day decisions which can only be made by you (or by parents of a child with diabetes). A lot of effort is being put into diabetes education so that people can make well-informed decisions. We hope this book will add to the education you receive and allow you to look up the answers as questions occur to you.
Remember that no one involved in diabetes, including healthcare professionals, ever stops learning more about it.
How to use this book
Most chapters comprise a series of questions and answers, and are not designed to be read from beginning to end. However, some chapters could well be read through at the outset, in particular Chapter 1: What is diabetes?, Chapter 4: Monitoring and control, and Chapter 9: Long-term complications.
If you are newly diagnosed, you may not be ready to come to grips with Chapter 10: Research and the future but you may want to discover what is known about the causes of diabetes (in Chapter 1). If you have just started insulin injections you should read the following sections at an early stage.
•Hypos (in Chapter 3)
•Other illnesses (in Chapter 5)
•Types of insulin (in Chapter 3)
•Blood glucose monitoring (in Chapter 4)
•Driving (in Chapter 5)
•Emergencies (Chapter 12)
People who have lived with diabetes for several years will want to check whether our answers in Chapter 5: Life with diabetes agree with their own experience.
Feedback is the most important feature of good diabetes care. This relies on people being honest with doctors, nurses and dietitians and vice versa. Not everyone will agree with every answer we give, but the book can only be improved if you let us know if you have found our advice to be unhelpful. We would also like to know if there are important questions that we have not covered. Please write to us c/o Class Publishing, Barb House, Barb Mews, London W6 7PA, UK or email: post@class.co.uk.
Comments on Type 1 Diabetes: Answers at your fingertips from readers:
‘It’s a great book! I’ve learned a lot from it. I have read previous editions, and much prefer this sixth edition, which is a book especially for Type 1s like me – and tells me things I need to know.’
J H,
Bristol
Comments on earlier editions from readers
‘An excellent book. It is comprehensive, informative, and easy to read and understand.’
DON KENDRICK,
Seaton, Devon
‘A marvellous book – just what the layman needs.’
MRS P PILLEY,
Hornchurch
‘I like the form it takes (questions and answers); it makes it much easier to find the specific areas when a problem does arise. Also it makes easier reading for picking up and putting down without having to wade through chapter after chapter of heavy medical jargon which for the lay person can be very difficult to take in and understand.’
MRS PAM MUNFORD,
Lincoln
‘I have read the book myself from cover to cover and found it to be most informative, up-to-date and presented in a format which is easy to assimilate by the majority of people with diabetes who will undoubtedly relate some question to a particular experience of their own – and find the answer.’
PHILIP WHITMORE,
Macclesfield
‘I think the book is excellent value since it answers all the basic questions of diabetes and has answers to questions I have not seen written down before. (In fact the whole family is interested in reading it.)’
D BALL,
Nottingham
Reviews of previous editions
‘Overall this is a most interesting and useful book suitable for people with diabetes, their families, health professionals and anyone interested in diabetes. It is a book that once bought will be used over and over again, and works out to be good value.’
BALANCE
‘. . . a guide, in lively question and answer form, to coping with diabetes. It is quite possible to lead a full life providing the sufferer understands and can control the disease.’
WOMAN’S JOURNAL
‘Has positive information to help both young and old lead active lives with the minimum of restrictions.’
GOOD HOUSEKEEPING
‘I would recommend it to people living with diabetes, but also to professionals in the diabetes field.’
PROFESSIONAL NURSE
‘The book is well presented, with good, clear illustrations and is reasonably priced. I highly recommend it for people newly diagnosed with diabetes and their families and as a source of reference for nurses dealing with diabetes.’
NURSING STANDARD
‘Woe betide any clinicians or nurses whose patients have read this invaluable source of down-to-earth information when they have not.’
THE LANCET
Type 1 Diabetes
Answers at your fingertips
SIXTH EDITION
Charles Fox BM, FRCP
Consultant Physician with
Special Interest in Diabetes,
Northampton General Hospital
Anne Kilvert MD, FRCP
Consultant Physician with
Special Interest in Diabetes,
Northampton General Hospital
CLASS PUBLISHING • LONDON
| Preface
Is this the right book for you? Do you have Type 1 diabetes?
This is the sixth edition of Diabetes: Answers at your fingertips and in this new edition, we have made some important changes. The original book was designed to answer questions about both Type 1 and Type 2 diabetes. In the new version, we have decided to write separate books for each type of diabetes and this book is for people with Type 1.
You may not be sure which type of diabetes you have. There is a general rule that people with Type 1 diabetes are usually young, tend to be underweight at the time of diagnosis and need treatment with insulin straight away. However, the rule does not always apply: people can develop Type 1 diabetes at any age and are not always underweight.
If your diabetes needed insulin treatment from the time of diagnosis or if you failed to respond to tablets, this book is for you.
This sixth edition is dedicated to Peter Sönksen
and Sue Judd whose inspiration and energy
led to the first edition of the book.
1|What is diabetes?
In this chapter we describe the central problem in diabetes, which is an increase in the amount of glucose (sugar) in the blood. We explain why this happens and why it may be dangerous.
There are two main types of diabetes.
•Type 1 – this type of diabetes usually appears in younger people under the age of 40 but may occur at any age. It is treated by insulin injections and diet.
•Type 2 – this type of diabetes usually appears in people over the age of 40. They may have had undetected diabetes for many years and may not feel particularly unwell. Diabetes in older people is often discovered by chance and commonly responds well to diet or tablets, although with the passage of time, most people need insulin therapy.
There are other rare types of diabetes, which we also mention in this chapter.
WHAT HAPPENS IN DIABETES?
The pancreas is a gland situated in the upper part of the abdomen and connected by a fine tube to the intestine (see Figure 1.1). One of its functions is to release into the gut digestive juices, which are mixed with food soon after it leaves the stomach.
These digestive juices are needed to break down food and help it be absorbed into the body. This part of the pancreas has nothing to do with diabetes.
The pancreas also produces a number of hormones which are released directly into the bloodstream, unlike the digestive juices which pass into the intestine. The most important of these hormones is insulin, a shortage of which causes diabetes. The other important hormone produced by the pancreas is glucagon, which has the opposite action to insulin and may be used in correcting serious hypos. ‘Hypo’ is short for hypoglycaemia, meaning low blood glucose. See the section Hypos in Chapter 3. Both hormones come from a part of the pancreas called the islets of Langerhans, which are scattered throughout the pancreas.
Figure 1.1 Location of the pancreas
Why does the body need insulin?
Without insulin the body cannot make use of the food we eat. Food is broken down in the stomach and intestine into simple chemicals, such as glucose and fatty acids, which provide fuel for all the activities of the body. These simple chemicals also provide building blocks for growth or replacing worn out parts, and any extra is stored for later use. In diabetes, food is broken down as normal but, because of the shortage of insulin (or sometimes because insulin does not work properly), excess glucose cannot be stored and builds up in the bloodstream. When glucose rises above a certain level, it spills into the urine through the kidneys.
The liver plays a dual role in processing food. It converts simple chemicals into complex substances which are then stored for future use and it also allows breakdown of these stores when they are needed for fuel. This process is controlled by insulin. For example, in the absence of insulin, glycogen (starch) is broken down into glucose, which pours out of the liver into the bloodstream (and then into the urine). Insulin switches off this outpouring of glucose and causes the glucose to be stored as glycogen. Thus insulin ensures that a perfect balance is kept between the production of glucose and its storage, and in this way it maintains the blood glucose at a normal level. Insulin plays other important roles, such as allowing glucose to get into other parts of the body to be used as a fuel, and regulating the processing of amino acids and fatty acids, which are the breakdown products of protein and fat.
Figure 1.2 Insulin production system
What happens to insulin production in diabetes?
In people who do not have diabetes, insulin is produced in the pancreas and released into the blood as soon as the blood glucose level starts to rise after eating. Insulin travels straight from the pancreas to the liver where it has the important role of regulating glucose production and the storage of glucose as glycogen. The level of glucose in the blood then falls and, as it does so, insulin production is switched off, allowing glucose to be released from stores in the liver (see Figure 1.2). In people who do not have diabetes this sensitive system keeps the amount of glucose in the blood at a steady level.
In diabetes this process is faulty. People with Type 2 diabetes can still produce some insulin but not in adequate amounts to keep the blood glucose level normal. This is because their insulin does not work properly (a condition called ‘insulin resistance’). People with Type 1 diabetes have little or no insulin of their own and need injections of insulin to try to keep the blood glucose level normal. Even if given four or five times a day, injected insulin is not as efficient at regulating blood glucose as the pancreas, which responds instantly to small changes in blood glucose by switching the insulin supply on or off.
There are three main factors affecting the level of glucose in the blood:
•food (which puts it up);
•insulin (which brings it down);
•exercise (which also brings it down).
Any form of stress, such as an illness like flu, increases blood glucose. Learning how to balance your blood glucose level in diabetes is a matter of trial and error. This involves taking a lot of blood glucose measurements and discovering how various foods and forms of exercise affect the levels.
TYPES OF DIABETES
I hadn’t realised that there were different types of diabetes until I was diagnosed recently. What are the different types?
Diabetes does exist in different forms. Two main types are recognised.
•Type 1 diabetes usually occurs in younger people. This condition develops suddenly and insulin injections are nearly always needed as soon as it is diagnosed. About one in ten of all people with diabetes fall into this category, which used to be called ‘insulin dependent diabetes’.