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Diabetes affects people from all walks of life from the very old to the very young. It is now considered as a growing epidemic by the World Health Organisation (WHO) with present numbers of people with diabetes set to double over the next 10 years to 240 million worldwide.

In Ireland, it is estimated that there are 200,000 people with diabetes and a further 200,000 who have diabetes but are unaware that they have the condition. The majority of these people will only be diagnosed through an acute medical event of the complications of long term untreated hyperglyceamia (high blood glucose). A further 250,000 people have impaired glucose tolerance or "pre-diabetes" of which 50% will develop diabetes in the next 5 years if lifestyle changes are not made.

Diabetes Mellitus, or just diabetes as it is more commonly known, occurs when the glucose (sugar) level in the blood is too high. This happens when the body is not burning up carbohydrates properly due to a defect in the pancreas, the gland that produces insulin. Insulin is the hormone which keeps blood glucose levels within the normal healthy range. Diabetes may be present either when no insulin is made or when insulin is made but not working properly.

There are two types of diabetes – ‘Type 1’, or ‘Insulin Dependent Diabetes’, which usually occurs before the age of 35. A person with type 1 diabetes makes no insulin and therefore needs to inject insulin to regulate blood sugar levels and remain healthy. Type 2, or non-Insulin Dependent Diabetes usually occurs in adults after the age of 40 and is extremely common in old age. In this case, the person with diabetes makes some insulin, but this does not function properly. Usually associated with being overweight, this condition responds well to weight loss through dietary regulation. Sometimes weight loss is not enough and tablets are required to help the person's own insulin to work. This type of diabetes is also known as ‘Adult-Onset’ or ‘Maturity-Onset’ diabetes.

Pre-diabetes – Before developing type 2 diabetes, many people develop a condition termed “pre-diabetes”. This occurs when glucose regulation is impaired but blood glucose levels are not high enough for diabetes to be diagnosed officially. Modest weight loss, dietary modifications and increased levels of exercise can often reverse pre-diabetes and prevent the onset of type 2 diabetes in up to 60% of cases.

With an average of seven years between onset and diagnosis, the earlier the condition is detected the easier it will be to manage. Early detection gives the ability to protect against heart attack or stroke.

Symptoms of diabetes vary in intensity but may include:

• Lack of energy
• Tiredness
• Excessive thirst
• Frequent passing of urine
• Blurring of vision
• Recurrent infection

Diabetes is detected by a simple blood test that detects how much glucose is in the blood.

The onset of type 2 diabetes is gradual and therefore hard to detect. Some people have few early symptoms and are only diagnosed several years (3 - 7 years) after the onset of the condition and in half of these cases various complications are already present.

Some people are more at risk of developing diabetes than others.

The known risk factors include:

• A family history of diabetes
• Being overweight (80% of people with diabetes are overweight)
• Age (the likelihood of developing diabetes increases with age)
• Lack of physical exercise
• Having had diabetes during pregnancy or having had a large baby

Waist Circumference*:

Waist circumference is a practical way of assessing abdominal fat and may be a better marker of Type 2 diabetes risk than either weight or BMI alone.

* Waist Circumference is not the same as your waist size for trousers. Waist circumference is a measurement taken which includes your belly. See below for details of how to take this measurement.

*IDF guidelines (Asian men are at an increased risk when waist >35inches (90cm))

Some additional statistics on the very strong link between obesity and type-2 diabetes:

• Women with a waist circumference* of >35inches are 7 times more likely to develop diabetes than women with a waist circumference of <32inches (Lancet 1998, 351:853-6)
• Compared to the risk of a man with a waist circumference of <34inches developing diabetes, the risk increases as follows:
  • for men with a waist measuring 34-36 inches the risk is doubled
  • for men with a waist measuring 36-38 inches the risk is trebled
  • for men with a waist measuring 38-40inches the risk is five times greater
  • for men with a waist measuring >40inches the risk is 12 times greater.(Amer. J. Clin. Nut. March 2005)
• For every 2inch increase in waist circumference the risk of premature death increases by 17%in men and 13% in women (Diab. Metab. 2008).

Measuring your Waist Circumference:

1. Remove or raise any outer clothing
2. Stand straight, abdominal muscles relaxed, arms at side, feet together
3. Locate the level of the top of the hip-bone. Using a measuring tape measure around the abdomen at the level of the top of this bone keeping the tape horizontal. The measurement should be taken at the end of a normal expiration
   

Living with diabetes starts with learning how to make the right food choices, increase your physical activity in an appropriate way and monitor your blood glucose level. Here, you will find more information on how to do exactly that and so improve your health...

Eat 3 meals a day:
Try to include starchy carbohydrate foods at each meal e.g. pasta, rice, potatoes, bread

Cut down on the fat you eat, particularly saturated fats:
Choose lower fat dairy foods such as skimmed or semi-skimmed milk, low fat or diet yogurts, reduced fat cheese

Grill, steam or oven bake instead of frying or cooking with oil or other fats

Choose chicken, turkey, lean meat and fish as low fat alternatives to fatty meats

Aim for five portions of fruit and vegetables per day - Try picking from the rainbow of colours available to maximize variety

Include more beans and lentils - e.g. kidney beans, chickpeas or red and green lentils. These may help to control your blood fats. You can add them to your salad or soup

Reduce salt intake - Too much salt can increase the risk of high blood pressure. Taste your food before seasoning and try flavouring food with herbs and spices instead of salt

Aim for at least 2 portions of oily fish per week - mackerel, trout, salmon and sardines. They are rich in omega 3 fats which help protect against heart disease

Limit sugar and sugary foods e.g. desserts, cakes, sweet tea and sugar-sweetened drinks

Drink alcohol in moderation only - That’s a maximum of 2 units of alcohol per day for a woman and 3 units per day for a man

You don’t need to buy/use diabetic foods - These foods often contain just as much fat and calories and can raise blood sugar levels

And remember- Enjoy your food and make healthy food choices!

For more detailed dietary advice click on the links on the right »

Mini greek chicken kebabs
Serves: 8 Serving size: 2 kebabs

Ingredients:
Marinade
1½ Tbsp oil
½ tsp lemon zest
1-2 Tbsp fresh lemon juice
1½ tsp Worcestershire sauce
1½ -2 tsp dried oregano leaves
½ tsp dried dill
1 medium garlic clove, minced
1/8 tsp dried pepper flakes
¼ tsp salt

Kebabs
Canola oil cooking spray
4 chicken tenders (8 oz total), rinsed and patted dry, each cut in fourths crosswise
½ small green bell pepper, cut into 16 cubes
16 grape cherry tomatoes
1 small yellow squash, quartered lengthwise and cut into 16 pieces
16 bamboo skewers (6-in each)

Preparation
1. Combine marinade ingredients in a quart-sized re-sealable plastic bag, seal tightly, and toss back and forth until well blended. Remove 2 tablespoons mixture, place in a small bowl, and set aside. Add the chicken pieces to the bag with the remaining marinade, seal tightly, and toss back and forth to coat completely. Refrigerate for 1 hour, turning occasionally.

2. Coat the grill rack with cooking spray and preheat the grill to medium-high heat.

3. Remove the chicken from the marinade and discard the marinade. Thread pieces of the chicken and each vegetable per skewer in this order: pepper, chicken, tomato, and squash. Repeat with remaining skewers.

4. Place the skewers on a grill rack and cook for 5 minutes or until chicken is no longer pink in center and juices run clear, turning frequently and being careful not to overcook. Remove from the grill, place on a serving platter, and brush the reserved 2 tablespoons of marinade evenly over all. Serve warm.

Nutritional Information
Calories: 60
Calories from Fat: 25
Total Fat: 3 g
Cholesterol: 15 mg
Sodium: 80 mg
Total Carbohydrate 2 g
Protein: 6 g

Roasted vegetable and feta cheese tart (vegetarian)
Serves 8

Ingredients
For the pastry:
125g (4½oz) self-raising flour
50g (1 ¾ oz) oatmeal
75g (2¾oz) butter

For the Filling:
1 red pepper, deseeded and chopped
1 yellow pepper, deseeded and chopped
1 courgette, sliced
1 aubergine, chopped
1 red onion, cut into wedges
1 tablespoon olive oil
1 clove garlic, crushed
2 tablespoons fresh oregano, chopped
75g/2¾oz feta cheese, crumbled
25g/1oz pine nuts
Salt and freshly ground black pepper

Preparation:
1. Preheat the oven to 200°C/400°F/gas mark 6.

2. Sift the flour into a large bowl. Stir in the oatmeal, then rub in the butter, until the mixture resembles fine breadcrumbs. Stir in enough water to combine the mixture.

3. Roll out on a lightly floured surface do that pastry is 20cm round, place on a baking sheet lined with baking parchment, chill for 15 minutes, then bake blind for 15 minutes, or until a light golden colour.

4. Meanwhile, place all the vegetables into a roasting tin, drizzle over the oil and toss through the garlic. Place in the oven and roast for 25-30 minutes until tender and slightly charred on the edges.

5. Toss through the oregano and season well, spoon over the pastry base. Sprinkle over the feta and pine nuts and return to the oven for 10 minutes until the cheese is melted. Serve warm or cold.

Nutritional information
Each serving contains:
231 calories
5 g protein
22g carbohydrates
14 g fat

Cod with herby cheese topping
Serves 2

Ingredients:
15g ( ½ oz) polyunsaturated margarine
15g ( ½ oz) plain flour
100ml (3 ½ fl oz) milk
25g (1oz) strong cheddar or other hard cheese such as Wensleydale, grated
1 teaspoon English mustard
2 tablespoons chopped mixed herbs
Freshly ground black pepper
2 thick chunks of cod fillet or any other chunky white fish each weighing about 150g (5oz)

Preparation:
1. Preheat the oven to 200C/400F/gas mark 6. Melt the margarine in a small pan, whisk in the flour and cook for 1 minute.

2. Gradually add the milk, whisking continuously, and simmer for a minute until you have a thick sauce.

3. Stir through the cheese, mustard and herbs, and season with the black pepper.

4. Place the cod pieces onto a baking sheet and spoon over the sauce.

5. Place in the oven and cook for about 15 minutes until the fish is cooked.

6. Serve with rice and your choice of vegetables.

Nutritional information
Each serving contains:
206 calories
19 g protein
8g carbohydrates
11 g fat

For a person with diabetes it is important to keep active. Exercise will help:

• Insulin to work better, which will improve your diabetes management
• Control your weight
• Lower your blood pressure
• Reduce your risk of heart disease
• Reduce stress

It is generally recommended that you should exercise for thirty minutes five times a week.
You can spread those thirty minutes out over the course of a day:

• Start slowly with just five minutes at a time if you need to, and build up gradually to thirty minutes a day.
• Plan with your diabetes nurse physical activities specific for you.
• Choose an activity that best meets your goals and is safe for you to do.
• If you have heart, eye or blood pressure problems, you must seek medical advice before starting a new exercise program.
• To prevent injury, make sure you warm up with gentle stretching before you exercise and repeat those gentle stretches afterwards.
• Take good care of your feet - Always wear socks and make sure that your footwear fits well. Be very aware of any developing blisters and take care of them properly.
• Be careful if you have diabetic foot problems. Running and treadmill work are not recommended exercises for you. Swimming or cycling are much kinder to the feet.
• Be careful if you want to lift heavy weights. Sudden lifting can increase your blood pressure.

In general, when you have diabetes, physical activity is likely to lower your blood sugar levels. This is not just true for people using insulin - some tablets can have this effect too. To avoid your levels falling too low:

• Always take a small snack before you start exercising.
• Before you begin, test to make sure your blood sugar levels are not too low.
• Have glucose tablets, a sugary drink or a snack to hand while you exercise, in case you feel a hypo coming on.
• Test again after you exercise
• Watch out for delayed hypos- If you have undertaken vigorous exercise, keep an eye on your levels over the next 36 hours as you may need to make some longer-term adjustments to your diet to avoid suffering a hypo later.

Click on the links to the right for further Information »

Be in control – your blood glucose monitoring explained

Not everyone with diabetes has to test their blood sugar regularly, but it can play an important role in your diabetes care. For people on tablets it can be helpful to clarify certain situations, and for those on insulin it provides essential information on a daily or even hourly basis.

Keeping a log of your results is very important. When you bring this record to your doctor or nurse, you have a good picture of your body's response to your diabetes care plan.

Experts feel that anyone with diabetes can benefit from checking their blood glucose. It is currently recommended to check your glucose levels if you have diabetes and are:

• taking insulin or diabetes pills
• on intensive insulin therapy
• pregnant
• having a hard time controlling your blood glucose levels
• having severe low blood glucose levels or ketones from high blood glucose levels
• having low blood glucose levels without the usual warning signs

Your diabetes is specific to you, and how often you test varies according to the type of diabetes you have, the treatment you are on and your individual circumstances.

Fasting and pre-meal blood sugar levels should be between 4 and 7mmol/l. Levels which drop below 3.5mmol/l are too low, causing hypoglycaemia (hypos) which can result in sweating, trembling, confusion and eventually loss of consciousness. Fasting and pre-meal levels which are consistently higher than 7.0mmol/l require alteration in treatment.

A person with Type 1 diabetes should carry sugary foods and identification with them at all times.

(Please note that these blood glucose targets are general. Your doctor may set more individual targets for you).

Glucose levels are usually recorded one to four times a day depending on the stability of a patient’s condition. If carried out four times daily, glucose levels are usually measured before meals and at bedtime. The following levels are commonly recommended:

• Before breakfast (fasting level): 5.5–6.0mmol/L (with no nocturnal hypoglycaemia)
• Before lunch and before evening meal: 4.0–6.0mmol/L
• Before bed: 6.0–8.0mmol/L

If postprandial (after eating) insulin levels are being monitored, they should be taken two hours after each meal and aim to be less than 8.0mmol/L. Some patients may be set different targets (e.g., those elderly patients who are prone to hypoglycemia).

Blood glucose meters

There are many meters to choose from. They are very simple to use, accurate, light weight and small. Some meters are made for those with poor eyesight. Others come with memory so you can store your results in the meter itself, or even download results to your computer.

Although meters may look different the basic technique is the same. A drop of blood is placed on a strip which is read by the meter and the blood glucose result is displayed electronically. Technology is changing quickly and meters are becoming easier to use all the time.

Lancets:
Every meter comes with its own finger-pricking (or lancing) device. You will get a supply of “lancets” from the pharmacy. These are the sharp needles which actually pierce the skin. A new lancet should be used each time you are measuring your blood glucose. This is important to prevent infection. Some newer meters like the Accuchek Aviva meters come with lancets pre-loaded in a barrel (‘Multiclix’ lancets). This reduces the amount of handling involved and makes it impossible for yourself or anyone else to accidentally prick your finger when changing lancets.

Glucose Test Strips:
Each type of meter uses a different brand of strips. These strips are available from your pharmacy. (They are available free-of-charge on either the Medical Card Scheme or the Long Term Illness Scheme). Some meters require you to “chip” or “code” the meter each time you open a new box of strips. Your pharmacist will be happy to show you how to do this.

Batteries:
Most meter companies will give you replacement batteries for your glucose meter. For other meters contact their customer care departments on the numbers shown.

Customer Care Numbers:

Abbott (Optium) Freephone 180077 66 33

Lifescan (One Touch Ultra): Freephone 1800 535676

Roche (Accuchek): Freephone 1800 709 600

(patients can order free batteries by phone or on-line via link on our website)

Bayer (contour): 1890 920 111

Interactive Demo

Check out the easy to use interactive guide for the Aviva Nano meter now online. Click here

 

For further information on blood glucose testing including meter user guides, customer care numbers for some of the meters available, click on the links to the right »

The HbA1C test is another blood test for people with diabetes. It measures your average blood glucose level over 2 to 3 months and is an important part of how your diabetes is managed. The HbA1C test is done by your doctor or nurse and it helps to show how well your blood glucose levels are being controlled month after month. It gives you a goal to work towards. By using the results from both home testing and your HbA1C test, you and your healthcare team will be able to make sure that your medicine, diet and exercise are all working hard to help you stay in control of your blood glucose levels day after day, and month after month.

Your HbA1C target should be below 53mmol/mol (or less than 7.0% using the older way of measuring HbA1C) although your doctor may set different targets for you.

For further information click on the link to the right »

Hyperglycaemia or high blood sugar occurs when your blood sugar is too high, typically above 10mmol/L

Causes:

• Eating large portions or eating sugar-rich foods
• Reducing your level of regular physical activity
• Your medication may need to be increased
• Illness or infection or injury
• Stress or emotional upset
• Some medications, e.g. steroids

Symptoms:

• Thirst
• Passing urine more frequently
• Tiredness
• Weight loss
• Blurred vision
• Repeated infections

Your treatment plan may need adjustment if the blood glucose stays over 10 mmol/l for 3 consecutive days. It is important to aim to keep your blood glucose under control, and treat hyperglycemia when it occurs. You should follow your diabetes team instructions or contact them if you are not sure what to do.

If your blood glucose runs high for long periods of time, this can pose significant problems for you long-term — increased risk of complications, such as eye disease, kidney disease, heart attacks, strokes and more.

Hypoglycaemia (low blood sugar) is dealt with in detail in the next section.

What are ketones and why should I test for ketones?

Ketones are the waste products produced when your body breaks down fatty acids for energy. Toxic ketone levels can build up and spill into urine. This is a sign that your diabetes is not well controlled e.g. perhaps because of tiredness and fatigue, and will cause you to feel increasingly unwell.

If left untreated, ketone build-up can lead to coma and even death. Contact your healthcare professional if you detect a build-up of ketones in your urine. Symptoms may include nausea and vomiting, shortness of breath and blurred vision. As ketones levels rise, it may cause your breath to smell like nail varnish.
You should test your urine for ketones if you are ill with a fever or if your blood sugar is higher than 15 mmol/l. Ketones can be detected using urine test strips or using an ‘Xceed’ meter (with ketone strips).

Hypoglycaemia (or hypos) occur when your blood sugar is less than 4mmol/l. This can happen from time to time to everyone who has diabetes. It is important to learn to identify the symptoms of hypoglycaemia and treat it quickly by raising your blood glucose level with some form of sugar.

There are a number of causes:

• Fasting for prolonged periods
• Delayed or missed meals/snacks
• Vomiting
• Breast feeding
• Exercising more than usual, e.g. spring-cleaning the house, digging the garden; a ‘hypo’ may occur anytime up to 24 hrs after vigorous exercise
• Too much insulin or some tablets for diabetes (e.g. Diamicron, Daonil)
• Hot weather
• Alcohol - particularly the “morning after”.

Warning signs occur as the body tries to raise the blood glucose level. These warning signs vary from person to person but often include feeling shaky, sweating, tingling in the lips, becoming pale, heart pounding, confusion and irritability.

Treatment is usually very simple and requires taking some fast acting carbohydrate, such as a sugary drink (NOT diet or sugar-free versions) or some glucose tablets, and following this up with some longer acting carbohydrate such as a cereal bar, a sandwich, piece of fruit, biscuits and milk or the next meal if it is due.

In the vast majority of cases the body will release its own stores of glucose and raise the blood glucose level to normal, though this may take several hours.

Your blood sugar can drop so low that severe hypoglycaemia symptoms such as disorientation, unconsciousness, and seizures or convulsions, can occur. This is an emergency, which requires immediate treatment. Permanent damage to the brain or even death may result if treatment is delayed.

Glucagon Hypokit: for an immediate response to severe hypoglycaemia

In the event of severe hypoglycaemia you will need someone to give you an injection of glucagon, a hormone that raises blood glucose levels. Every person with diabetes should have a ‘hypokit’ (glucagon injection). Make sure your family, friends, and co-workers know where to find the injection kit and how to use it. Teach them before an emergency arises!

See the link to the right for more detailed information »

Eye Complications

Diabetes can affect your eyes in many ways. Be aware of your eye health and have your eyes checked regularly, including a dilated eye examination at least once a year. Remember; be sure to maintain good glucose control.
Some complications can be treated, especially if caught early. Also, good glucose control can prevent some complications from occurring in the first place, or can delay their progression.

All people with diabetes should be aware of the threats to their vision:

• Diabetic Retinopathy (changes in blood vessels/circulation in the retina i.e. back of your eye)
• Refractive Changes (changes in vision)
• Macular Edema (swelling in the central retina)
• Diabetic Cataracts (clouding of the lens in the eye)
• Nerve Palsies (damage to the nerves that control eye muscle movement)
• Glaucoma (disease of the optic nerve)

Have your eyes examined at least once a year or more frequently if signs of eye disease have already been detected. There should be a retinal screening service for people with diabetes in your area - check with your hospital clinic or your GP surgery.

Heart disease and High Blood pressure

An important part of taking care of your heart is keeping your blood sugar, blood pressure and cholesterol under control.

High blood pressure (also called hypertension) raises your risk for heart attack, stroke, eye problems and kidney disease. If you have diabetes, your healthcare team will help you to aim towards a target BP level of 130/80mmHg or less. When you keep your blood pressure below 130/80 mmHg you will be lowering your risk for diabetic complications. Your blood pressure is stated as two figures, e.g. 130/80mmHg. The first figure is known as the systolic pressure and relates to the pressure as the heart contracts and pushes blood through the arteries. The other figure is the diastolic pressure which is when the heart relaxes to refill with blood.

It is important to have your blood pressure checked at least once a year as part of your annual review for diabetes. This helps to ensure that it is in the target range and not increasing your risk of developing diabetic complications.

Lipids are the cholesterol and triglycerides in your blood. Cholesterol is a type of fat found in all of us. Not all cholesterol is bad. Some of it, HDL (high density lipoprotein), can actually protect against heart disease. Low levels of this protective HDL cholesterol increase your risk of cardiovascular disease.

However, LDL (low density lipoprotein) cholesterol is the bad form of cholesterol in the blood. High levels of this lipid are linked with an increased risk of heart disease.

Triglycerides are another type of fat in the blood. If you have raised cholesterol and raised triglycerides you have an increased risk of cardiovascular disease.

Targets

• Your total cholesterol level should be below 4.0mmol/l
• LDL levels should be less than 2.0mmol/l.
• HDL levels should be 1.0mmol/l or above in men and 1.2mmol/l or above in women.
• Triglyceride levels should be 1.7mmol/l or less.

If you do not know your lipid levels, ask your doctor or nurse to arrange a simple blood test for you.

Nerve damage and pain

Elevated glucose levels may damage the nerves (neuropathy), usually in the feet and legs, and this can result in pain, discomfort, and/or numbness. Numbness presents a particular problem as it can be very difficult for someone to detect if he/she has a wound on one or both feet, which could be dangerous. If someone is not able to feel a puncture of the skin that causes a wound or the pain that follows, a cut or scratch may be overlooked and eventually become infected.

The best way to cut your risk of developing neuropathy, or prevent it becoming worse, is to control blood glucose levels.If you develop any of the symptoms of pain and discomfort described above, be sure to talk to your doctor as medications exist that can be taken to help alleviate these symptoms.

Kidney disease

The kidneys remove waste products from the blood. Diabetes can damage the kidneys and cause them to fail. Failing kidneys lose their ability to filter out waste products, resulting in kidney disease. When diagnosed early, kidney disease can be slowed with treatment.

Therefore, it is important to have the following tests done annually:

• Urine test – this is a special urine test that tracks excess protein in the urine, known as microalbuminuria
• Blood test that measures the level of creatinine - this test will show your kidneys’ filtering capacity.

Sexual health

Uncontrolled blood sugar levels can cause diabetes-related sexual dysfunction in both men and women.

Men:
Diabetes can cause nerve and artery damage in the genital area, disrupting the blood flow necessary for an erection. This is more common in older men who have had diabetes for a long time. High cholesterol, high blood pressure and obesity - all common among men with diabetes, as well as smoking, can contribute to the problem.

Women:
Diabetes-related nerve damage can cause vaginal dryness that makes intercourse uncomfortable. Nerve damage also can lead to loss of sensation in the genital area, making orgasm difficult or impossible to achieve.

Issues for both men and women:
Urinary infections are more common in people with poorly controlled diabetes. This can cause discomfort for women during intercourse and for men during urination and ejaculation. These are generally temporary complications, but they can recur. Sexual activity should be stopped during treatment of urinary tract and yeast infections, which also are relatively common in people with diabetes.

Sexually transmitted diseases (STDs) can be transmitted easily because of the dry, cracked skin found in many people who have diabetes. This makes it important to practice safe sex.
Chronic high blood sugar levels can lead to reduced testosterone and may contribute to decreased sexual interest (libido). Chronic high blood sugars can also lead to abnormal nerve function, leading to pain with only light touch.

Heightened sense of pain associated with neuropathy can make sexual relations uncomfortable.

Because intercourse is exercise, people with diabetes should watch for signs of hypoglycemia (low blood sugar) after sex.

Make an appointment to see your doctor if you are experiencing sexual dysfunction.

Dental and gum care

People with diabetes can have tooth and gum problems more often if their blood glucose stays high. High blood glucose can make tooth and gum problems more severe.

Signs of tooth and gum damage from diabetes include: red, sore, swollen or bleeding gums, gums pulling away from your teeth so your teeth look long, dentures (false teeth) that do not fit well, loose or sensitive teeth, bad breath.

It is important that you get your teeth cleaned and checked twice a year.

Foot care

Making foot care a part of your daily diabetes regimen is essential for avoiding serious complications such as neuropathy, vascular disease, and injury.

Follow these simple steps to help you take good care of your feet:

• Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.
• Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.
• If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.
• File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower.
• Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.
• Always wear shoes or slippers to protect your feet from injuries.
• Always wear socks or stockings to avoid blisters. Do not wear socks or knee-high stockings that are too tight below your knee.
• Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger.
• Break in shoes slowly. Wear them 1 to 2 hours each day for the first 1 to 2 weeks.
• Before putting your shoe on, feel the insides to make sure they have no sharp edges or objects that might injure your feet.

Skin care

People with diabetes are prone to dry skin, particularly when blood glucose levels run high. This causes the body to lose fluids and skin to become dry. Dry skin can crack and itch, which can lead to infection. You may also get dry skin with diabetes if you have neuropathy. The nerves in the legs and feet may not receive the correct message to sweat, which is necessary to keep skin soft and moist. Keeping your skin moisturised when you have diabetes is one of the easiest ways to prevent skin problems.

Click on the links to the right for further Information »

Diabetics who smoke are more at risk of aggravating their health problems. If you are a smoker with diabetes here are 10 good reasons to quit

Heart attack or stroke: Diabetics who smoke are at a higher risk (three times) to die of heart attack and stroke than diabetics who do not smoke.
Blood glucose: Blood glucose shoots up further among diabetics when they smoke.
Blood pressure: Blood pressure elevates when a person suffering from diabetes smokes.
Cholesterol: The cholesterol level increases among diabetic patients who smoke.
Infections: Smoking damages the blood vessels of the diabetics which makes harder for their body to heal. So, the risk of getting infected increases which can finally end up in amputations.
Kidney and nerve disease: Diabetics who already suffer from kidney and nerve disease can damage the same when they smoke.
Joint mobility: Diabetics, who experience problems in the mobility of their joints, are at higher risk of losing joint mobility due to smoking.
Cancer: Diabetics who smoke are prone to develop life-threatening cancers in mouth, throat, lung and bladder.
Erectile dysfunction: People who have diabetes and smoke have greater risk of being impotent.
Respiratory diseases: Diabetics who smoke face difficulty in fighting against cold and other respiratory diseases.

Smoking with diabetes can greatly reduce your life expectancy and quality of life

For more information on quitting, talk to your Hickey’s Pharmacist today.

Click on the links to the right for further Information »

People with type 1 diabetes will need to take regular injections of insulin or may use an insulin pump.

People with type 2 diabetes can usually be treated by exercise and diet. There are many different types of tablets available for the treatment of type 2 diabetes.

Your doctor will prescribe a treatment which is best suited to you. Your medications will help to control your blood sugar levels in combination with a healthy diet and regular activity.

Oral Tablets

Many of these tablets work differently from each other and often more than one type of tablet is used. These are:

• Biguanides e.g. Glucophage –stop the liver making new glucose and help insulin carry glucose into muscles and fat cells more effectively.
• Sulphonylureas e.g. Diamicron - help the pancreas make more insulin and help your body use insulin better. Can cause Hypos.
• Glucose regulators e.g. Starlix– help the pancreas make more insulin
• Alpha glucosidase inhibitors e.g. Glucobay- slow the digestion of food and absorption of glucose
• Thiazolidinediones e.g. Avandia- help the body use its own insulin more effectively
• DPP-4 inhibitors e.g. Januvia- these are newer drugs that work by increasing the amount of insulin released from the pancreas when required and reduce the amount of glucose produced by liver.

In addition to glucose lowering tablets, you may also have to take tablets to control blood pressure, to reduce cholesterol and a “blood-thinner” e.g. aspirin. Make sure you have your blood pressure checked regularly.

Tablets are not always sufficient to control glucose levels and some people may need to take an injection. This may be in the form of insulin, or newer emerging anti-diabetes medications e.g. Byetta, Victoza.

Your doctor will prescribe a treatment which is best suited to you. Your medications will help to control your blood sugar levels in combination with a healthy diet and regular activity.

Insulin

Here is a short description of a variety of Insulin products.

Rapid-Acting Insulin e.g. Novorapid, Apidra, Humalog
These insulins are also known as "rapid-acting insulin analogues", which are clear solutions containing a modified form of human insulin. The modification results in a faster absorption of the insulin from the injection site, and consequently in a rapid onset and shorter duration of action than the traditional short-acting insulin (see below). Because of this feature, rapid-acting insulins can be injected immediately before a meal and are considered to better mimic the normal state of insulin release after meals.

Short-Acting Insulin e.g Actrapid,
This insulin comes also in a clear solution, and like rapid-acting insulin is also intended to be given at meals. An injection should be followed by a meal or snack containing carbohydrates within 30 minutes. Short-acting insulin can be of animal origin (mainly pigs) or human, which is manufactured using recombinant DNA technology.

Intermediate-Acting Insulin e.g. Insulatard, Humulin I
This is an insulin formulation that contains a substance which delays or retards the absorption of insulin. The combination of insulin and a retarding substance usually results in the formation of crystals which give the liquid a cloudy look. The insulin crystals must be homogenised (mixed) evenly before each injection. Intermediate-acting insulin takes approximately 1 ½ hours before it begins to have an effect. The largest effect occurs between 4 and 12 hours after the injection, and after approximately 24 hours, the complete dose has been absorbed.

Long-Acting Insulin e.g. Lantus, Levemir
These are long-acting insulins which have a slow onset and duration of more than 24 hours.

Premixed Insulin e.g. Humalog Mix 25, Novomix 30
These insulins contain a combination of a short-acting and an intermediate-acting insulin in standard proportions. These products eliminate the difficulty some individuals encounter while mixing insulin. The products come in several different premixed combinations containing 10-50% short-acting insulin and 50-90% intermediate-acting insulin.

Insulin pumps

An insulin pump is a small computerised device that delivers insulin continuously throughout the day. It attempts to mimic the normal pancreas's release of insulin, but you must tell the pump how much insulin to inject. It delivers insulin in two ways: a basal rate which is a continuous, small trickle of insulin that keeps blood glucose stable between meals and overnight; and a bolus rate, which is a much higher rate of insulin taken before eating to "cover" the food you plan to eat.

Effective, safe use of the pump requires:

• Commitment to checking blood glucose at least 4 times a day, every day.
• Using carbohydrate counting.
• Adjusting insulin doses based on blood glucose levels, carbohydrate intake, and physical activity.

Examples of insulin pumps include:

• Minimed Paradigm (Medtronic)
• Roche Accuchek Pumps
  

Diabetes is covered under the LTI scheme for people resident in the Republic of Ireland. This means that all medication for diabetes and related conditions is available to you free of charge under this scheme. This includes medication for high blood pressure and high cholesterol and glucose testing strips.

How to apply for the LTI scheme

If you want to register for the LTI scheme:

• Ask your doctor to complete the LTI application form
• Submit this form to the local Health Service Executive office.
• Your doctor/pharmacist should be able to tell you where the local office is located.
• When you are registered under the LTI scheme, you will receive an LTI book in the post.It shows your registration number.

Registered patients will get any prescribed diabetic medication free-of-charge from their pharmacy. Ask in any Hickeys Pharmacy for more details.

Remember, the Long Term Illness Scheme does not depend on your income or other circumstances and is separate from the Medical Card Scheme and the GP Visit Card Scheme.

If you have a medical card you will get your diabetes medication under the medical card scheme instead of the LTI scheme.

Click on the links to the right for further Information »

(of particular importance to insulin dependent diabetics)

When you are sick, your blood glucose levels go up, so you need to be extra careful with your diabetes management. It can put you at risk of developing diabetic ketoacidosis.

Remember:

• Always take your diabetes medication. If you are having trouble keeping the medicine down (vomiting), call your doctor.
• Do NOT stop taking insulin, even if you are not eating
• Check your blood glucose every 2-4 hours
• Check your urine or blood ketone levels every 2-4 hours
• If blood glucose remains high and ketone levels are positive, you will need extra insulin
• Drink at least 100 mls of water or sugar free drink every hour to prevent dehydration
• Stick to your normal meal plan, if possible. If you are not able to eat normally, have foods that are easily tolerated e.g. milky drinks or soup
• Monitor for hypoglycaemia and treat if required

Call your doctor or diabetes specialist team if:

• Blood glucose and ketone levels continue to rise despite extra supplements of insulin
• You are vomiting and unable to take fluids for more than 4 hours
• You have fever greater than 38ºC lasting for longer than 24 hours
• You are unsure or unable to follow the above instructions

Advice for Parents:

Depending on personality and age, your involvement in your child's diabetes care will vary.

If your child is young you may play a bigger role in diabetes care. As your child gets older, it's important to help him/her learn self-management skills and start to own their diabetes care.

Parents need to work with a health care team that is knowledgeable about paediatric diabetes.

It is also important to:

• See the health care team regularly – at least four times a year and be honest - do not be afraid to tell them what is difficult for you and your child.
• Stay positive with your child. Tell him or her all of the things they are doing well, rather than focusing on what they need to work on.
• Be mindful of your facial expressions and what you say, especially when you see an out of range blood glucose. Stress to your child that there is no “bad” blood glucose, because you want him or her to be honest about their blood glucose levels.
• Find time to check in with your child about diabetes management.
• Make sure that you talk about non-diabetes issues as well, like you do with your other children.
• Make sure your child does everything that he or she would have done if your child was not diagnosed with diabetes (sports, sleepovers, parties, etc.).
• Prepare healthy foods for the entire family. A healthy meal plan for someone with diabetes is the same for someone without diabetes.

Managing diabetes during pregnancy

• Changing hormones in the body during pregnancy cause blood glucose levels to rise, and high blood glucose levels in early pregnancy (within the first four to six weeks) can cause complications later in pregnancy.
• Controlling your diabetes before and during pregnancy can improve your chances of a safe and successful outcome for both you and your baby.
• If you suspect you are pregnant you should contact your doctor, midwife or diabetes care team for urgent referral to a specialist antenatal clinic for women who have diabetes.
• Your diabetes care team will help you achieve near-normal blood glucose levels by encouraging you to test your blood glucose before each meal and at bedtime and helping you reach these important targets.
• Remember - regular testing will help you to achieve good blood glucose control.

Gestational diabetes

• Gestational diabetes is a form of diabetes that occurs only during pregnancy. Gestational diabetes mellitus (GDM) affects 2 to 4% of pregnancies
• It usually strikes between the 24th and 28th week of pregnancy, and typically ends after pregnancy. The good news is that gestational diabetes can be managed – you can have a healthy pregnancy and a healthy baby.
• After you have successfully managed gestational diabetes, it is important to be vigilant about eating right and staying active. This is because women who have had gestational diabetes have a 50% risk of developing type 2 diabetes in 10 to 20 years after the birth of the child.

Benefits of Breast Feeding in Diabetes

Apart from the obvious bonding and nutritional benefits of breast-feeding, there are a number of additional benefits in diabetes:

• Breast-feeding is associated with a lower incidence of childhood and adolescent obesity.
• Non-lactating women have a higher risk of developing type 2 diabetes in the future.
• Breast-fed babies have a lower risk of developing type 1 diabetes in the future.
• Breast-feeding also appears to enhance psychomotor development.
• Breast-feeding lowers maternal glucose levels and insulin requirements drop by 25%

Click on the link to the right for further Information »

Travelling with Diabetes

Travelling and holidays should be planned in advance and advice sought from the diabetes team when necessary.

Insulin and traveling

• Patients should find out what types and strengths of insulin are available in the area in which they will be travelling (refer to Diabetes UK or Pharmaceutical Company).
• Insulin’s used in Ireland and many other countries are of the strength U-100. In some countries, insulin may come as U-40 or U-80 strengths. These insulin’s are not interchangeable. If they are to be used, the appropriate syringes are required.
• Insulin should be kept out of direct sunlight and kept cool.
• Insulin should never be allowed to freeze; therefore, when travelling by air, insulin should always be carried in the cabin luggage.
• Insulin might be absorbed faster in warmer climates, so regular monitoring is important.

Preparing for travel

Whether you travel by car, plane, train or boat, you'll want to keep a "carry-on" bag with you at all times. Pack this bag with:

• Twice as much insulin, syringes or pens, needles, tablets and testing equipment and strips as necessary (include extra batteries for your glucose meter).
• A diabetes identity card or jewellery.
• Carbohydrate- quick-acting (e.g. Lucozade, glucose sweets) and slow acting carbohydrate snacks eg. (biscuits, fruit) in the hand luggage to cover any travelling delays.
• A letter, from either your GP or Diabetes Centre, with a contact telephone number and address confirming the need to carry needles and syringes.
• Glucagon injection.
• Ketone strips.

Storage of Insulin

• Do not put luggage into the ‘hold’ of the plane. (Insulin could freeze here and therefore be rendered ineffective for use).
• Carry all equipment (Insulin, meters, snacks) as hand luggage.
• Keep out of direct sunlight.
• Use containers available e.g. Frio bags, cool-bags, flasks.

Climate Control

• Insulin may be absorbed faster in warmer climates so regular blood glucose monitoring is important.
• Insulin requirements may need to be reduced.
• Some blood glucose test strips may over read in very hot weather.
• Some blood glucose test strips may under read in very cold weather.

Vaccinations

• Patients should be advised to find out what vaccinations are required for the proposed destination.
• Occasionally these can cause sickness or flu-like symptoms and it is best to have them performed one month in advance of travelling.

Advice: Coping with Illness

• If sickness or diarrhoea develops, insulin or tablets should never be stopped even if solid foods cannot be tolerated.
• Carbohydrate intake should be maintained in the form of regular sugary drinks.
• Monitor blood glucose levels frequently.
• Urine should be tested for ketonuria as an early sign of decompensation.
• If sickness or diarrhoea persists medical advice should be sought.
• Specific rules for Sick-Day Management can be provided by your G.P or Hospital Diabetes Care Team.

Insurance for traveling

• Free or reduced cost, emergency treatment is available in other EU countries. The European Health Insurance Card has now replaced the E111. The EHIC application form is available from your local Community Care Office, local Health Office, Health Centre, or online at www.EHIC.ie
• Travel insurance is vital. Patients should inform the insurance company of the presence of diabetes and ensure that the insurance package provides adequate cover.

Long-haul flights

• If crossing time zones or travelling for many hours, specific advice regarding adjustments to insulin regimes can be obtained from the hospital team.
• Patients should bring along a flight schedule and information on time zone changes to help plan the timing of injection.

Identification and Customs

Require identification as a diabetic – letter available from your G.P. or Diabetes Care Team.

Click on the link to the right for further Information »

It is the legal responsibility of the patient to inform the the Driving Licence Authority as soon as possible after a diagnosis of diabetes that is being treated with either insulin or oral hypoglycaemic agents.

For people with type 1 diabetes, and some with type 2, driving requires extra care. Unexpected hypoglycemia (low blood sugar) can cause you to feel dizzy, shaky, or disoriented. In order to avoid hypoglycaemia you need to make sure to:

• Always carry fast acting carbohydrate food in the car e.g. glucose tablets.
• Not to drive for more than two hours without eating a snack.
• Check blood sugars before and during the journey.
• Carry identification.

If symptoms of hypoglycaemia do occur, you need to:

• Stop driving as soon as it is safe to do so.
• Immediately take a glucose drink/tablet.
• Remove the ignition key and move into the passenger seat to avoid any suggestion that the patient is in charge of the car.

If you have an accident attributable to hypoglycaemia you are liable to the charge of driving under the influence of drugs.

Click on the link to the right for further Information »

For more information contact your Hickey’s pharmacist, GP or visit some of the following websites:

Diabetes Federation of Ireland: www.diabetes.ie
Diabetes dictionary on Diabetes.ie: Click here
Roche Accucheck Website: Click Here
Foreign language booklets: Click Here